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Hand clinic at DGMC is patient-centered

Image of the skeletal structure of a patient’s hand displayed on the monitor of a mobile X-ray machine, Aug. 22, 2017, at the Orthopedic Hand Clinic, David Grant U.S. Air Force Medical Center, Travis Air force Base. Calif.  DGMC's Orthopedic and Podiatry Clinics are comprised of dedicated and compassionate professionals who specialize in the comprehensive care of patients with bone and joint disorders of the extremities. (U.S. Air Force photo/ Heide Couch)

Image of the skeletal structure of a patient’s hand displayed on the monitor of a mobile X-ray machine, Aug. 22, 2017, at the Orthopedic Hand Clinic, David Grant U.S. Air Force Medical Center, Travis Air force Base. Calif. DGMC's Orthopedic and Podiatry Clinics are comprised of dedicated and compassionate professionals who specialize in the comprehensive care of patients with bone and joint disorders of the extremities. (U.S. Air Force photo/ Heide Couch)

Lt. Col Dana Hess, a surgeon with the 60th Surgical Operations Squadron, David Grant U.S. Air Force Medical Center, examines the hand of Senior Airman Jeremy Perkins, a C-17 Globemaster aircraft crew chief with the 860th Aircraft Maintenance Squadron, Aug. 22, 2017. Perkins injured a tendon in his left wrist in 2013 while pushing an electrical power unit. He had surgery in May to remove the affected portions of the tendon and to shrink the surrounding ligaments. (U.S. Air Force photo/ Heide Couch)

Lt. Col Dana Hess, a surgeon with the 60th Surgical Operations Squadron, David Grant U.S. Air Force Medical Center, examines the hand of Senior Airman Jeremy Perkins, a C-17 Globemaster aircraft crew chief with the 860th Aircraft Maintenance Squadron, Aug. 22, 2017. Perkins injured a tendon in his left wrist in 2013 while pushing an electrical power unit. He had surgery in May to remove the affected portions of the tendon and to shrink the surrounding ligaments. (U.S. Air Force photo/ Heide Couch)

Lt. Col Dana Hess (left), a surgeon with the 60th Surgical Operations Squadron, David Grant U.S. Air Force Medical Center, conducts a right ulna resection arthroscopy on a patient, Aug. 31, 2017, Travis Air Force Base, Calif. Responsible for assisting Hess during the operation, Staff. Sgt. Scot Butler (right) and Airmen Alyssa Avelino (center), 60 SGCS, surgical service specialists, ensure that the procedure goes as smoothly as possible.(U.S. Air Force photo/ Heide Couch)

Lt. Col Dana Hess (left), a surgeon with the 60th Surgical Operations Squadron, David Grant U.S. Air Force Medical Center, conducts a right ulna resection arthroscopy on a patient, Aug. 31, 2017, Travis Air Force Base, Calif. Responsible for assisting Hess during the operation, Staff. Sgt. Scot Butler (right) and Airmen Alyssa Avelino (center), 60 SGCS, surgical service specialists, ensure that the procedure goes as smoothly as possible.(U.S. Air Force photo/ Heide Couch)

TRAVIS AIR FORCE BASE, Calif. – “When a patient comes in to see family medicine, family medicine may order X-rays and (laboratory tests) and then they may want the patient to go for therapy. The patient is running all over the hospital trying to find out where to go.  Instead, we bring everyone to the patient."   

The scenario Lt. Col. (Dr.) Dana Hess, 60th Medical Group orthopedic surgeon, described is the reason he started a Tuesday morning “hand clinic” for his surgical patients at the David Grant USAF Medical Center at Travis Air Force Base, California.

“Instead of the patient running all over the hospital, we bring everyone to the patient,” said Hess.

The team includes occupational therapists, orthopedic technicians and dual-qualified occupational and physical therapy technicians.

“Occasionally, I'll have a resident from family medicine who wants to do rotations and learn about orthopedics," said Hess.

While completing a fellowship at the Philadelphia Hand Clinic in Pennsylvania, Hess realized how much more efficient and effective it was to have services brought to surgical patients, so when he arrived at DGMC three years ago, he started his own patient-centered clinic.

“If the patient needs a brace, I send someone to get it,” said Hess. “If they need an X-ray, injection or impression, we can do that in the clinic.”

Hess is one of seven orthopedic surgeons at DGMC but the only one who operates on hands.  He also performs surgeries on wrists, arms and shoulders – “the areas needed for everyday living,” he said.

His patients range in age from infants to a 97-year old rancher who lost sensitivity in one hand. 

Hess performs eight to 10 surgeries each week – not including those resulting from on-call cases or those referred by family medicine – and brings most patients in for follow-up treatment and therapy five days later.  Patients with nerve or tendon repairs are seen the next day, he said.

Since patients see him so soon after a procedure, Hess does not give them a lot of post-operation instructions.

“If the patient is not fully awake, that’s a barrier to communication,” said Hess.  “I think they appreciate knowing they can go home, rest and recover.  It’s all about the patient.”

This arrangement also benefits the occupational therapists. 

“Nothing is lost to interpretation,” said Hess. “Everything is done face-to-face so they don't have to guess what I need, make something up or read a book.” 

It is common for some surgeons not to see their patients for two weeks after surgery.

“That means the patient has to stay in the post-surgical dressing, which gets itchy and uncomfortable,” said Maj. Laura Dorsett, an occupational therapist who worked closely with Hess before being reassigned earlier this year to Spangdahlem Air Base, Germany. “Our patients are happy to be seen so quickly. We have about 99 percent positive feedback and people come from all over the hospital to see how we do it. I briefed this at our occupational and physical therapy symposium last year and several bases have implemented similar programs.”

Some of the most common reasons for surgery at Travis include nerve and tendon lacerations, fractures in the hands, wrists and elbow and trigger finger, which is caused by repeated movement or force use of the finger and thumb, rheumatoid arthritis, gout and diabetes. 

“From the short time I’ve been here, I’ve seen him perform carpal tunnel surgery on a patient and, while in there, he’s seen something else wrong and repaired it, too, so the patient didn’t have to return for another surgery,” said 1st Lt. Andrew Antonio, 60th Medical Operations Squadron occupational therapy element chief.       

Hess invites the therapist and technicians to view surgeries, which improves their ability to help patients recover.

“I can answer questions for patients who ask ‘why does this feel like this?’” said Dorsett.  “I can tell them, Dr.  Hess had to do X, Y and Z, which is why this is happening.”

Prior to surgery, Hess meets with patients to explain their procedure. 

“I tell them what I’m going to do, what my back-up plans are and what to expect in post (operation)," said Hess.

Some procedures are difficult to imagine, so Hess draws pictures. He also uses his computer and teaching photos to explain what he plans to do to correct a problem.   

Patients visit the hand clinic about three to 12 times, based on how they are healing. 

The mood in the pre-operation appointment and in the post-operation clinic is light as Hess jokes with patients. 

“I try to put everyone at ease,” said Hess. “If I’m operating on you, I need you to be comfortable with me as a person and as a surgeon.”

Hess also takes on challenges that other surgeons have passed on. 

“We had a chief master sergeant who had been told nothing could be done for his hand,” said Dorsett.  “Dr. Hess examined him and said, ‘Yeah, I think I can do that.’  He came to me and said, ‘I need this and this’ and we figured it out.”

Of course, not every outcome is equally successful. 

In 2013, Senior Airman Jeremy Perkins, 860th Aircraft Maintenance Squadron C-17 Globemaster III crew chief, suffered a ruptured tendon in his right wrist while pushing an electrical power unit.

“I felt the pull through my whole arm but there was no pain,” said Perkins.

With the aid of several steroid shots, Perkins worked despite the pain until May when he had surgery to remove the tendon.

Three months later, Perkins is “further along than average," said Hess. 

“His wrist will be tighter than before and his wrist won’t be as strong, but it will be functionally strong,” said Hess.  “He may not be able to do the pushups that the Air Force requires, but he will be able to do his job.  He will have a new normal.”