Will my insurance pay?

I have a Sirius radio in my car. The other day, I was listening to the plastic surgery show on Doctor Radio as I was driving on a road trip. Throughout the course of the show, people kept calling to ask about different procedures. The most common question was, "Will my insurance pay for this?"

Although I don't advocate that insurance cover cosmetic surgery, the question gave me an idea.

I have been working on my fitness levels, and I have started working out. When I decided to do this, I thought that I would just buy a workout video (I bought the Power 90 workout by Beach Body) and would go to town. Unfortunately, it's not that easy. This is an intense workout series and there is more expense than just the videos. At any rate, as part of my preventative health care, I think that I should be able to use my insurance premium to pay for a gym membership or hire a trainer to get me going. I don't go to the doctor very often, if ever at all, outside of perhaps a yearly exam and annual vision screening. This would be an excellent way to utilize all of the money that I poor into the insurance company's bottom line.

Obesity is becoming an epidemic in our country. A quick Google search showed this CDC website on obesity. The graph animation on the website is an interesting visual to show how quickly obesity in our country is spreading. Perhaps this would be a way to help lower the cost of health care overall...

Pelvic Fractures, Pt. 2

Here is the finish to the post on pelvic fractures. In my previous post, I discussed some basics to pelvic anatomy and the anterior-posterior patterns (D - F in the figure below) of fracture in the pelvis. In this post, I will briefly describe the lateral compression patterns (A - C) of pelvic fractures and then also discuss the vertical sheer pattern (G).

Also, worth review in this post is the importance of identifying pelvic fractures early in the trauma evaluation. This is one injury that orthopaedic surgeons that treat which is truly life threatening. Early identification of these injuries can save lives in the trauma bay. It is always rewarding to get called to a trauma, look at an AP pelvis and note a pelvic fracture, and then go into the trauma bay to see that the patient is hypotensive and tachycardic, put a binder on the pelvis and watch the heart rate decrease and the patient become more normotensive. Closing that pelvic space is something that must be done ASAP because it can make a huge difference in the hemodynamic status of the patient.


There are three types of lateral compression (LC) fractures in the Young-Burgess Classification. These injuries occur due to a compressive force on the lateral side of the body. The type of injury seen depends on where the force is applied. In this type of injury, the ligaments responsible for pelvic stability become shortened. Pubic ramus fractures often accompany LC fractures and can be on the ipsilateral or contralateral side.

LC I - This injury pattern results in compression of the sacrum. This injury pattern is often associated with transverse pubic ramus fractures.
LC II - In this injury pattern, a posterior iliac wing fracture is noted. Depending on the amount of disruption to the posterior ligamentous structures, varying amounts of instability will be noted. This injury pattern, however, is a stable pattern of injury in the vertical plane.
LC III - This is the so-called windswept pelvis. In this pattern, either an LC I or LC II injury pattern is noted, but the force transmitted by the lateral compression results in an APC injury on the contralateral side. Of note, this injury pattern is especially vulnerable to circulatory damage and hemorrhagic shock.

Treatment of LC pelvic injuries is similar to those of APC type injuries. Treatment is selected based on the stability of the injury In general, non-operative treatment can be selected for patients with <1.5cm of displacement of the posterior ring or ramus fractures with no posterior displacement. Gross displacement of hemodynamic instability can necessitate more aggressive treatment ranging from angiography and coiling of arterial lesions to operative fixation.

Vertical Sheer (VS) injuries are the result of a vertically applied force due to a fall on an outstretched extremity. This injury results in disruption of the symphysis and the posterior ligaments. This is a very unstable injury pattern and often results in cephaloposterior displacement of the pelvis. VS injuries are often associated with vascular compromise and hemodynamic instability. Operative fixation will likely be required to close down the sympyseal diastasis and the posterior ring in addition to aggressive resuscitation to maintain perfusion of vital organs.

These injury patterns do not often occur as a single entity. Combination type injuries are possible.

As I mentioned in the previous post, it is important to be cognizant of DVT prophylaxis in the setting of a pelvic injury. Other injury associations include bladder and urethral injuries in men. Because of this , it is important to send urine to look for red blood cells which might indicate damage to the urinary system. If a urethral injury is present, the patient will need intervention ranging from a Foley catheter and observation to operative repair.

In the next post, we'll take a look at acetabular fractures, their classification, and discuss a little bit on their treatment.

Wrong Mindset

I was doing my daily read through the web, and I found this story on MSNBC. The story is questioning the use of helicopters to transport patients. The author of the story points out that this service is very expensive and that insurance companies will only usually cover part, if any, of the 8 - 25 thousand dollar cost of the flight.

In explaining the high cost of a helicopter transport, Craig Yale, the head of a company that specializes in helicopter transport tries to explain the soaring costs of this questionably overused service. For one, Mr. Yale states that the service requires an enhanced state of readiness, which is expensive. In addition, the cost of equipment drives up the bill, not to mention the highly specialized staff who work in very challenging environments.

I'm okay with those reasons, but one additional statement that he makes in defense of the high cost I found to be ridiculous. "If a given flight costs $7,000, an ambulance operator has to charge $14,000 to make up for people who don’t pay, discounts for Medicare and Medicaid and reluctant insurers, Yale said."

I have to say this excuse to charge more money in the health care industry makes my blood boil. How is it that we've gotten to the point where we just accept the fact that we can overcharge the crap out of people to make a profit and blame the problem on people who cannot afford to pay their bills.

Another quote by an EM physician in California who runs a billing company for air transport professionals exemplifies this. “We’ve got to collect enough money for the service, or the service goes out of business.” The article goes on to quote that this physicians company managed 500 million dollars in revenue in 2008 and 20 million in net income. I'm no expert in finance, but it doesn't sound like this company is struggling to keep the lights on.

Let's look at another example. I went on the web to find the annual report for a mega conglomerate of hospitals, Ascension Health. This corporation had revenues of $407 million. They had a net loss of $710 million in 2009, but this was due to losses that came from a poor market. In 2008, $512 million in revenue led to $356 million dollars in income. In FY 2009, the company lists over $800 million in uncompensated care. Imagine what the profit would be if everyone was paying their over-inflated bills.

I tell this story to say this - the health care industry is NOT hurting for money! Hospitals continue to build, even in this poor economy, and they aren't building double rooms with standard definition televisions. They are building private rooms with flat screen televisions, staffing the cafeteria with chefs and treating putting in applications for Michelin stars.

I'm not saying that making money is inappropriate, but I do think that it would be worthwhile to change the mindset of our industry. Maybe it's time to find a way to focus on providing quality care at reasonable prices to as many people as possible.

Pelvic Fractures

As I promised in a previous post, here is a post on pelvic fractures. It will probably take two or three posts to do the topic some justice.

The pelvic bone is made up of two innominate bones, each made of three separate bones that ossify to become one - the ilium, ischium, and pubis. These bones form a ring and connect posteriorly at the sacrum to form the sacroiliac (SI) joint. Anteriorly is the pubic symphysis. It is important to understand this pelvis as a ring concept, because when fractures occur in the pelvis, the often occur in pairs, as it is impossible to break a solid ring in only one place. The classic comparison is to think about a pretzel. Next time your eating lunch, give it a try.

Pelvic fractures are difficult to diagnose because there is not always an obvious sign of an injury, and can be life threatening if not diagnosed quickly. It is important to have a high index of suspicion if the mechanism of injury is blunt trauma. This is the main reason that the AP pelvis is included in the trauma evaluation with the AP chest. For more on reading an AP pelvis, see one of my previous posts.

There are two common injury patters in high energy pelvic fractures: the anterior-posterior compression injury and the lateral compression type injuries. There can also be vertical sheer injuries and combination type injuries.

In this post, I will discuss the APC type injury (D-F in the image below), and will cover the lateral compression and vertical sheer injuries (A-C, G in the image below) in the next post. The image below is a depiction of the Young-Burgess classification system, the most common classification of pelvic ring injuries. Other classification systems (which I will not discuss) include the Tile and OTA classification systems.


On initial AP pelvis evaluation, APC injuries are suggested with widening or diastasis of the symphysis pubis or in the setting of vertical fractures through the rami. On an adequate AP pelvis, there should be no more than 4-5mm (may be up to 9mm in the setting of pregnancy) between the right and left innominate bones at the symphysis pubis. This injury should always be considered in the case of hemodynamic instability with no other obvious etiology. In order to completely understand the pathology of pelvic fractures, we need to first discuss pelvic ligaments.


In considering pelvic stability, there are five main stabilizing ligaments to consider: the symphysis, the sacrospinus ligament, the sacrotuberous ligament and the anterior and posterior sacroiliac ligaments. This ligament complex is quite strong, hence the high energy trauma required to disrupt them. Rotational stability is provided to the pelvis by the short posterior sacroiliac, the anterior sacroiliac, iliolumbar and sacrospinous ligaments. Vertical stability is provided to the pelvis by the long posterior sacroiliac, sacrotuberous and lateral lumbosacral ligaments.

APC I - In this injury pattern, the symphsis pubis is less than 2.5cm and vertical fractures of the rami may be noted on the APC pelvis. The posterior ligaments are intact.
APC II - In this injury pattern, there is greater than 2.5cm of diastasis of the pubic symphysis. This results from disruption of the ligaments that stabilize the symphysis. One may also note widening of the SI joint due to disruption of the sacrotuberous and sacrospinous ligaments. This is the classic open-book injury. While rotational instability is noted in this injury pattern, there is no vertical instability in this injury pattern.
APC III - In this injury pattern, there is complete disruption of the stabilizing ligaments, including the symphysis, sacrotuberous, sacrospinous and sacroiliac ligaments. This is a very unstable injury pattern and is the pattern most often associated with neurovascular injury.

As stated earlier, in the appropriate setting, it is important to have a high index of suspicion for this injury. Given that this is an injury that should never be missed with potential serious morbidity and even mortality, I have been taught by my seniors to make a habit of looking at the AP pelvis before entering the trauma bay. When these injuries are identified, they should be taken seriously and addressed promptly. Fluid resuscitation should be started, especially in the setting of hemodynamic instability, and blood products should be readily available. One of the easiest ways to stabilize APC type injuries (and often have a noticeable impact on vital signs) is to use a standard sheet folded and then wrapped around the pelvis at the level of the trochanters. The sheet can be fixed anteriorly with some Kocher clamps. There are commercially available products as well.

Treatment of these injuries depends on the pattern of injury and the hemodynamic status of the patient. In the setting of hemodynamic instability, a combination of external fixation and intravascular intervention can be used to correct vital signs emergently. Bleeding can be venous or arterial. Depending on the injury pattern, up to 15 units of blood may be needed to replace losses. There is a good recent article in the JAAOS detailing treatment of pelvic fractures in the setting of hemodynamic instability.

Once the patient has been stabilized and other life threatening injuries have been addressed, these injuries can be stabilized internally with plates and screws. Anterior injury patterns can be treated with external fixation alone but posterior injuries require internal fixation.

A note about coagulopathy. In the setting of pelvic fractures, venous thrombus formation is common. Because of this, anticoagulation is essential to prevent embolism and potentially life-threatening complications. At our center, we anticoagulate patients for 6 weeks after their fixation. When anticoagulation is not possible, prompt placement of an IVC filter is essential.

Sources for this article include Handbook of Fractures by Koval and the AAOS Comprehensive Orthopaedic Review. Images were taken from the AAOS Comprehensive Review.