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Becker’s Healthcare Podcast
Armen Voskeridjian, Director of Anesthesia Services at Jefferson Surgery Center at The Navy Yard
00:25:19
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- [00:00]
A
Hello, this is Francesca Matthews with the Becker's ASC Review podcast. I'm thrilled to be joined today by Armin Vaskarigian, Director of Anesthesia Services at Jefferson Surgery center at the Navy Yard. Armin, thank you so much for being here today.
- [00:14]
B
Thank you for having me Francesca. A lot has gone on since our last Beckers podcast. We did with Alan in November 21st of 2024. For those of you that missed that podcast, you may want to go back and take a quick listen. It's only 19 minutes long to that podcast but we're going to be I would like to follow up with the information I presented there. At the time it was pretty preliminary but we've got some rock hard facts now. We got some data enough for two studies and I would like to share that with the Beckers community.
- [00:51]
A
Absolutely. Very excited to hear all about that. But just to start us off, could you please introduce yourself and tell us a little bit about your background?
- [00:59]
B
Sure, sure. Again, as you said, my name is Armin Vaskarijian. I'm a double board certified in internal medicine and anesthesiology physician. I work primarily out of a small ambulatory surgery center in the Navy Yard in South Philly. I trained mainly in New York. I'm actually going to my 40th high school reunion at the end of this month, so I give a little shout out to the Bronx High School of Science if there are any alumni out there. I went to college at NY Medical School at the State University of New York Downstate in Brooklyn. Shout out to Brooklyn. And then I did my internal medicine residency in Staten island and passed my boards and then did the anesthesia residency at New York Hospital Cornell on the Upper east side. Stayed there for two years as a teaching adjunct. Did private practice for two years, did not like it at all. And then I came to Philadelphia to be closer to my family where I worked at Albert Einstein Medical center in north philly for about 10 years. And then I found this job at the Navy Yard which was primarily focusing in outpatient ambulatory orthopedic surgery. We do everything except for joint replacements unfortunately. But everything else we do, we work on everything from collarbone fractures, shoulder cases, rotator cuff repairs, elbow, wrist, hip scopes, knee scopes, ACL repair, MPFL repairs, quad tendon, patella tendon and foot and ankle cases. Everything from Liz Frank fractures to Achilles tendon repairs. And I became director of the anesthesia services there about three years ago now. So that's basically my CV in a nutshell.
- [03:00]
A
Excellent Great. Well, we, we do have some questions here kind of about ASCS at large and sort of some zoomed out large level industry questions. But I am first interested in these studies that you were discussing. If you could just enlighten us a little bit as to what you've been working on.
- [03:17]
B
Sure. So last time I spoke with Beckers we, we, I was bragging about some incredible results we've been getting. At this point we have submitted our first paper to the online Journal of Sports Medicine. This is our ACL study. Our subjects were 131. So n equals 131. We split that into two groups. One group getting liposomal bupivacaine with mixed with aqueous bupivacaine and then the other group would get liposomal bupivacaine with the aqueous bupivacaine and the additional preservative free dexamethasone. Now although the theory being that the dexamethasone would prolong the effects, we didn't see that greater reflection of prolongation of effects on the ACL study. We'll get to that. In the foot and ankle study there was only approximately about 24 to 30 hours extra by adding the dexamethasone. However, the more stunning result is in both groups if you just take the N of 131. 77% of those 131 patients took zero narcotics after their ACL repair surgery. And that includes quad tendon, patella tendon and allograft. The allografts did the best. Obviously they're known to have less pain because it's a cadaveric donor of the ACL of the ligament. And those patients usually come out complaining of zero to one pain. The ACL patients came out complaining of about three to four on average is the score out of 10. And they took zero. 77% took zero narcotics. And this is now documented. This is going to be published. I'm hoping we'll get the results. The yes or no from the online Journal of Sports Medicine soon. Of the 23% of patients that did did take narcotics after their ACL repair surgery, the average number of pills they took was less than 2,5 milligram oxycodone pills. These are in my opinion incredible results. I think any orthopedic surgeon would be hard pressed to deny that. So we're very proud of these results that we're getting here. For the foot and ankle study, we have not yet submitted that for publishing, but we have our abstract out. We have the preliminary Data out, I believe, was 129 patients with a foot and ankle study. And there we did notice a significant improvement in the block length duration for those that. For the group that did get the dexamethasone, the preservative free dexamethasone in the foot, popliteal and saphenous nerve blocks. So again, two groups of patients, total 129. One group received liposomal bupivacaine with aqueous bupivacaine and no dexamethasone, no preservative free dexamethasone. The second group received liposomal bupivacaine plus aqueous bupivacaine and preservative free dexamethasone. So one group basically had no preservative free dexamethasone. The other group did. And we took all types of surgeries from surgeries that the surgeon had requested a block previously from the anesthesiologist. So that included everything from lisfranc fractures to complex bunionectomies, Achilles tendon ruptures, trimal bimalolar ankle fractures. Of those 129 patients, I believe, and don't quote me on this, but I believe the average number of pill takers, narcotic pill takers, in both groups was. I'm sorry, I'll take that back. In the dexamethasone group was 0.7%. That just means that out of every 100 patients, only seven people took narcotics.
- [07:22]
A
Yeah. These are remarkable.
- [07:24]
B
Yeah, yeah. Unbelievable. And the length duration that the dexamethasone was able to extend was approximately 36 to 40 hours. But again, don't quote me on that. I'd have to. Look, I don't have the results in front of me right now, but I did send them to you, and I can go over them later on. But these are unbelievable results. This is unheard of right now. The only thing that comes close to these kinds of results was when we were placing catheters. And catheters were great for what they were accomplishing, but unfortunately, we were only placing them on one of the two nerves that we blocked, the one that did the most lifting, the heavy lifting, which was the popliteal nerve, we would let the saphenous nerve go. So patients invariably had a plateau of pain control, wherein they felt great when they left the surgery center. But after 24 to 36 hours, when the saphenous nerve block wore off and they were just relying on the catheter for the popliteal nerve, you'd see a spike in Complaints about pain, obviously, because the sapenous nerve was now activated and narcotic use would go up. Depends on the patient, depends on the surgery. All that taken into account, though, this was what we were seeing. And so it was good for what it was at the time, but it was not, it was not the best that we could do. And I believe this is going above and beyond providing both nerves with a complete blockade that's lasting us about six to seven days. And I'm saying that with some hesitation because. And I'll get to this a little bit later, but I've modified my use of the liposomal bupivacaine. After the first podcast came out in November of last year, I got some shout outs from colleagues across the country. And the most disconcerting comment I was receiving was that I'm very fortunate myself. I'm very fortunate to be able to use this much liposomal bupivacaine. And we'll get into the amounts in a moment simply because their institutions, the pharmacy, wouldn't even allow them to touch liposomal bupivacaine. Or if they did, it would only be the 10cc vial, not the 20cc vial. So liposomal bupivacaine comes in two volumes, 10cc and 20cc. And that made me rethink this is after the studies were already finalized, but it made me rethink my approach. I was very fortunate to have an administrator at RASC at the Navy Yard, Jefferson Surgical center at the Navy Yard who saw the results we were getting, saw the patients almost taking minimal to zero narcotics, saw the responses of the surgeons, which were positive all across the board, and allowed me to sort of. She didn't complain about my liposomal bupivacaine use. And as everybody knows who's listening, liposomal bupivacaine is definitely expensive. So another report I'd like to make on this podcast is, is that I've reduced the amount of liposomal bupivacaine with minimal in both of those blocks, the foot and ankle and the ACL with minimal changes in narcotic use and patient satisfaction and patient pain scores. But I don't have any data for that. But I'd be more than happy to share that if you're interested in delving. Giving me a couple more minutes more.
- [10:57]
A
Yeah, I mean, go, go into any more detail that you feel like is appropriate. I, yeah, I want to get the full breadth of this before we kind of dive into how, how it might affect the industry going forward.
- [11:06]
B
Wonderful. Thank you, Francesca. I appreciate it. So the study for the ACL that is being submitted for publication at the Online Journal of Sports Medicine. In that initial study, we were using 30ccs of liposomal bupivacaine. So one 20cc vial and one 10cc vial. In my subsequent reevaluation, I've gotten that down to one 20cc vial. And if anybody wants to reach out to me, I'd be more than happy to share how I'm doing it. You can reach me on LinkedIn or I'm sure if you, they can contact me through Beckers as well. So the ACL amount of liposomal bupivacaine was reduced by one third. So Instead of using 30ccs, I'm using 20ccs for the foot and ankle. I was using 20ccs for the study of liposomal bupivacaine. For a final volume of 30ccs, I've got that down to now 10cc of liposomal bupivacaine, a final volume of about 21ccs with the dexamethasone in it. Having reduced the amount of bupivacaine, I'm now administering preservative free dexamethasone to everyone. So basically what these studies have shown is that even though the manufacturer states that you shouldn't be mixing anything with liposomal bupivacaine besides aqueous bupivacaine, with the caveats for how much you can add, how many milligrams you can add, we've shown at the Navy Yard that you can actually add preservative free dexamethasone without compromising the liposomes. That's the first thing. And then we've shown that with adding the preservative free dexamethasone, you can prolong the effect of the blocks that you getting. And finally, that you can do this with less liposomal bupivacaine than our studies actually showed. And that's anecdotal that part, but I'd be happy to talk to anybody that's willing to talk to me about it. So the ACL Again, 20cc's of liposomal bupivacaine and the foot and ankle blocks, we're using 10ccs of liposomal bupivacaine. And to add to that, Francesca, I believe we discussed this during the interview we had a couple of weeks ago. This formulation where you're mixing the liposomal bupivacaine, the aqueous bupivacaine and the preservative free dexamethasone will work on any of the blocks that we're doing. So this works for superficial Cervical plexus blocks for clavicle fractures. It works for the interscalene. And that's the last study we'll be publishing that's still underway. We're still collecting data for that. So it will work for the interscaling blocks, it will work for your ACL blocks and as a side and foot and ankle blocks, your popsaf blocks as a side note. The final discovery that we were able to publish in the ACL study was that we've added a third infiltration for ACL knee surgeries. In other words, your standard blocks for the ACL surgeries, where your adductor canal block, done at the apex of the triangle of the adductor canal, and your IPAC block for behind the knee pain. I've added a third block to that, which is the supra sartorial infiltration. And we get into that in the study as to how I was motivated to do that. And by adding that third block, I think we've. That that is also another strength. And it's not just a liposomal bupivacaine. It's by doing these three infiltrations that you can truly get superior coverage of blocking the knee. So the suprasortorial infiltration, your adductor canal block at the apex of the triangle, and your IPAC infiltration. I've used this on four total knee replacements, one of them for a very close friend of mine, three of them at the Rothman Orthopedics. Actually, all four were at the Rothman Orthopedic Specialty Hospital in Ben Salem, Pennsylvania. And narcotic use was basically eliminated postoperatively by the patients. And these are patients that went to rehab approximately eight hours after their surgery, six to eight hours after their surgery. The pt, the physical therapists were pretty impressed at the results they were getting. And so this is not a motor block. There's no motor blockade. The volumes are kept low, and the satisfaction and the pain control is superlative. I can't express how happy we are with the results that we've gotten.
- [15:36]
A
Absolutely. And kind of given all that, taking a step back, what do you see as the potential influence of this discovery on the ASC industry at large and for outpatient surgery?
- [15:48]
B
I can only speak from personal observation. But what we're seeing is basically with the government cutting funding for reimbursements for procedures, and then the private insurance is following suit. Reimbursements for anesthesia. Both the CRNA and the anesthesia position are getting less. Salaries are going up. This makes for an impossible scenario. You can't cut reimbursements and increase and have an increased cost of living and plus competition as well. Increase in salaries and expect the revenue from your insurance company reimbursement to cover everything. So what I've been seeing at our institution is that unfortunately our anesthesia group has had to ask the ambulatory surgery center to start paying outside. In other words, paying the ambulatory, the anesthesia group separately. And the anesthesia group is telling the ambulatory surgery center you keep the collections because it's just not enough. And this unfortunately means that the ambulatory surgery center has to dig into its profits to pay for an anesthesia group now. And this is a big strain. It's a big chunk of money. This is not small amounts of money we're talking about here, especially if you're running a four to six room ambulatory surgery center. So what does this bring? This brings the anesthesia group saying that we're not just here asking for reimbursements and increased reimbursements or increased money. This is what we're bringing to you. We are bringing to you, top of the line, cutting edge anesthesia nerve blockade for outpatient surgery where your patients are going home and they're basically not taking any narcotics. The surgeons have almost stopped prescribing narcotics, if not severely curtailing their narcotic prescriptions, sometimes switching to lesser, quote, unquote, lesser forms of narcotics like tramadol versus using oxycodone. And some of the patients are not even taking that. This is a big deal when it comes to advocating for the group. The surgeons will be the first person to advocate for them. Any anesthesia group that adopts this type of for outpatient orthopedic surgery or for perhaps other types of surgery, this will work for tap blocks. This will work for the surgeons doing infiltrations when they're using liposomal bubbivacaine. Whether they're General Surgeons or OBGYNs, if they add preservative free dexamethasone to their liposomal bupivacaine and aqueous bupivacaine mixture, it's going to make their blocks last longer. Again, no data. It needs to be studied. This needs to be shown to be the case. Maybe like the ACL study, it will be shown that the difference in adding preservative free dexamethasone doesn't make a clinically significant difference. But again, these are avenues ripe for study in the future. But again, the anesthesia group can say, look at what we're doing with your outpatient ambulatory orthopedic surgeries. This is what we're bringing. No pain, no narcotic use to minimal narcotic use. That's a big draw, especially in this day and age of opioid epidemics. The no pain act that was just passed for 2025 in Congress. This can be only a feather in the cap of the anesthesia group that adopts these measures.
- [19:26]
A
Absolutely. It sounds like a win win for, you know, physicians and for patients, you know, given the benefit to the added value that anesthesiologists would be bringing, given, you know, this clinical development. And then it is also the improvement in patients patient satisfaction and overall outcomes. Just. Yeah, absolutely.
- [19:43]
B
When, when you mentioned patient satisfaction, we're going to be starting to be. Reimbursements are going to be tied to patient satisfaction scores. So all of this comes. It becomes one big box present with a bow tie on top. And you give that to the anesthesia ASC provider, the administrator, and hopefully, you know, they take it with a grain of salt and they see the benefit in that. Absolutely. Yeah. Great.
- [20:10]
A
Yeah, absolutely. And you know, taking a bit of a step back away from this development, what are some other trends that you're following in healthcare and ASCs today?
- [20:23]
B
So to me, these are the number one and number two issues, at least for ambulatory orthopedic surgery centers. Obviously, what I'm saying is not going to affect places that do colonoscopies and endoscopies. That is outside of my purview. We don't do that at my institution. But any place that does outpatient ambulatory orthopedic surgery is definitely going to be benefiting from this. And unfortunately, what I see in the future is this is the trend that we're seeing. We're going to be seeing more and more anesthesia groups requesting their payments directly from the asc, cutting into the profits of the asc. While the ASC now struggles to make their collections from the insurance companies for anesthesia services provided. This puts an undue burden on the asc, unfortunately. But there's just. I don't see how it's going to change if the government keeps cutting reimbursement rates. And as we know, inflation is constantly there as a backdrop to our yearly lives. Cost of living is going to go up. They're going to have to be competitive. ASCs are going to have to offer or anesthesia groups are going to have to keep up with the salaries, and the salaries are increasing by 2 to 3% every year, if not more, in some places, depending on where you are. And in order to do that, you're not. You can't depend on reimbursement from the private insurance companies or the government. Obviously not the government. For a long time, it's not been enough. But what's really been impactful in the past couple of years is that now even the private insurance reimbursement rates are not enough. If you're mixed and your ASC patient population starts to change, what was good 2, 3, 3, 4 years ago May not be any good anymore because suddenly the demographics of who's coming to your surgery center, new surgeons are onboarded, old surgeons start to retire. So the patient demographic may start to mix also. And once that happens, you can't rely on past performance. As we know past performance is no indication of future returns. So this is a big stress on ASCs, and I think we're going to see a slowing down, if not already in the upstart of new openings of ASCs around the country.
- [22:51]
A
Absolutely.
- [22:52]
B
This is a big. This is an alarm. Sort of a canary in a coal mine.
- [22:57]
A
Yeah, definitely. I think that that's echoing concerns I've heard from other ASC leaders as well. Kind of on the flip side of, you know, know concerns. This is obviously an incredibly exciting development. What else are you excited about right now in this space?
- [23:11]
B
Oh, if anything, that's what I just said. Really? Nothing. Because everything I just told you is eclipsed my view of the future. For it's been a while now. My head's been. My nose has been in the grindstone and I'm just now taking time to look up and get some air. I'll defer that question to perhaps another interviewee.
- [23:38]
A
Got you. Gotcha. No worries. I mean, I can completely understand that. And everything you've discussed so far is also just kind of so interconnected between the clinical developments, outcomes for patients, and then obviously the sustainability of ASCs in the future. So I can understand how that's definitely, like you said, just eclipsing everything. We are kind of close to time here. Is there anything that we haven't touched on so far that you would like to mention.
- [24:03]
B
Again, if anybody's interested in the work we're doing, obviously we'll be publishing soon in the online Journal of Sports Medicine. We will be submitting the Foot and Ankle Study, but we haven't decided which journal yet. We're waiting to hear from, back from a few. But if anybody has any questions, feel free to reach out to me. You can either do that through LinkedIn or, or I'm sure through Becker's ASC people can get in touch with me as well. I would love to share my data, anecdotal or otherwise, with anybody interested in bringing this type of cutting edge regional ultrasound guided regional anesthesia to their asc. It would be my pleasure.
- [24:45]
A
Absolutely. All right. Well, that is all I have for you today. Armin, thank you so much for joining us. It's been a pleasure.
- [24:52]
B
It does.
- [24:53]
A
Yeah, yeah, of course. We're. Yeah. So excited to hear more about your findings. And I look forward to connecting with you again in the future.
- [25:01]
B
Likewise. Thank you so much.
- [25:03]
A
Absolutely. You have a good one.
- [25:04]
B
Thank you. Bye. Bye. Bye.