American Medicine: I survived the death knell thanks to the devil.

Chapter 91 Value Integrals

"Doctor, the surgery is too expensive—"

The daughter's English was heavily accented, and she gripped her mother's healthy left hand tightly, her knuckles turning white.

Lynn reached out and lifted the old lady's right forearm, slowly palpating along the distal radius fracture line with her fingertips.

The back is angled at about 30 degrees, presenting a typical "fork-like" deformity, with the wrist pointing towards the back of the hand like a fork.

A radius shortening of less than four millimeters means that the bone has not undergone severe compression or collapse.

Most importantly, the fracture line is completely outside the joint surface, and the cartilage surface is smooth and intact, without any step-like feel.

A typical Reye's fracture in joint surgery.

Absolute indications for conservative treatment.

"Conservative treatment is sufficient; surgery is not necessary."

The daughter stared blankly, her mouth agape.

"Local anesthesia, manual reduction, 20 minutes. Then plaster cast immobilization for six weeks, with regular X-ray follow-ups. The total bill can be kept under 400 yuan."

The old lady couldn't understand the complicated English vocabulary, but she understood the tears that welled up in her daughter's eyes in an instant.

Lynn drew 10 milliliters of 1% lidocaine with a syringe and, under the guidance of X-ray fluoroscopy, precisely inserted the needle tip into the hematoma cavity at the fracture site.

After a fracture, the broken ends will form a closed cavity filled with blood clots. Administering anesthetic directly into this hematoma cavity can precisely paralyze the nerve endings on the periosteum.

Hematoma blockade anesthesia.

The cheapest and most direct pain relief solution.

While waiting for the medication to take effect, he instructed the nurse to prepare a plaster cast and a bucket of warm water.

"Bone friction can produce a slight cracking sound, relax."

Lynn pressed his thumbs against the fractured fragments on the dorsal side of the distal radius.

To exert force, we must do the opposite, first exacerbating the deformity.

Briefly push the fractured ends dorsally to forcibly loosen the bone cortex that is stuck together.

Only by removing the embedded bone can the bone be realigned.

A subtle bone-grinding sensation came from my fingertip as two misaligned gears disengaged.

Immediately afterwards, pressure was applied to the palm side under continuous traction.

The thumb steadily pushes the fractured bone fragment back into place towards the palm.

A very faint muffled thud.

Fracture reduction.

The entire process took only ten seconds.

X-ray after reduction showed: radial tilt angle of 22 degrees, palmar tilt angle restored to 11 degrees, and radial length fully restored.

The biomechanical structure of the wrist joint is back on track.

The old lady trembled as she grasped Lynn's fingers with her healthy left hand, repeatedly saying "thank you" in Spanish.

Lynn gently patted the back of her hand.

"Remove the cast in six weeks. Clench and fully extend your fingers into a fist at least two hundred times a day. Muscle contraction promotes venous return and reduces swelling, while also preventing tendons from sticking together in the cast. Follow the instructions strictly."

Medical record settlement system entry: Operation code 25605, closed reset, with manual operation.

Workload relative value score: 3.62.

As the mother and daughter left the consultation room, the daughter turned around and bowed deeply.

Lynn was already flipping through the next medical record.

Patient number seven.

Sean Hartley, a 41-year-old white male.

A handcrafted camel hair coat with platinum cufflinks.

The Patek Philippe watch on his wrist was worth five hundred times the price of the plastic waiting chair he was sitting on.

The right wrist is immobilized in a cast, and the referral slip comes from a top private orthopedic clinic on the Upper East Side.

The reason for the referral was stated very vaguely: the patient requested a second opinion.

Translated into plain language:

The private clinic's approach was too conservative, and this gentleman, being extremely picky, came to the Metropolitan Hospital seeking a more radical medical intervention.

Lynn plugged the video footage into the viewing lamp.

Fracture of the distal radius on the right side.

The dorsal angle is 20 degrees, the radius is shortened by 3 millimeters, and the articular surface has a step-like feel that is just at the edge of 2 millimeters.

-

This is a classic gray area.

The private clinic's proposed treatment plan: closed reduction and plaster cast immobilization for six weeks.

From a purely medical perspective, this is an extremely reasonable and conservative choice.

Lynn turned to look at Hartley.

"Dr. Lin, Dr. Brian said conservative treatment is sufficient. But I have a very important sailing race in September, and I need to be 100% recovered. This hand must be able to grip the rope tightly."

Sailing race.

Lynn picked up the pen flashlight and examined the X-ray from a different angle.

The joint surface has a step-like feel of two millimeters.

The fracture line split into the joint cavity, causing a two-millimeter difference in height on the originally smooth cartilage surface.

This is right on the threshold for surgical indications.

He turned off the flashlight and said cautiously, "Mr. Hartley, judging from the imaging, your step-off sensation at the joint surfaces is at a critical level. Conservative treatment is more than sufficient for daily life. However, you mentioned high-intensity wrist exercises."

Lynn remained silent for a few seconds, allowing the information to fully develop in the other person's mind.

"If secondary displacement occurs in a fracture while it is in a cast, there is a high probability that one to two millimeters of unevenness will remain on the joint surface after healing."

"It is sufficient for daily use, but when dealing with high-load pronation and supination movements, such as manipulating the sail, long-term stress will accelerate the wear and tear of the wrist joint cartilage."

"These tiny frictions can develop into traumatic arthritis after five or ten years, causing chronic pain."

Every word is true.

He merely selectively amplified low-probability risks, legitimately pushing a case that could have been treated conservatively into the gray area of ​​surgery.

Hartley frowned. "What's your suggestion?"

"To achieve the best functional recovery, I recommend open reduction and locking plate fixation. The skin is cut open, and the joint surfaces are aligned perfectly. The screws locking the plate will lock into place, forming an extremely robust internal support."

"You don't need a cast at all. You can start early activities a few days after the surgery, begin progressive strength training at ten weeks, and return to sailing after six months."

"cost?"

"Are you using the UnitedHealth Preferred Network Platinum Plan?"

Lynn glanced at the insurance information on the cover of the medical record.

"right."

"The total bill for surgery, anesthesia, implanted supplies, and hospitalization is approximately $32,000."

"Your plan has a 10% co-payment rate, which is about $3,200. Post-operative physical therapy will be once a week for 12 weeks, with a co-payment of $20 to $40 per session."

Three thousand two hundred dollars.

For someone who wears a Patek Philippe, it's simply the price of opening a bottle of red wine at a Michelin-starred restaurant on the weekend.

"Arrange the surgery," Hartley said decisively.

Lynn filled out the surgery application form neatly.

Operation code 25609, open reduction and internal fixation of distal radius fracture, intra-articular type.

Workload relative value score: 14.35.

This is a set of workload measurement standards established by Medicare in the United States. The higher the score, the more compensation doctors and hospitals receive.

Dr. Murray, the attending physician in the department, signed his name in the supervision section of the application form.

Since that incident, he has never questioned Lynn's surgical plans.

Including the preoperative high-level outpatient assessment and all follow-ups during the 90-day global period after surgery, the performance points contributed by this one patient are equivalent to those of several elderly Mexican women.

The real difference is that Hartley's commercial insurance will cover the huge hospital bills in full.

The $400 emergency medical bill for the elderly Mexican woman will most likely become a bad debt on the public hospital's financial statements.

The underlying logic is extremely clear:

Patients whose medical insurance is paid for always deserve "more aggressive treatment options".

Lynn closed the medical record folder and pressed the call bell again.