This is Alan Condon with the Becker's ASC podcast, and I'm thrilled to be joined today by doctor Armin Voskiridyan, director of anesthesia services at Jefferson Surgical Center at the Navy Yard in Philadelphia. Arman, a real pleasure to have you on your podcast today with us. Before we dive into our discussion, could you I'm gonna turn the floor over to you just to hear a little bit more about your role and your background at Jeff Jefferson Surgical Center. Sure, Alan. It's a pleasure to be here. So I'm double boarded in internal medicine and anesthesia. I started out in education in terms of working at my residency program for 2 years. I did private practice for 2 years, and then I moved down to Philadelphia. That was in New York City. I moved down to Philadelphia. I worked at, Albert Einstein Medical Center in North Philly for 10 years, and then I found a job at a private practice surgical center, and that's where I am now and I that's where I've been for the past 10 years. I did not learn how to do nerve blocks in residency. At the time, there was no ultrasound miniaturization. The ultrasounds were huge and they weren't used at the bedside. And, the methods that were used at that time were basically anatomical landmarks and using electrical stimulation, decreasing the current, getting closer and closer to the nerve, and almost 50% of the time, the blocks wouldn't work. So I was not a fan of doing this because in the end, we had to give some morphine or some sort of narcotic in the recovery room. So what was the point of doing all this? This all changed in around the, early 2000 mid 2000 year, era. I think it was DARPA that was given the, initiative by the military to miniaturize the ultrasound and during Iraq war 1. And so this this occurred. And when I started seeing the ultrasound being used in nerve blocks where you can actually see the nerve, you can see the needle, you can approach, you can see the larger vessels, I immediately lit up. And I said, this is something I wanna do. And so, credit to my chairman. He saw that I was pretty good at it. He, said, go ahead and take your weekends and go to any type of CME courses you can, and that's what I did. I went all over the country from Florida to Colorado, Harvard, California, and, I any 3 day weekend course that there was, I took, and it just took off from there. So my skills became very valuable, when I entered this ambulatory surge orthopedic ambulatory surgery center. So all we do at this ambulatory surgery center is outpatient orthopedics. Everything from shoulder, scopes and rotator cuff repairs, elbows, wrists, hips, nothing joint replacement related, but everything other than that, hip scopes, knees, ACLs, MPFLs, any kind of knee surgery in that, quadriceps repair, patella tendon repair, and all foot and ankle cases. Liz Frank cases, Achilles tendon ruptures, trimal, bimal. So that's, my background, basically. Fantastic. So all honestly, very orthopedic focused. That's all you do. No joint replacement from what you from what I gather. And do you is spine surgery a specialty that that that takes place there or no? No. It's actually, we don't do any spine cases. Although, I work very closely with the Rothman doctors at my facility. They do have a specialty hospital close by that does spine cases, but we don't do any at our ambulatory surgery center. Gotcha. Very familiar with, doctor Alex Vaccaro and a lot of the surgeons at Rotman as well. Oh, exactly. No doubt your next door neighbors there. Yeah. I would love to get some perspective. Obviously, in in the in the ASC space, so much going on at any one point in time. But what what are 2 or 3 trends that you're really paying close attention to, in the ASC space today? The one that's most impactful I think currently is the cost of anesthesia providers, cRNA and physicians. The cost is escalating, the reimbursements are declining And when the federal government reduces its rates, the private insurance insurance companies follow. You can't keep reducing reimbursement and keep expecting to hold on to talent. That's one of the big trends that I'm noticing. It's getting harder and harder to maintain talent and to maintain successful practices because of the lack of reimbursement. What's eventually happening is that anesthesia practices are requiring, supplemental incomes from either the institution they're working at, whether it be a hospital or a surgical center, and that's becoming burdensome because it's cutting into their profits. So this is definitely one of the trends negative trends that I'm seeing. The positive trends are an incredible ability, especially again in my field, which is outpatient ambulatory orthopedic surgery, for nerve blocks, ultrasound guided nerve blocks, and the use of liposomal bupivacaine, to prolong the action of those blocks and may basically make outpatient ambulatory orthopedic surgery a non narcotic 0 narcotic to minimal narcotic use procedure experience for the patient. These are, I think, are the top two trends that I can, speak most strongly on. Yeah. Yeah. Absolutely. I think the the first one, in terms of the cost of anesthesia providers, no doubt such a challenge across the health care space in terms of to your point, how do you retain talent, especially with anesthesia providers requiring supplemental income? I'm curious to hear just a little bit more about that. No doubt it is a challenge to retain the top talent in this area. But is there anything that ASCs or your organization is doing to to help keep, keep a hold of those, the top talent in terms of anesthesia providers? I wish I had a magic bullet type of answer for you. Unfortunately, the bottom line becomes finance, money. People are not gonna work for free. And when other institutions that do have the financial backing, whether that be private or through other means, are offering larger salaries, the talent is gonna go where the money is. And that's gonna require a lot of interesting solutions, which I I unfortunately don't have the answer to right away, as to how to address this. Ambulatory surgery administrators are going to have to get very creative in trying to maintain and retain their talent, whether that means limiting the hours of the surgical center so that we don't have later days running, whether that means extra weeks of vacation or, financial remuneration, which will unfortunately have to come out of the bottom line of the ASC. Otherwise, I don't I don't see a way out of this conundrum. Yeah. No doubt no doubt it's something that's top of mind for providers, ASCs, independent practices across the country. I'm curious to hear a bit more about Jefferson Surgery Center. When you think about the next 12 months to 24 months, obviously, the orthopedic focused surgery center, how are you thinking about growth? Is it adding more providers, expanding specialties, more higher acuity procedures? What are you most focused on? I think the focus is going based on what we just talked about, understandably, newer surgeons are going to be slower than experienced surgeons, but there are some even within the experienced surgeons, there's variation. The administration of ambulatory surgery centers is going to have to focus and find a way to try and maximize the efficiency of all their surgeons. We want increased productivity. Obviously, it's safety is always the key issue here. We want safe, successful operations, but within that range, there are some surgeons that are slower than other surgeons. And to maximize efficiency, you have to be able to reward the surgeons that understand this fact and somehow either encourage the other surgeons to try and emulate that or, unfortunately, if they can't keep up, you'll have to try to find a way to tell those surgeons to this this is not the place for you. This is an ambulatory surgery center is not the real place to do teaching like a, an educational center. And, then it it's it's very difficult because you form relationships with your surgeons. You don't wanna tell someone that you have a good relationship with. You need to speed up or move out. But, unfortunately, this is the reality that's that the administration the administrators are, coming face to face with. You can't keep slow surgeons and a profitable surgery center. It's just not gonna work. Mhmm. Yeah. I'm curious from your perspective, obviously, as director of anesthesia services, and and the surgeons that you work with, they use such a close partnership with. What do the the best surgeons or, I should say, the most efficient surgeons, what do they do exceptionally well? Oh, it's hard to pinpoint exactly what they're doing. Again, I'm an anesthesiologist. So seeing from surgical technique, it's you'd know who the efficient ones are. What they're actually doing that makes them more efficient is more of a surgical question than an anesthes and from an anesthesia perspective, I wouldn't be able to pin pinpoint what those are. I can tell you who the efficient surgeons are, and I can tell you who the inefficient surgeons are. But, unfortunately, I I can't determine how that, how to how that translates when you're actually hands on. Now we do have residents and fellows coming through our, surgery center at Jefferson, and I understand the necessity of teaching residents, surgeons. I also have partnered with Jefferson System to get a fellowship program for ultrasound guided regional anesthesia, and I've been able to incorporate that teaching, without slowing down the pace of the operating room. There are ways that this can be accomplished. There are teachers that teach and work efficiently as well. There are others that are not so, efficient, unfortunately, and it's the balance has to be struck, and this is a difficult conversation to have because, again, like I said, you develop relationships with your surgeons. No. You don't wanna tell anybody that, they're not keeping up. However, there may be ways that administrators can, achieve this, whether that be, Excel spreadsheets where you can compare surgeons and surgeries and, you know, have a meeting with them and say, look. These are our top performers. These are our middle performers. These are our lower performers, and it has to be, it has to be a group effort. The surgeons have to be on board with this, and perhaps they can communicate with each other and see learn from each other and pass these tips and tricks onto each other as to how to be more efficient. Yeah. Because we all know that answered your question, Alan. No. Absolutely. I think we all know, you know, how competitive surgeons can often be as well. I think that might be a a great little insight to take away in terms of tracking performance, measuring, sharing some of these tips and tricks along the way, especially to your point, some of the the newer surgeons, the next generation who might be coming out of residencies and fellowships as well. Armin, really, really fascinating discussion so far. I get more of an insight into you, your background, your surgery center. When you look ahead to the future, what are you most excited about? I am most obviously, this is gonna be a little selfish of me. I'm most excited about the work we're doing at the Navy Yard and the work I'm doing with the liposomal bupivacaine. I've come up with a formulation, on my own, believe it or not. And, what we're getting the results we're getting, with these with this formulation is astounding to say the least. We have 3 papers that are in the process of of of we're we have 3 studies that we are in the process of, getting to to journals. The first one is on ACL repair. The second one is on foot and ankle, and the third one is on shoulder surgery. But I've used this formulation of mine on clavicle fractures, on elbow surgeries, on hip surgeries, and the results we're getting are tremendous. Let me circle back and say we are on the cusp of announcing 0 to minimal narcotic use outpatient ambulatory orthopedic surgery. We're doing cases for the foot and ankle, Achilles tendon rupture repairs, trimalleolar, bimalleolar ankle fractures, Liz Frank Liz Frank fractures of the foot, and our patients are taking 0 narcotics. We're getting upwards of 10 days of numbness from my nerve blocks. This formulation, I think, has the potential to change the face of outpatient ambulatory orthopedic surgery. For ACL repairs, I'm getting approximately 5 to 7 days of pain free nerve nerve blockade. If I can drop names, it was doctor Christopher Dodson who first noticed it. I actually sort of snuck in this formulation without telling any of the surgeons. I did my own little research, and I just started doing what I wanted to do, so to speak, despite the fact that liposomal bupivacaine comes with a couple of, caveats that you're not supposed to mix it with anything. But suffice it to say, that I took the extra step there in faith and myself and, my skills, and I did, take mix it with something, and, that will be revealed in the studies, obviously. But, the bottom line was, about 6, 7 months into it, doctor Dodson pulled me aside, and he said, what's going on, Arman? And I said, I don't know what you're talking about, Chris. And he said, well, all of my physician assistants and all of my physical therapists are coming up to me and not telling me that the patients aren't using their narcotics. They're going through rehab without complaining of too much pain and without taking narcotics pre and post. I haven't changed my surgical technique, Armin, so it's you. What are you doing differently? And that's when I had to confess to him, that, I had come up with this formulation with liposomal bupivacaine, and he was shaking his head, and he said, Armin, this is a game changer. We need to publish this. We need to get studies done. This has to get out there. We need to we need to broadcast this to the rest of the, ambulatory orthopedic community and the sports community as well. This is a game changer, he said. So, encouraged by his, kind words, I went we went ahead and we got IRB approval from, Jefferson Health System. And like I said, we have these 3 studies. The first step will be published is the ACL study. I believe the second will be the foot and ankle study, and then we'll have the shoulder study to compare. As just an anecdotal, if I can continue? Yeah. Absolutely. As an anecdotal example, I have dinner with, my, friends from Einstein. I have, close friends from there, 2 cRNA friends, and I was bragging to them about my results. And one of my friends, George, he started tearing up, and he said, Armin, I've been putting off my knee replacement surgery for 2 years now. I'm so scared of the rehab and the pain involved. Would you be able to do this for me? And I this is my buddy. So I I said, look. Well, let's try. Let's try ahead. And so we talked to doctor Matt Austin at, at that time, he was at the Rothman Orthopedic Specialty Hospital doing knee replacements. I believe he's at the hospital for special surgery now in New York City. But, I told him my plan. I made my request. He, graciously approved. And so George went ahead with his knee replacement. I did his spinal. I did his, nerve blocks with the liposomal bupivacaine formulation that I come came up with. And, Alan, he went through his knee replacement. They put him back to rehab the very day that very day. He I followed up with him every day for 25 days, texting him constantly, calling him. He took 0 narcotics after his total knee replacement. So this is not just for the ambulatory surgeries we do at the Navy Yard. This, I think, can have long reaching effects for, replace joint replacement surgeries as well. Now granted, that's just one patient, but the results were so glaringly obvious that I think it's going to make a difference. And then we'll have to study that as well, publish a study on that. Perhaps not myself, someone else might be able to do that because we don't do joint replacement. But I think this is a very this is what I'm most excited about. Well, I'm I'm so glad that you took the opportunity to to toot your own horn there. I mean, so so very well deserved and fascinating to hear about all the excellent work that you're doing, that your team is doing. 0 to minimal narcotic use for some of these outpace outpatient orthopedic procedures. And no doubt the patients are reaping the benefits there as well. I'd love if you could share those studies with us when they inevitably do get published. We'd love to publish them and cover them also on Becker's. Armit, a real pleasure to have you on the podcast today. Fascinating discussion. Congratulations on everything you achieved and really, really, all the best for the future as well. Thank you so much. Alan, thank you very much. And and I wanna focus on one last thing that you just said there. It's a team effort. This is not something I could do by myself. There's so many people that are involved in supporting us in what we do at the Navy Yard. Everybody from environmental services to our surgeons to our administrators and most of all, of course, our nurses and nurse anesthetists. It's a team effort. Nobody is no one individual is more important than any other individual. So and again, thank you for the opportunity for speaking with me and, getting this information out there. Thank you. My pleasure. Thank you so much, Aaron.