Kids ingesting pot; explaining fibromyalgia; speedy joint replacement: Upstate Medical University's HealthLink on Air for Sunday, Jan. 7, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a toxicologist shares precautions about cannabis intoxication.

Michael Hodgman, MD: ... When someone ingests a THC edible, the onset of clinical effects may not be for 60 to 90 minutes after you ingest the product. And there's a real risk there. ...

Host Amber Smith: A doctor of family medicine discusses fibromyalgia.

Alex Hensel, MD: ... It typically is something that's present for months or years, and it's an ongoing process. ...

Host Amber Smith: And two orthopedic nurses tell about going home from the hospital the same day you have a hip or knee replacement.

Pete Jaskula: ... We advise the patients that they should avoid overactivity, as that can increase the pain and aggravate those muscles after that nerve block wears off. ...

Host Amber Smith: All that, and a visit from The Healing Muse, right after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll explore how people are diagnosed with fibromyalgia and what the treatments are. Then we'll hear about same-day hip or knee replacement surgery. But first, what's important to know about cannabis intoxication?

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

As more and more communities legalize recreational marijuana, the rate and severity of cannabis intoxication among children is also growing.

Dr. Michael Hodgman is an Upstate toxicologist from the department of emergency medicine and the Upstate New York Poison Center, and he contributed to a recent article about this in the journal Clinical Toxicology, and he's here to tell us about it.

Welcome to "HealthLink on Air," Dr. Hodgman.

Michael Hodgman, MD: Thank you, Amber. It's a pleasure to be here.

Host Amber Smith: This article had contributions from colleagues in 17 states in addition to New York, plus Canada and Israel. So it seems like this is a concern nationally and internationally.

Michael Hodgman, MD: Yes. With the increasing legalization of marijuana here in the United States as well as in other countries, and in particular, the what I call now, the retail availability of cannabis products, particularly edibles, we're just seeing a dramatic increase in the number of exposures to these products. Really, not only in kids, but in adults as well who may be naive to some of the effects of these drugs.

Host Amber Smith: Well, for your study, what was the time period that you looked at?

Michael Hodgman, MD: This study was between 2017 and 2020, so you might say it was in the three years right before the COVID era struck us. We have a consortium called ToxIC, T-O-X-I-C (Toxicology Investigators Consortium), which involves a number of academic centers here in the United States, most of them who have medical toxicology fellowships (specialty training programs), as well as several hospitals in Canada and a few in other countries.

And what we do with that ... we have a database, and every patient that we see at the bedside gets entered into this database. And so it really allows us to do some really high-quality research and epidemiology by involving so many centers. And one of the sub-registries we had had to do with pediatric marijuana exposures, and this is the first report that comes out of that sub-registry.

Host Amber Smith: So by children, or pediatrics, is this 18 and younger?

Michael Hodgman, MD: Yeah, this was really, I mean, you might say an 18-year-old is really an adult, so this was quite a broad range of ages. It went up to 18 and all the way down to under a year of age.

Host Amber Smith: And you looked at different modes of ingestion, smoking or eating?

Michael Hodgman, MD: Yeah. The only criteria, really, for entry into this sub-registry was the patient was seen by a medical toxicologist, and the diagnosis was cannabis intoxication, or cannabis was the primary reason for their intoxication. So it could be from ingestion or it could be from smoking. It really could be it just had to do with cannabis by some route, leading to intoxication.

Host Amber Smith: And so we're looking at a three-year-plus time period. How many pediatric cases were included during that time?

Michael Hodgman, MD: There were about 140 cases.

Host Amber Smith: And were some of them from Central New York?

Michael Hodgman, MD: Yeah. I don't recall how many I put into this, but I would think we probably had two, three or four cases. And I know also that Strong (Memorial Hospital) in Rochester is also a member of the ToxIC consortium. And they contributed at least to a case as well. Again, I don't know the exact numbers. But I would guess that maybe up to five cases, five cases in this report, came from Upstate New York.

Host Amber Smith: Can you tell us about the outcome for the kids that were included in this study that had an overdose of cannabis? Were they all admitted to the hospital, or what ended up happening to them?

Michael Hodgman, MD: Well one thing is, this was a, you might say, somewhat select group, because they were more significantly intoxicated, which is why we may have been consulted to see them at the bedside. And so the majority of these kids ended up getting admitted, and it was usually for something like CNS, or central nervous system, depression. So they were profoundly lethargic. Or they may have been confused. Or they may have had some vital sign abnormalities.

Host Amber Smith: Did you discover how to predict which of the patients who arrive at the emergency department with cannabis intoxication would go on to recover, versus go on to require intensive care?

Michael Hodgman, MD: Well, one of the findings from the study was that there were really two flags of who might need hospitalization, two major ones. And one was if it was an edible ingestion. And I have to say that was skewed by the fact that these were primarily in the younger children. In fact, most of them were under the age of 5.

They were probably between the ages of, most of them were between the ages of 2 to 3, maybe 4 years of age. And the reason for that is, is that that's an age when exploratory behavior is very common. Anyone who has young kids at home knows that they'll get into everything. And so, No. 1, they have a predisposition to get into things.

And No. 2, these are attractive looking. These edibles are very attractive. They look like candy. They look like food. And so, the one predictor was an edible exposure in a younger child. The other predictor was in the older children, teenagers basically, who had used cannabis and also used something else. So they were intoxicated with several things. So it might be marijuana as well as alcohol, or perhaps an opioid or a sedative drug like a benzodiazepine such as Valium or Ativan or something like that. But they had several drugs on board. So in the older kids, a predictor of requirement for more, a higher level, you might say, of hospitalization was a polysubstance exposure, including marijuana. And then in the younger kids it was just exposure to an edible.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking about cannabis intoxication with Dr. Michael Hodgman, a toxicologist at Upstate from the department of emergency medicine and the Upstate New York Poison Center.

I'm curious, since the study covered cannabis intoxication in a variety of communities across the world, is the treatment the same everywhere?

Michael Hodgman, MD: I would say yes. Realistically for this, it's supportive. I mean, with the more severe intoxications, occasionally we'll see respiratory depression. And in a very select few cases, sometimes they have to be placed on a ventilator to support their breathing for a while. Uncommon, but a very severe outcome.

In young kids, we've occasionally had complications, including seizures, which is really, really rare in an adult related to cannabis. But in these really young kids, we've seen that. And that may require special interventions. And, also, again, more in the younger age group, we'll sometimes see issues with low blood pressure and very slow heart rates.

Host Amber Smith: Now, the study you were involved in was pre-COVID, and here we are kind of post-COVID in Central New York. What are the numbers looking like now? Are you still seeing that this is an issue with especially younger kids having access to cannabis?

Michael Hodgman, MD: Absolutely. Absolutely. In fact, I have to say as far as with the teenage exposures, I can't comment specifically, but at the time of this study in children under 10, it was exclusively exposure to edibles, because you can understand they're not going to be smoking or anything like that. So the exposures in young kids are exclusively edibles. And in teenagers at the time of this study, about three-quarters of the exposures in teenagers were from smoking, either plant material or perhaps vaping a THC (tetrahydrocannabinol) product.

And I suspect that we're seeing a greater percentage of the teenage exposures now are due to edible products as well, because edible products are the growth industry or growth product for marijuana producers, you might say. For example, in Canada,they legalized marijuana. I don't recall the (year), maybe 2019 or so. But it was about a year later before retail sales were allowed in Ontario, and on the first day there were retail recreational marijuana products for sale, the stores in Ontario sold out of edible products. I mean, it was, it was crazy. And we're seeing the same thing in other states where the products that are having the greatest year-to-year change in growth are these edible products.

Host Amber Smith: There's a range of edibles, right? They're not all candy. And there are a variety of candies. Some are chocolates, and some are fruity-flavored or hard candies. And aren't there drinkable beverages too?

Michael Hodgman, MD: Yeah, there's infused beverages. We've even had a few cases with infused hot sauce, infused barbecue chips. I mean, it's just crazy.

Just getting back to your question, what's changed is we're continuing ... . I've been more interested in the younger age groups, so I've been looking at zero to 5 and 6 to 12, and we're just seeing year to year, exposures are continuing, at least calls to the poison center that we're getting. And so this is a real focus for us at the poison center for prevention and education. And to your point, I think the No. 1 exposure product that we get called to the poison center are gummies. I mean, they're just unbelievably popular. And again, they're easy to leave laying around, and these young kids get into them, and it's been a real issue.

Host Amber Smith: For the people that are purchasing gummies, does reading the label help protect you from taking too much, or taking them the wrong way? Do the labels specify a safe way to use them?

Michael Hodgman, MD: In New York state, there's very specific labeling requirements. And again, this is for a product that's following all the rules and comes from a licensed dispensary. And the rollout of licensed dispensaries in New York state has been very, very slow. And I believe right now there's still only one in Syracuse, but there's a lot of places that you can go in and get one of these products.

So a lot of these products, they're not following the New York state labeling. But if the label's proper, first of all, it's got to be kind of a bland label with bland font for the print. It can't be like real colorful print or anything. And it has to have what the total amount of THC is in the package, what the unit dose is. The maximum unit dose for a single dose for an adult is 10 milligrams. And so the product has to have that, the total dose. It also has to have precautions on it. about the differences in when you experience the clinical effects when you ingest THC tetrahydrocannabinol versus when you smoke it.

Again, when you smoke marijuana, the absorption through the lungs is very rapid to the brain, and the clinical effects are within minutes. When someone ingests a THC edible, the onset of clinical effects may not be for 60 to 90 minutes after you ingest the product. And there's a real risk there. Somebody can take it and a half-hour later say, "Huh, nothing's happened. I'm going to eat another one." And so this is something we call "dose stacking." And so by the time you start getting the effect from the first one, then there's more after that. So the onset of effects is delayed, and that can affect anyone who's not aware of that. And the duration of effects from edibles is more prolonged than it is from smoking because, again, when somebody smokes it, they have the clinical effect very rapidly. And so they're able to titrate the effect because then they stop. Whereas with these edibles, if you've still got more that's going into your system, it can last a lot longer.

And if we go back to young kids, the other problem with young kids is whatever a unit dose is, that's a big dose for a little child. When you consider that a 10 milligram dose is what an adult should get. You get a 2-year-old that takes that same dose, that's a lot more. But the problem is also it's a gummy. It tastes good. Or it's a piece of candy. It tastes good. So how many stop with one or two pieces of candy, or how many people have only eaten one barbecue chip? The dose effect in these young kids can be really, really significant.

Host Amber Smith: Could a gummy ingestion kill a child under the age of 2?

Michael Hodgman, MD: Well, it's really hard to titrate the exact dose in young kids. We don't know, sometimes, how many they took. But if we just consider maybe a 2-year-old child that weighs 25, let's say 30 pounds, or about 15 kilograms that would be. And there have been some estimates that a dangerous dose in a kid that age could be about 1.7 milligrams per kilogram, or that might bemaybe 25 milligrams. So you could say a kid, a young child who just eats two to three gummies, they've already crossed that threshold to the potential for severe intoxication.

A lot of the kids that we see that just get into a few, I mean, their clinical course is like you might expect with an adult. They're a little goofy, a little lethargic. Their behavior isn't quite normal.

But then the more severe effects, as I said, we can sometimes see, is really profound sedation. Paradoxically, some kids will get very, very agitated and restless. And so we can see the whole spectrum of changes there.

Host Amber Smith: So those are some good red flags for parents, because they may not see a child eat this. The eating may happen out of the parents' sight, and they would maybe just notice symptoms afterward.

Michael Hodgman, MD: Correct. Correct. And, a real change in practice in the emergency department, I think in 2023, compared to maybe 10 or 15 years ago, we never saw this in toddlers. But in the differential of a toddler that is brought in, that's altered now. Cannabis is right there with all the other things that we have to think about as an emergency physician, as perhaps the reason for their not being themselves. So, yeah, it's just, it's added one more thing there.

Host Amber Smith: Well, this is really helpful. Dr. Hodgman, thank you so much for making time for this interview.

Michael Hodgman, MD: You're welcome.

Host Amber Smith: My guest has been Dr. Michael Hodgman, a toxicologist at Upstate from the department of emergency medicine and the Upstate New York Poison Center. I'm Amber Smith for Upstate's "HealthLink on Air."

How do you know if you have fibromyalgia? -- Next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Fibromyalgia does not have a cure, but treatments are available for this disorder, which is characterized by widespread musculoskeletal pain with fatigue and sleep, memory and mood disorders.

Today we'll learn more about fibromyalgia from my guest, Dr. Alex Hensel. He's training in family medicine at Upstate.

Welcome to "HealthLink on Air," Dr. Hensel.

Alex Hensel, MD: It's good to be here.

Host Amber Smith: Can you first describe what fibromyalgia is?

Alex Hensel, MD: Fibromyalgia is a syndrome. It's a collection of symptoms. I wouldn't think of it as a single disease or a single disorder, but more, it's a way for us to describe how this collection of symptoms presents.

And like you mentioned on the introduction, it usually has a couple features to it. Diffuse pains in several parts of the body, as well as systemic, bodywide, different symptoms that you'd feel: fatigue, low energy state, kind of these vague, overwhelming effects it has on the body.

Host Amber Smith: How does it typically present?

How does someone learn that they have this, or does it come on gradually?

Alex Hensel, MD: It typically is something that's present for months or years, and it's an ongoing process. It tends to develop in middle adulthood to later adulthood when it first develops, and currently it's identified solely on clinical criteria. That means we look at the picture, we discuss with a person, and we get part of their history to see if it fits the pattern, if it fits the story, for fibromyalgia.

We don't have any reliable blood tests. We don't have any tests or any imaging or anything that can really say yes or no to fibromyalgia.

Host Amber Smith: What part of the body is most impacted by fibromyalgia?

Alex Hensel, MD: So it can be very diffuse. That means it can affect different people in pretty substantially different ways. Most often when people are having symptoms, or they think of it, it's with weakness or aching-type feelings in their extremities: the arms, the legs, sometimes the neck.

That's where people tend to notice it the most, but it can affect even the abdomen, even an upper back. You can have vague, diffuse feelings of aching, feelings of soreness, at those sites. Really, the rule with fibromyalgia is that you have these diffuse symptoms that can be all over the body, but they come, and they go.

Host Amber Smith: Are there other conditions that someone with fibromyalgia might also have, other medical conditions?

Alex Hensel, MD: Yeah, there certainly is, and there is quite a bit of coincidence. People who have fibromyalgia, we also see more of an incidence, more of a happening, of other chronic inflammatory, other chronic irritation, conditions.

And that's part of why diagnosing fibro is difficult. We have blood tests that can tell us, yes, your body's inflamed, but is that because of fibromyalgia or is that because you have rheumatoid arthritis? So we can't use those types of blood tests to say it's fibro without anything else.

Host Amber Smith: Well, I want to talk to you more about how the disease is diagnosed, because if someone comes in, or they go to their primary care provider, with musculoskeletal pain, fatigue, maybe mood issues, how do you go about determining what it is that's causing it?

Alex Hensel, MD: And that can be difficult. There oftentimes isn't a clear and absolute picture with a disorder like fibromyalgia. There are a couple tools, clinical questionnaires, basically, that ask a series of questions and ask a series, kind of, of steps to go through for the medical provider to kind of arrange how things are presenting.

And those clinical questionnaires have a score that's associated with them, so then you add up the answers to that score. Some of the older types, they then have to multiply and do some other things. Some of the newer types of scoring metrics, you basically just add the numbers together, and if you're above a certain threshold, it suggests fibromyalgia is part of what you're looking at.

Host Amber Smith: Are there conditions that you have to rule out that maybe look like fibromyalgia, and you want to take care and make sure that it's not one of those things?

Alex Hensel, MD: Historically, a lot of conditions were referred to as rule-out conditions, where you'd want to make sure it's not X, Y or Z before you could say it is this definitive, final condition. Medicine in general has moved more and more away from the rule-out conditions, and part of that's because you can have fibromyalgia on top of rheumatoid arthritis.

If you have rheumatoid arthritis, we drive our treatment after that, and we just ignore the possibility of fibro while we're not comprehensively managing what your clinical situation is. So no, we don't really use rule-out, but there is coincidence.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking about fibromyalgia with Upstate family medicine resident Dr. Alex Hensel.

Let me ask you, do we know what causes fibromyalgia?

Alex Hensel, MD: Definitively, no. There's a couple ideas, a couple theories, as to what it is and what causes it. We know that there are a couple things that if they're present, they make it more likely, they make it more possible, for a person to develop fibromyalgia later in their life.

And some of that is genetic patterning. If you have a family history of fibromyalgia in one or two parents, that increases the chance that you will develop it later in life. But some of those things are also situational or lifestyle or driven by exposures. People who've had severe trauma, PTSD -- post-traumatic stress disorder -- or, even if they don't develop PTSD, if they had a severe traumatic event, they have an increased risk of developing fibromyalgia later in life. And that's part of what we're learning, new things about it, year on year, about why it happens and why some brains develop it and some don't.

Host Amber Smith: Is it true that more females have fibromyalgia?

Alex Hensel, MD: It is more common. We look at it in terms of a statistic called "incidence," how many new cases, how many new diagnoses, of a condition do we have in a period of time. And the incidence for fibromyalgia is higher in females than in males, so yes, it does happen more often in females than males.

Exactly why, we're not clear about. There is a theory that it has something to do with the estrogenic access or the pro-inflammatory nature. A lot of autoimmune autoinflammatory conditions, such as rheumatoid arthritis or such as Sjogren's syndrome, those are more common in females.

Why?

There's a lot of theories, but I don't think there's a definitive answer to that yet.

Host Amber Smith: In terms of disease management for fibromyalgia, is this a condition that's treated by primary care doctors, or when would a patient be referred to a rheumatologist, say?

Alex Hensel, MD: That is something that's a bit up in the air, I would say, because it is a condition that we are figuring a bit more out about fundamentally what it is.

Historically, it's been lumped in as rheumatologic condition. It was thought that it was really driven by the body attacking itself as an autoimmune process. But some of the theories, some of the work, we've been seeing, it's less likely to be autoimmune driven, to be that kind of disease process. So it really doesn't fit into a rheumatologic model, in which case, rheum (rheumatologists), they can deal with the inflammatory components, but if it's more driven by a central nervous system change, by the brain's chemistry changing, well, rheum really isn't a good fit for that.

I'd argue -- I have a little bias because I'm a family medicine provider -- but I'd argue that it's a good fit for primary care to tackle. But if we get to a point where it's beyond the scope, where it's more extreme than primary care can handle, rheumatology is still in the scope; they're one specialty we could talk to. Another that would be good to consider would be pain management.

Host Amber Smith: Are there effective medications that you can prescribe to someone?

Alex Hensel, MD: There are. There's a handful of agents that we know work decently well, and research is ongoing for other ways to use those or other approaches to them.

The medicines that seem to have the best effect are actually the antidepressant and anti-seizure class medicines. And then specifically in the antidepressants, a class of medicines we call the SNRIs; those are the serotonergic (and) noradrenergic reuptake inhibitors. We don't exactly understand why, but modifying the way that the brain signals respond changes how it perceives pain signals with these medicines.

An example of these would be duloxetine. That one is a fairly widely studied medicine that does have a benefit on fibromyalgia.

Host Amber Smith: Are there lifestyle modifications that you recommend?

Alex Hensel, MD: Yeah, this was actually something I came across when I was doing some research into this subject a little while back.

Just having some education, having an insight and understanding, in how the disease process works, having an educational conference with a provider, and it was a small class of 20 patients. That actually helps people to experience less pain and less lifestyle fatigue and other lifestyle impacts. So just talking, just having an understanding of what the disease, what this process, is and why it happens, that helps with it.

The lifestyle modification that's the most studied and seems to have the biggest impact, though, is exercise. Regular physical activity doesn't need to be particularly strenuous, but something that increases the metabolic activity of the muscles and increases the strain on the joints, not excessively; jogging, swimming are great examples, cycling, any of those that increase the heart rate, put some strain on the muscles, that changes the way the brain perceives pain signals, and that really is what fibromyalgia is, in our understanding of it.

Host Amber Smith: Well, let's talk about what life is like for someone who has fibromyalgia.

How much does this disease impact everyday life?

Alex Hensel, MD: That can vary quite a bit, person to person. In some cases, it's something in the background that people just kind of muscle through or push through to live the life that they want to live. In other cases, it can be quite debilitating and can interfere with every activity of daily life.

There's quite a wide spectrum of the impact it can have, but even in mild cases, it is something that affects well-being. So getting it better controlled and having less of a detriment, less of an exhaustion, with it, there is benefit to be had even in those situations.

Host Amber Smith: Are there complications that patients need to be on the lookout for?

How would you know if it's getting worse?

Alex Hensel, MD: It can be a progressive condition where things can get slowly worse as time goes on, and it builds and builds to a more extreme extent.

It's usually not "suddenly, things get worse."

It's progressive; it's slow. It does wax and wane as well, where you have a building of symptoms, a worsening of what you're experiencing, but then that can resolve over the course of a few weeks and get a little bit better. Then it can pick back up again.

It's very individual, the progression and how it impacts people.

Host Amber Smith: What sort of long-term outlook do you see for people who have fibromyalgia?

Alex Hensel, MD: That also varies In most cases, it's not something that you're going to cure. It's not something you're going to eradicate completely. It's a condition, it's a way that a brain is functioning. We can affect that and some the lifestyle benefits, the lifestyle modifications, the exercise, the neuroeducation, the reducing inflammation, in a big sense. Those are the things that have the best long-term impact. Medicines, medications, supplemental approaches: Those do have an impact on disease progression and burden, but they tend to be more time limited.

Medicines work up to a point, and then once this condition, once the sensitivity of the brain, gets to a certain extreme, they stop being as effective.

Host Amber Smith: Well, Dr. Hensel, I want to thank you for making time to tell us about fibromyalgia.

Alex Hensel, MD: No problem. It was nice to be on.

Host Amber Smith: My guest has been Dr. Alex Hensel. He's training in family medicine at Upstate.

I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air": going home the same day you have a hip or knee replacement.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

More and more people who need hip or knee replacements are going home the same day of the operation. To understand who is eligible and what's involved, I'm talking with two Upstate nurses. Lia Fischi is the orthopedic program manager, and Pete Jaskula is a nurse navigator.

Welcome to "HealthLink on Air," both of you.

Lia Fischi: Thank you.

Pete Jaskula: Thank you.

Host Amber Smith: Do I understand correctly that Upstate offered one-day hip or knee replacements to certain patients before COVID-19, but the numbers climbed during and since the pandemic?

Lia Fischi: Yes, Amber, that is correct. Same-day total knee and hip replacement is not new to us. We started these in about, I want to say, 2018. And before the COVID-19 pandemic, we were averaging about six (same-day) total hip or knee replacements per year. And then when the COVID pandemic hit, and when we were allowed to resume elective surgeries, we came up with a scoring system that would allow us to quickly identify those that would meet criteria for same-day hip or knee replacement surgery. And our numbers grew. In 2021, we then went up to 75 patients. In 2022, we went up to 226 patients. And in 2023, January through October, we're at 208 patients that are leaving same day after a total hip or knee replacement.

Host Amber Smith: So let me ask you, are the criteria the same regardless of whether the person needs a hip or a knee replacement? Are you looking at the same criteria?

Lia Fischi: We're pretty much looking at the same criteria. You know, the patient needs to be healthy. There's a number of things that the surgeon and the team look at, such as the body mass index of a patient. They pretty much have to be healthy. We look at certain things with diabetics.

The patient also has to be motivated and willing to pursue rehabilitation in a pretty much an outpatient level of physical therapy. And they also need to have a supportive system at home for same-day discharges.

Host Amber Smith: Well, what is different about a Swift hip or knee compared with a regular hip or knee replacement? I wonder, is the replacement joint the same?

Lia Fischi: Yes, the surgery is the same. Patient care is the same. The difference is when the patient actually leaves the hospital, is discharged. So if they meet criteria to discharge the same day, a Swift means that they will be swiftly discharged, meaning the same day. So it's the timing piece of when they are discharged.

Host Amber Smith: Well, let's talk about who qualifies for a Swift hip or knee operation. Is there an age cutoff?

Pete Jaskula: Typically, age does not play a big factor. It's something that we assess for in our screening. The nurse navigators, we use a screening tool -- WSRR, which is willingness to discharge the same day, supports upon discharge, their RAPT (risk assessment and prediction tool) score and risk score of less than four, which is based on their medical history. So age does play a factor in that, but we have had successful Swift patient patients at 80 years old.

Host Amber Smith: Oh, interesting. Now you mentioned BMI, body mass Index. Is there a weight limit for this sort of procedure?

Pete Jaskula: We factor in the BMI, as opposed to weight. Our inclusion criteria includes a BMI of less than 35 for diabetic patients and less than 40 for nondiabetic patients.

Host Amber Smith: Now what about gender? Do you see more men or women that qualify for Swift?

Pete Jaskula: I have not looked at the data, but gender does not impact on being a candidate.

Host Amber Smith: What about previous history, if they've had previous knee or hip surgeries or other problems with the joint?

Pete Jaskula: That really doesn't play that big of a role. Most of our patients have a history of joint pain, osteoarthritis or rheumatoid arthritis, so they all have mobility issues. These factors are the reason why the patients are seeking having this procedure done.

Host Amber Smith: Are there nonmedical considerations?

Pete Jaskula: Willingness to discharge the same day of surgery is the biggest nonmedical consideration in qualifying for Swift, along with having a good support system at home because you will need those supports at home upon discharge to help you out. Without these factors, the success rate of our Swift program would probably be low.

Host Amber Smith: So is there anyone who is not a candidate for Swift hip or knee?

Lia Fischi: I'll speak on this. We do have exclusion criteria. So if the patient has a history of a deep venous thrombosis, that's a deep blood clot in the vein, if they have a bleeding disorder, and if they have chronic comorbidities (additional medical problems), if their medical history is extensive, these will be reviewed by the surgeon, anesthesiologist, and approved by the team for inclusion. So these patients are all reviewed, not just by the nurse navigator, but the whole entire team to make sure that the patient is a good candidate for a Swift hip or Swift knee.

Host Amber Smith: So do you ever have the situation where someone comes in fully expecting to go home the same day with a Swift hip or knee, but something comes up in the surgery or they're not really recovering like they should? Do you ever have to have them stay longer?

Lia Fischi: That's the beauty of this program, is that these surgeries are done in our surgery center that's connected to the hospital. It's still part of the hospital. So we have the safety net of the hospital. So if the patient, for whatever reason, you know sometimes your blood pressure might just dip a little bit, so we want to continue to watch you. So they will go then be moved to the floor, the unit, and stay overnight.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking about Swift hip and knee replacement surgeries with two Upstate nurses, Lia Fischi and Pete Jaskula.

Let's talk about what happens after a person and their surgeon decide to move forward with a Swift hip or knee. What sorts of testing is done ahead of time?

Pete Jaskula: I'll answer this. The patients have to go for medical clearance with their primary care provider. They may also need additional clearances, such as a cardiac clearance or pulmonology clearance. So any clearances would need to be obtained prior to surgery.

There's usually blood work that is done to get a baseline data such as a complete blood count, basic metabolic panel, type and screen for surgery. And they also would screen for MRSA prior to the patient having surgery, to help reduce their risk of an infection with surgery.

Host Amber Smith: What is MRSA?

Pete Jaskula: MRSA is methylicillin resistant Staph(ylococcus) aureus. So it is a type of bacteria that's out there in society that is resistant to certain types of antibiotics. So if a patient were to test positive for that, the surgeon is going to treat them with an antibiotic ointment that they would apply to their nostril twice a day for five days before surgery to reduce that bacteria, to reduce their risk of infection with surgery. And we would also know which antibiotic to treat with, prophylactically.

Host Amber Smith: So that sounds like a lot of the kind of standard for pre-op for any sort of operation. Is there anything specific for Swift hip or knee? Do they have to talk with physical therapists beforehand?

Pete Jaskula: Well, that's a good question. All the patients do meet with their nurse navigator two weeks prior to surgery to get them prepared for surgery, make sure they have all their support systems in place. And we also have a joint class that all patients are attending, and they will meet with a physical therapist on that. And physical therapy does go over a PowerPoint presentation with them, getting the patients prepared. They talk about their precautions and exercises and the importance of "prehab," which is one to two physical therapy sessions before surgery.

And they're going to get educated on mobility, how to properly use their DME, how to safely do stairs, some of those common asked questions, so that way when they're here in the hospital, we're focusing more on getting the patient safely discharged home and not doing the education piece while they're here.

During the class the nurse navigators also do a PowerPoint presentation to go over what to expect on the day of surgery, what to expect afterwards. It's a lot of education ahead of time to get the patients prepared for surgery.

Host Amber Smith: And you said DME. That's durable medical equipment?

Pete Jaskula: Yes.

Host Amber Smith: Which would be, what, crutches or ...?

Pete Jaskula: Typically a rolling walker. Sometimes it is crutches. But typically it's a rolling walker. They may also need, like, a raised toilet seat or a tub bench, shower chair. So these are all things that the nurse navigators discuss with the patients at our risk assessment appointment.

And we go over all these medical equipment and what is typically covered and not covered by insurance companies and advise patients what's going to be best for them so they can maintain their independence and adhere to their precautions after surgery.

Host Amber Smith: So what is the day of the procedure like? How early do patients arrive?

Pete Jaskula: The day of the procedure, the patients arrive two and a half hours prior to their surgery time. At this time, the patients get registered. They'll go over to the surgery center, meet with their nurse there. They'll get prepared for the OR (operating room), get an IV started. They'll meet with their anesthesiology team member at that time, as well, to go over the anesthesia procedure as well. And then they get all prepped for surgery and then go in and have the procedure itself, which typically takes about an hour and a half.

Then after surgery, the patient will go over to the recovery room. Time in the recovery room is, on average, I'd say about an hour or maybe two hours. And then they will get transferred over to the surgery center. And from the surgery center they'll work with PT (physical therapy) at that time to determine if the patient can safely ambulate, walk, climb stairs, do all these with their support systems.

And once the patients are medically stable, they pass their PT evaluation, tolerating their pain medications, we do like the patients to urinate before they leave as well. And once they meet all that criteria, the patient will be discharged home.

Host Amber Smith: What have you seen the first night at home be like for most patients?

Pete Jaskula: Most patients, the first night at home, it can vary vastly because patients typically get a regional nerve block, which is a peripheral nerve block where they numb the operative leg for pain control purposes. And the duration of that can last anywhere from four to 24 hours. It's really dependent on many factors. So typically the first day is not so bad, that first night, because that nerve block is in effect. It's more, the next day is when that nerve block wears off and patients start experiencing that postoperative pain.

That's what we were preparing the patients more for, is how to deal with that pain after that nerve block wears off. So we advise the patients that they should avoid overactivity, as that can increase the pain and aggravate those muscles after that nerve block wears off. And we advise them to kind of routinely take their pain medications for the first day or so. That way at least there's pain medication in their system already, pre-medicating them, because if that nerve block wears off and there's no pain meds in their system, it's going to be a lot harder to control the pain at that point. So we want to intercept that pain ahead of time.

Host Amber Smith: So once they get the pain sort of managed, or under control, let's talk about what other postoperative red flags the patient and their loved ones are supposed to look out for.

Lia Fischi: I'll talk on that. So I want to say, I just want to mention that the support system from the nurse navigators is huge, contributes to the success of the Swift program. So, like Pete was mentioning about the pain elevating, the nerve block wearing off on day one, the day after surgery. That's when our nurse navigators will contact the patient and kind of support them and kind of help them with their pain control, give them tips and strategies.

As far as red flags, what's expected? I would say some pain is expected. A little swelling is expected.What's unexpected is: a fever; pain that doesn't go away with the prescribed medication; swelling, like significant swelling or redness, that could indicate an infection; difficulty breathing, shortness of breath, chest pain. That would indicate call 911 for that. Calf pain or swelling could indicate a blood clot. And so call, definitely. Numbness or tingling, joint instability. Some red flags are wound issues, if you have increased drainage, sudden weakness or inability to move. Those are things to call or call 911.

Host Amber Smith: I know you said when they're in the recovery room, they go to the surgery center, and you said they walk before they leave, which is amazing. It wasn't that long ago hip and knee replacement patients were in the hospital for a week, and now they're walking just hours after the surgery. It's pretty amazing. When do they start regular physical therapy, where they are working on certain exercises?

Pete Jaskula: As soon as possible. Typically, like you said, they will work with physical therapy while they're in the hospital, and that's usually within two hours of the patient getting to the surgery center, where we get up and mobilize them. But as far as, like, outpatient PT, their first appointment for our Swift patients, we like them to go and start that two days after their surgery.

Host Amber Smith: So, pretty quickly.

Pete Jaskula: Yes. Mobility is key to success with a joint replacement.

Host Amber Smith: Long-term, do Swift hips and knees work as well and last as long as those implanted through regular open surgery?

Pete Jaskula: Yes. I honestly feel that our Swift patients probably typically do better than the inpatient population. These patients are highly motivated to leave the same day of surgery and prepare themselves for success. By leaving the same day, the patients have to mobilize once they're home, and early mobilization has been proven to be a key factor in a successful joint replacement.

Host Amber Smith: Can listeners who are interested to see if they qualify, can they make an appointment on their own or do they need a referral from a primary care provider, and how do they go about doing that?

Lia Fischi: , We only need a referral for VA (Veterans Administration) and Tricare (insurance for active-duty military) patients, but they can request an appointment by calling, and I'll give a phone number: (315) 464-8600. Or, going to the website of upstateorthopedics.com.

Host Amber Smith: Very nice. Well, I appreciate both of you making time for this interview, Mr. Jaskula and Ms. Fischi.

Lia Fischi: Thank you.

Pete Jaskula: Thank you for having us.

Host Amber Smith: My guests have been nurse Lia Fischi, the orthopedic program manager at Upstate, and nurse navigator Pete Jaskula.

I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Colette Parris is a Caribbean American attorney who has returned to her literary roots during the pandemic. She sent us a poem that captures the aftermath of a devastating diagnosis on the parent trying to process such unwelcome news. Here is "Upon Receiving the Diagnosis, I Am Fraught":

that is to say

that I am countless leagues

under the sea,

sans submarine

that is to say

that your knives

shaped like syllables

have punctured my protections

resulting in leakage of vermilion

terror

that is to say

that when you suggest

sympathetically

that once I've wrapped my head

around your serrated knives,

I may want to make some calls

I laugh uproariously (to myself)

as I wonder when,

exactly, will that be

that is to say

that I am repeating on a loop,

in my internal voice,

the impossible thing

you have told me;

that there is something wrong

with my child

do you have any idea

how hard for me

that is to say

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," ethical concerns about artificial intelligence.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.