Transcript: Interview with an Orthopedic Nurse Practitioner

​Liz Rohr:
Well, hey there. It's Liz Rohr from Real World NP. You are watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. You are in free treat this week. This episode is a recorded interview that I did with Yessica who is an orthopedic nurse practitioner. We gathered questions from the audience. So, if you want to participate in that process, definitely join us on the email list, which I'll link to down below. You can submit your questions as well, but basically, what we talked about are the main burning questions of primary care providers for an orthopedic specialist.

So, what are the main pitfalls that you see from primary care providers and what to avoid? We talked about imaging and ordering imaging in the right way. We talked about treatment. We talked about how she became an orthopedic nurse practitioner. I know a lot of people are interested in going into that field. We talked about so, so many things and we could have talked for hours. She is a wealth of knowledge, so I really hope you enjoy this episode. Without further ado, I'm going to share my interview with Yessica. Awesome. Thank you so much for being here. Can you introduce yourself?

Yessica Salazar:
Of course. Actually, it's my pleasure to be here. I'm a big fan of everything that you've been doing lately for all these nurse practitioners that I think are benefiting so much and I appreciate very much what you've been doing. But I'm Yessica Salazar. I created NP Insiders and I basically did that because I see a need for clinicians, nurse practitioners especially, to learn a little bit more about orthopedics. We see so many orthopedic patients in primary care, in the urgent care setting, in the emergency room. A lot of these patients go to these places looking for nurse practitioners and clinicians that can help them relieve their pain and that is mainly their goal.

I was looking at some of the data from the literature and I found out that about 213 billion healthcare dollars are spent every year on these patients. The back pain, the shoulder pain, and the knee pain, and then we also have all these patients getting older and older. We have to learn how to properly manage them and how to treat them. Not always the answer is a referral. There's a lot that we can do in primary care to take care of them.

Liz Rohr:
Totally. So, you are a primary care or an orthopedic NP?

Yessica Salazar:
So I'm an orthopedic nurse practitioner, but I'm board certified in orthopedics and I am board certified as a family nurse practitioner. I do work also in the walking clinic where the majority of the patients that come in have orthopedic conditions. So, I see a lot of the back pain, the shoulder pain, the knee pain, recently the elbow pain, which is not so much elbow. A lot of epicondylitis. Then, unfortunately, they have been given things that perhaps don't really work properly and I've been so glad to be able to help them in those terms.

Liz Rohr:
How long have you been working in orthopedics for?

Yessica Salazar:
So, orthopedics landed on my lap. I remember graduating from NP school. All my experience from graduating actually back when I was a nurse was in ICU and then I did family and then I graduated. Then I had a three jobs. I had a job, I think, it was at an urgent care, like walking clinic. I had a job at a plastic surgeon office and then there was this job at the orthopedics department at a university. The lowest paid was the one I chose. It was the orthopedic job. I think that the reason that I chose it was more of a strategic decision rather than, "Oh, my God. I've always wanted to do this," because from my interviews, I felt that I was going to learn so much more from this opportunity. I think that was the right decision.

I was trained alongside the residents. I was trained by world-renowned orthopedic surgeons and they really supported my growth. I mean, the first year was really hard, because in NP school, as you know, you don't get a lot of orthopedic experience. I mean we're very good and we hammer down the heart stuff and the lungs and the kidneys and the diabetes. But then musculoskeletal is like, "Yeah, yeah, they have pain, but that's not like life-threatening." These are the things that you need to know.

So, to land a position right out of school in orthopedics was a big challenge, but I said to myself, "Okay, I'm ready and I think that I'm going to be able to learn the most out of this opportunity." One of the things that I was thinking earlier today is at least for me, I like to be the engineer or the architect of my career. I think that as NP, sometimes we marry with a certain specialty or what have you and we don't see the trees for the forest or the forest for the trees. I can't remember the right way to say it.

Liz Rohr:
Either.

Yessica Salazar:
But that is so true. Because I opened my eyes, my mind and I just took the plunge, this has led to so many opportunities. I've been able all these years to first assist. I love that. Unfortunately, recently when you work at a university level or university hospital-based, there are a lot of residents. So, you don't get to do a lot of the hands-on things, which I'm trying to do more on the outside. That's something that I also have in the works, right? Because I'm a first assist, but I'm also getting the actual certification. I think I mentioned that earlier to you off camera that unfortunately, from nurses, we are asked so much to show for. Okay.

Well, if you're an NP, you have to be either family or acute or you have to this specialty and you have to have this certification board and you have to have this other certificate. If you don't have that, then you cannot do that. Then we see other healthcare providers that are not asked for as many things as we are and whatever. It is what it is, but I continue to grow and to invest in my knowledge. I think that as nurse practitioners, we have to do this to be able to get to where we want to get to. It is possible.

Liz Rohr:
So, we asked some questions. Well, questions the audience had for you as an orthopedic NP, and one of the questions on that topic was how you came into it. Did you find a job, apply? Did you know a person? Did you do a fellowship? Did they just happen to train you because that's just the culture of orthopedics? Do you know what I mean? Was there any formal fellowship or residency program that you did?

Yessica Salazar:
So, I think no, no, no.

Liz Rohr:
Just went for it.

Yessica Salazar:
I get this a lot, right? My experience was very different. I went into the interview and I did do a lot of research before I went into the interview. I knew a lot of diagnoses when I went to the interview. So, I was clinically ready to answer orthopedic-related diagnoses questions. I think that [inaudible 00:07:57] them during that interview that even though I was a family nurse practitioner with relatively zero experience in orthopedics, I had that desire and I read an entire book. It was about a thousand pages of orthopedics. I'm very intense when I wanted something.

Liz Rohr:
Woman after my own heart. I love that.

Yessica Salazar:
So, they saw that initiative and they saw that desire. I think that that's what won them over during the interview. They also noticed that I had ICU experience and the word around the block is that ICU nurses love to learn and they're very focused and demand a lot from themselves and give a lot of themselves. So, I don't know if that helped them to make the decision and to hire me, but I think that I want to believe it did. Then the interview just went really well. I had three rounds of interview. I was interviewed by a CFO first and then I was interviewed by the clinical manager and then I was also interviewed by a panel of surgeons.

Liz Rohr:
Oh, my gosh. Wow.

Yessica Salazar:
That was very intense. Then I was interviewed again by the same surgeons because they really wanted to go with me, but they wanted to make sure that I was the right fit.

Liz Rohr:
Yes, for sure.

Yessica Salazar:
So that was the final interview.

Liz Rohr:
That's awesome.

Yessica Salazar:
But that's how I landed that position. One thing I want to say to nurse practitioners, do not be turned off if you see a job posting that says you need three years of experience in this specialty or that specialty. My personal life real experience is that that job said that you needed three years of orthopedic experience and I had zero.

Liz Rohr:
Yeah, totally.

Yessica Salazar:
So it really comes down to wanting to do and wanting to be prepared and then just happening to be in the right place at the right time and then the opportunity lands on your lap.

Liz Rohr:
That's awesome. That's so awesome. So, some of the other questions, you and I could talk for a very long time. So, we're going to try to narrow it in and we have talked for a very long time about this, but I think it's so hard to pick. All of the questions that people had were so good. I think it could be hours if we wanted to talk about all of them. So, we're going to try to focus in. I think the main theme of the questions were a couple things.

I think the general theme of what I'm trying to convey in these interviews is, "What do specialists wish we knew in primary care?" They're like, "Oh, my God. Another referral that is for this that shouldn't have come to me," those kinds of things. There's no judgment, there's no shame about referring people. I think that our aim here is to help with the educational piece because I think a lot of new grads feel uncomfortable with the amount that they refer anyway, so no judgment on that. Yeah. So, from that perspective, what are some common pitfalls you see of primary care providers sending to orthopedics that shouldn't come to orthopedics, for example?

Yessica Salazar:
So I'm going to preface my answer by it depends. Everything is relative.

Liz Rohr:
Perfect.

Yessica Salazar:
So far, I've been in orthopedics almost, I think, six years. It's going to be six years soon. I've had two different positions in two different hospitals in orthopedics. So, the first one had a different approach. The one that I'm in right now has a more strict approach and they do desire for the patients to be worked up before or prior to referral. Where I was before, it was more a financial-driven specialty. So, they didn't mind seeing whomever. However, there's a caveat. There's a lot of surgeon dissatisfaction when they see 20 patients in one clinic day and only one or two were surgical. They're not really using their specialty and their skills to the top of what they could do if that is the bulk of what they're doing, right?

I'm not a surgeon, but I've worked with plenty of amazing surgeons, but the mindset and this is for all NPs to know the mindset of the surgeon is that they want to do surgery. So, it is awesome if you can get into a relationship with surgeons where you get the patient to do conservative therapies and to exhaust conservative measures before you do that referral. This is very common in osteoarthritis unfortunately. So, you get a lot of, "Yes, I have knee pain." Okay, for how long? For three months and it's like mild. They haven't really tried any conservative treatment and they're coming to a specialist.

If I were a patient, I definitely would like for my primary care provider to know that I'm going to be spending a lot of money going to that specialist and probably not going to get so much out of that visit. So, if I can save that money by doing more of the conservative treatment that are out there that I can do and that I'm interested in doing, then by all means. If I have failed that, then by all means I want to go and see a surgeon.

So, that's something that I do have noticed a lot, but then the other side of the coin is that if as a primary care or urgent care or even emergency provider, you're seeing these patients coming in but you're not very familiar with what to do, then you have no choice but to refer. So, then how do we figure that out? I've been doing a lot of thinking in that. Well, learning more.

Liz Rohr:
Yes. For sure, for sure. I think it's challenging because when I have students and new grads that I'm mentoring, I talk about what is the rationale for referring. Because I think I remember when I was a new grad, especially being so nervous that I just would do something, instead of, "Okay, take a second. What is the rationale for this? Don't panic." Because the main reason to refer is either for diagnostic clarity or for treatment. So, it's not wrong to refer people to orthopedics for diagnostic clarity, but there's so much opportunity for us in primary care to know more stuff so that we can hold onto that sooner.

Yessica Salazar:
One thing too is to have at least your differential diagnoses, right? Unfortunately, and you see this a lot, I am referring because of a symptom. Well, let's try to at least get to a diagnosis. What is this? What are we talking about? Let me bring up the knee, because knee pain is so common in primary care. So, knee pain is a symptom. It is not a diagnosis. So, what is this, right? Is the patient an older patient? Are you thinking more of a degenerative finding? Is this osteoarthritis? Is this a municipal tear? Are we talking about a patient in their 20s, in their 30s?

I do see a lot of clinicians going for the MRI before they even order the x-ray, right? The plain x-ray. Then especially on our older patients in their late 50s or 60s, they come in with MRI and yet they don't have plain films. Well, we should start with the plain films first. Then talking about the plain films, you mentioned some of the questions earlier, but there's a right way of ordering the plain films and we can talk about that.

Liz Rohr:
I was going to say maybe let's segue into imaging because I think that's such a big question. I know for me, my orthopedic knowledge is fair, but I am not an orthopedic NP. I'm a primary care. I try to be a jack of all trades, but it's not as robust as I would like. So, I think for me, I'll just speak from my own personal experience. So, for example, if I have a knee pain, I've done a couple of interviews talking about physical therapy and please don't take offense of this. I think might've already told you this, but I think the general pathway of orthopedics is NSAIDs, physical therapy, injections, and surgery. That tends to be the general arc. I don't know if that's real, but that's like what I've seen in primary care at least.

So, I tend to refer patients to physical therapy, but when it gets to that place, if they have fully engaged in the recommended physical therapy for that full course, no improvement, then I'll refer them to orthopedics. I personally don't love ordering imaging first, because it feels like there's a different request based on the office I send to and maybe that's not real. So, why don't you tell us? I'm sharing that as an anecdote because I think that's a very common experience for people where they're trying to do right by the patient, still are not clear with diagnostic clarity, and then aren't quite sure where to go from there because it seems like sometimes orthopedics will order different imaging or reorder imaging, things like that.

Yessica Salazar:
So orthopedics does that because a patient is basically coming with the wrong images.

Liz Rohr:
I mean not good obviously.

Yessica Salazar:
I think we can save the patient time and money if we get this cleared up. So, I don't know how it works at your clinic or different hospitals work differently, but the main type of films out there for knee pain or for knee x-rays is like a three view or plain three view AP lateral. Unfortunately, that is not the right one. That typically is done mainly in the emergency room when the emergency providers are trying to rule out a fracture and you don't want to get an x-ray on a weight-bearing status. You don't want to get weight-bearing x-rays. You want the patient to be non-weight bearing, so that in case they have a fracture, you're not damaging or giving more harm to the patient.

But the right films to order, now I'll give that to you. There is actually four of them and the first one is the AP. The AP is it has to be weight-bearing. When you order that, you have to stay that and I have to do it all the time even in specialty practice. Standing AP or weight-bearing AP and that is actually the only way that you can visualize the joint space. The practicality of having a weight-bearing AP is so that you can see if there's narrowing of the medial joint line or lateral joint line, if the patient no longer has any cartilage and the knees bone and bone or if there is enough cartilage and this is a benign x-ray. So, when you have enough cartilage, then basically the cartilage doesn't show on the x-ray. You just see a gap.

Fortunately, I know in primary care, a lot of the providers are mainly reading the reports rather than actually visualizing the x-rays. But if you do have some time and you do have the chance, look at the x-rays because you're going to learn so much from them. So, that's one of the views, right? Then you also want to get a weight-bearing flex knee or a PA view, and that's basically from the back of the knee. That way, you don't miss osteoarthritis, but in the back, the posterior aspect. Then you can also get a merchant view. It's also called the sunrise view, and that's basically looking at the knee from the top and looking at the patella-femoral joint. It can guide you into your potential diagnosis, if there's narrowing, how much narrowing there is.

Then if you have narrowing in that merchant or sunrise view, then maybe the patient has some patella femoral syndrome of some sort, especially if the patient says, "I'm having pain walking down the stairs," and then you see a merchant or sunrise view that is narrowing, then that clicks. Then they could also have osteoarthritis of the medial joint line and the lateral joint line. But then you're also, depending on the symptoms and the history that you get, could be leaning more towards the one that is causing most of the symptoms.

Then the last view is the lateral view, but that one doesn't give a lot of information. So, if you don't have to get that one, you don't get that one, but definitely the weight-bearing AP, that's essential. That one is essential. The merchant view, I definitely do recommend it in and the weight-bearing, the posterior interior view. That one is also called the Rosenberg view, but those are the main ones. Otherwise, then you do miss the correct diagnoses.

Liz Rohr:
Totally. Do you ever get x-rays and then you can skip the MRI because you've gotten all of those images?

Yessica Salazar:
Oh, absolutely.

Liz Rohr:
Cool. That's good to know, because maybe this is just the healthcare system, but I feel like sometimes I see that where it's almost like you need an x-ray to buy you an MRI, right? Because the MRI doesn't get approved unless you have something first. So, sometimes it feels like there's going to be an MRI done anyway, so I'm going to let them do the right one, but that's really helpful. That's really great.

Yessica Salazar:
When it comes to imaging, a lot of the times you don't even need that MRI. I think that's why too, they have implemented and put all these things into place, because unless you are completely incapable or unable to diagnose based on clinical symptoms, physical exam, and plain x-ray, then really there's no merit for that MRI. The MRI mainly looks at the soft tissue. So, if you're trying to rule out osteoarthritis or even a fracture, x-rays are the things to get. MRI is more so the clinical picture that I'm thinking when I want an MRI is 20+, 30+ year old who just engaged into trauma or had some injury exercise related sport and then he's complaining of instability of his knee and then he has a big swelling knee.

I can't even do the instability testing, the maneuvers to test for the ACL or MCL because they're in so much pain. Then I do definitely want to get an MRI, so the MRI can look at the sub-tissue and the ligaments and then I can rule out or rule in an ACL tear or even the media lateral or lateral ligament tears. So, then that's one of the reasons why I would go for that MRI before even thinking of the x-ray. But definitely if no one takes anything else except the imaging, go for the x-ray first.

Liz Rohr:
And the right imaging.

Yessica Salazar:
Yeah, correct.

Liz Rohr:
I have a question based on that. So, my experience of ortho so far is in school, I think every school does their best effort to do as much as they can with the amount that we need to learn that time. I feel like at least the takeaways that I've gotten from ortho is like, "Oh, it's just the structures that are in front of you. This is easy. Just do these special tests and you'll have your answer." Is that real? I'm being very candid on this interview. I don't know. I do feel you feel comfortable with the special test. So, I guess the context is that I work with a lot of new grads and I think there's this expectation similar to ordering a lab test, being like, "Okay, here's this lab, here's your answer."

For me, it feels like those special tests are difficult to learn, difficult to feel the true differences and may or may not be related to the actual underlying. I feel like your knowledge as a specialist NP is so sophisticated that you can see the whole picture and it's not a plug and plaything. Do you know what I mean? Does that make sense?

Yessica Salazar:
Yeah, no, 100%. So, here's the thing. I think the difference between let's say orthopedics and other specialties or even as a family nurse practitioner, I also practice a little bit and I also do work also in the urgent clinic like I was telling you earlier, but here's the thing. Orthopedics is very hands-on, so we don't depend so much so on labs rather than on our touching and feeling and watching and seeing. You need to develop this tactile sense and also you depend a lot on the imaging. So, you're not reading reports. As a matter of fact, when patients come in and they just have the little piece of paper, that's another pet peeve. Tell your patients to take the CD with the images-

Liz Rohr:
Good. That's a really helpful tip.

Yessica Salazar:
... when they go to the specialist. Yeah, that's a big takeaway. If you go to an orthopedic surgeon and you take your little report from the radiology department that says that you have an impression and you have a list of a million things, that's not high yield. The orthopedic surgeon wants to see what the knee looks like, the intricacies. What does it look like on imaging? Because many times things either, I'm not going to say they get missed, but there's many, many things that you can think of when you correlate that clinically.

So, in school, I just think that they threw out of so much and it was like, "Oh, so comprehensive, I cannot do this." But there's a lot of high yield physical exams that you can do that are so easy. I don't know if I say this because I have done this so much, but I really think that nurse practitioners have the capacity. I promise you, you and everyone as a nurse practitioner have the capacity of doing these essentials. Let me just walk you through a physical exam for the knee now that we're talking about the knee, right?

Liz Rohr:
Let's talk about knees. Let's do it.

Yessica Salazar:
So, watch the patient walk. Do they have a limp. That will tell you a lot and you don't have to have them run the catwalk or walk the catwalk. No, it can be just five feet. You can notice that. Do they have a Trendelenburg gait? So that's something that you can pick up in less than two seconds. You don't want to miss that. Visualize the knee, visualize the skin. That's another key thing. I've had many patients come in with very tight clothing that they cannot lift their jeans or pants, and I'm like, "No, I'm going to have to step out of the room and you're going to have to get on a gown. You have to do that."

If you're dealing with musculoskeletal things, you have to visualize the skin, because the last thing that you want to miss is redness or warmth or big swelling or a draining wound and pus. You don't want to miss that because you didn't look under the hood, right?

Liz Rohr:
Totally.

Yessica Salazar:
Let's say that if you're in primary care, you can prepare for the next day and you see that the main complaint is like that, the knee pain or hip pain or shoulder pain. Then I don't know if you have clerks or MAs that can do the call and just say, "Hey, you're coming for this musculoskeletal complaint. Bring comfortable clothing or clothing that can be removed really quickly so that the clinician can visualize and look at the skin and do a thorough assessment." So that is another key. Then you don't really have to do that when you have the patient in front of you and you're dealing with diabetes or hypertension, but these are little nuggets of wisdom that you don't want to think about when you're dealing with musculoskeletal care.

Liz Rohr:
Every single time I have a knee pain, they're always wearing tight jeans. Oh, man.

Yessica Salazar:
Then you can see it and then something that I've seen a lot, you ask the patient, "Okay, so have you had any surgeries in the past?" Oh, no, no surgeries. Then I'm looking at the knee and I'm like, "What is this thick scar?" Oh, yeah, some surgery. I was so young. I'm like, "Okay." So then by just visualizing the skin, you can really get a lot of information. Then the next thing is super easy when they're either sitting on the examination table or laying down, you can feel for crepitus.

So, you put your hand on the patella and then have them extend and bend the knee and then you feel that grinding. Then that could either be patella-femoral or just arthritis that is really advanced. So, that's another key thing that you can pick up right away. Then you lay them on their back and then you want to assess the range of motion. I will try in my channel to give visualization of how to do this because I know in words, it doesn't always translate properly than when you see it.

Liz Rohr:
Totally.

Yessica Salazar:
But you want to know the limits of range of motion. Can the patient make the leg straight that's zero degrees? Can they bend it in? How far? Sometimes you can miss a contracture when you don't have them laying flat because they cannot make their leg straight, their knee. Basically, there's a bend. They cannot go all the way down to zero. Then you'll want to do ligament testing. You'll want to test your MCL, your ACL. There's certain maneuvers that are better than others in clinical practice.

Then that's a quick knee assessment. It doesn't take that long once you know what you're looking for. If you don't know what you're looking for and if you don't know how to do it, then I feel you're going to just be all over the place. You're not going to be focused. Then that can be a little bit overwhelming for both the patient and the clinician. Then you have so much information that you don't really know where to go.

Liz Rohr:
I think I've noticed that too myself in terms of when it comes to orthopedics, so a lot of people think about it from the diagnostic step, the diagnostic maneuvers first. It's almost like you have to go backwards where you need the differentials and the structures and then you're verifying it with the maneuvers versus maneuvers first and diagnostic clarity next. Does that make sense?

Yessica Salazar:
Yeah, no, totally. One of the main things is the history. It's so important because it really can guide you into what you need to test and what you should pay attention one thing more than the other. For example, if I have a patient and the patient is in their 60s and they're having pain that is chronic and it's bilateral. They're having pain going up and down the stairs and it's a thing. They have tried everything and nothing works. So, I'm thinking, "No, this is arthritis." Now, if I have a younger guy or younger girl, a younger patient in general coming in and they say that they just have been experiencing a lot of swelling, it's constant on and off. Then I'm thinking, "Could this be a meniscal tear?"

If I have a patient that comes in and says, "I had this injury and I feel that my knee is giving away," then I'm thinking, "Well, could this be an ACL tear, an ACL related injury?" So, I'm paying attention to what they're telling me and the complaint that they're saying in the history and then that history is really what's going to guide me into then my physical exam and then what kind of imaging and treatment I want to do. Especially in primary care, I think we can start treatment even without getting the imaging, especially if it's something chronic.

Liz Rohr:
Yeah. Actually, I think that's a beautiful segue. So, I just want to ask you all the questions. I'm trying really hard to hold myself back. You are a wealth of knowledge, my friend. We want to segue into talking about some treatments. If I remember correctly with so many questions, I think the main thing and you actually can also speak to the main things that you're seeing in orthopedics and also in urgent care, but I think arthritis is a huge question of how to help people. Then people also have questions about opiates, which you can talk about or not talk about. It's up to you. I know it's controversial, but any insights you have to share or things you wish primary care providers knew about treatment in general, but specifically arthritis plus or minus opioid.

Yessica Salazar:
No, absolutely. We don't like opioids. This is something that is the spiel that I give to my patients. Opioid medication is going to only mask your symptoms. It's not going to target the pathology. I try to say that in much simpler words.

Liz Rohr:
For sure.

Yessica Salazar:
But you do understand what I'm saying, right? We give all these medications, and unfortunately, we have this epidemic of patients becoming addicted to opioids. It's because we want a quick fix, but you know what? That quick fix can actually do more harm than good. So, when it comes to medications, especially for osteoarthritis and musculoskeletal, you want to decrease the inflammatory process. You don't do that with opioids. You don't do that with trauma though. You don't do that with coding, you don't do that with morphine, you don't do that with any of that. You do that with nonsteroidal anti-inflammatory medications.

So, yeah, there's some go-to that I go to, especially if the pain is chronic in nature or if the pain is acute. I do have my go-tos and if it's the knee, the shoulder, and the back, but NSAIDs are like my go-tos for musculoskeletal complaints, especially osteoarthritis. So, when it comes to osteoarthritis, mild, moderate, and severe osteoarthritis, NSAIDs really, really do help. Well, actually, the treatment guidelines is high dose long term. Now there's a caveat with that, because then you can get into trouble with NSAIDs, patients with renal disease, patients with GI complaints, patients with blood disorders.

I mean nothing in healthcare or medicine is straightforward and everything is tailored to the patient you have in front of you. So, you need to make sure first if this is safe for the patient. So, in the setting of osteoarthritis, you can always go to the cortisone shot. You have the cortisone injection. So, let's say that you have a 65-year-old female who comes in. She has renal disease and you're afraid of giving that NSAID that you know is basically what's going to help with their pain. Well, you can do that cortisone injection, that intraarticular cortisone injection. If the arthritis is moderate to severe, there's nothing else that you're going to make worse. It's already bad. I mean, this pathology is not going to get better. So, you're not going to make it worse if you give the cortisone injection. You're not going to give the cortisone injection monthly, but definitely giving a trial of a cortisone shot is... I don't know if you want to get into what I use.

Liz Rohr:
Sure, if you want.

Yessica Salazar:
Kenalog 40 milligrams, particularly with some lidocaine, that definitely does the trick for patients. So, that helps a lot for these type of patients that have osteoarthritis and that you're afraid of throwing that instead that can actually worsen other comorbidities. So, I think that a lot of clinicians don't know that and they abstain from that or just refer out. That's something else that I would love to do. I would love to teach because I was reading a paper about this. I would love to teach primary care nurse practitioners and nurse practitioners everywhere how to do these procedures because this is a high yield and even financially and also for your growth that you can show to your employee or even if you have your own clinic. Hey, I can offer this as a service.

That is something that I used to do in my other job. They work based off of RVUs. My RVUs were really high because I actually implemented a procedure clinic day. So, a lot of the patients I saw, I'm like, "Oh, I think that you would benefit from this or that." Then I would do cortisone injections or hyaluronic acid injections depending on who I was dealing with. Then those procedures really helped to also showcase nurse practitioners in the field. I think these are tricks that all of our colleagues can learn from and these procedures definitely will put them at another level if they like.

Liz Rohr:
Yeah, no, totally. I love procedures. I think they're so fun. I think the main hesitation that I've heard from people with starting them is that discomfort with a diagnostic clarity. I think that if it was very clear already either from their own diagnosis or a specialist diagnosis of here's what they have, here's the treatment or they've already gotten one injection, it's like, "Oh, okay. I can't keep doing injections in primary care, but I don't know if I feel comfortable enough making that definitive diagnosis that it's not something of all these other options."

Yessica Salazar:
One thing with the injections, especially with cortisone, you don't want to do it, like I said, very often, but you can do it twice or even up to three times. I've seen some surgeons being comfortable with a year, especially if it provides a lot of symptoms relief for the patient. It's also saving the nuclear option, which is a total knee replacement. So, if we can continue to manage our patients that way, then by all means. You mentioned it like physical therapy.

Liz Rohr:
I was going to say, I'm trying to hold back from talking about physical therapy, because I'm obsessed. I understand what they do now. I'm like, "How do we not talk about this more?"

Yessica Salazar:
So here's the thing. So, when I started my practice in orthopedics, I'm like, "Wow, physical therapy. I mean this patient's in a lot of pain and their knee is swollen." Then even the patients themselves say, "Oh, I can't even exercise because it hurts so much. How am I going to do physical therapy?" Well, you have to understand, like you said, the meaning behind physical therapy and the theory is evidence based is that the motion and the physical activity actually increases the joint capsule flexibility and the compliance.

So, it allows the joint inside to expand and it decreases the interarticular pressures that are happening because there's so much inflammation and swelling and the knee can only swell so much. So, physical therapy can help that too. It also strengthens the periarticular structures around the knee as well. That load of the weight from the body doesn't automatically go to the knee. It can be redistributed if the quadricep is strong.

Liz Rohr:
Absolutely.

Yessica Salazar:
But one more treatment and we missed this and I stressed this. Half the patients lose weight and it sounds so simple, but I think in osteoarthritis and in musculoskeletal pain and complaints and aches, it is so valuable. I've read so many studies about that 15 pounds, which yeah, sure it's a lot. But in someone who is a little more on the overweight side, it's not so much. If they stop drinking sugary beverages and decrease the amounts of carbs, then definitely they can get there, but 10 to 15 pounds of weight loss can drastically change their symptoms.

I had this one patient. She had end stage OA, but her BMI was about 40. I unfortunately do see and it happens, patients are getting joint replacements with this very high elevated BMIs, but sometimes it's a disservice because when they are obese and their BMI is so high, then you basically are exposing them at the actual knee joint failing because of the weight load. So, you didn't really target that basic non-invasive treatment. You didn't exhaust that. You didn't have them lose weight. I think that having our patients lose weight, they will feel it. Going back to what I was going to say, I had this patient that I had a one-on-one deep conversation with her and I convinced her to lose the weight. She came back three months later. She had lost 35 pounds.

Liz Rohr:
Gosh. Wow.

Yessica Salazar:
Despite the fact that her knee still hurt, it wasn't as overwhelming. It was the first time. She was so happy and excited. She even brought everything that she had done and then I'm like, "I want to use you as a model to all my patients."

Liz Rohr:
Case study.

Yessica Salazar:
I'm inactive, I cannot do any exercise. Well, you can stop exercising your mouth. I don't say it like this, but definitely, I know it's really hard. It's really hard. Yes. Losing weight is hard, but 80 to 90% of our weight loss comes from what we eat or we don't eat.

Liz Rohr:
Totally. Totally.

Yessica Salazar:
I've set a lot of initiatives at my place of employment where I utilize a lot the nutritionist and they have helped big time.

Liz Rohr:
Absolutely.

Yessica Salazar:
Then there's so many resources online too where patients can go to and that I've definitely recommended books, online resources that they can utilize so that they can work on their weight loss.

Liz Rohr:
Absolutely.

Yessica Salazar:
Then I love to see them back and they're so happy and they're so trim and then they're like, "I'm doing so much better." It's such a satisfying feeling that without throwing so many things at them and just one or two things, you had such a big impact and such a high yield impact on them.

Liz Rohr:
Totally.

Yessica Salazar:
Also, their complaints and their pains and aches.

Liz Rohr:
Absolutely. Actually, just for reference, if anybody watching hasn't seen it, I have two videos on weight loss counseling and management for medications. Because I think like you were saying, sometimes it's hard. Not to go off on a tangent, but I feel like in terms of schooling, that's another area that we are briefed about, but it's an art. That's lifestyle modification. That's habits. There are so much involved in that. So, I think if there's one pearl to take away, talking about having those conversations about weight loss as it relates to orthopedic issues is treating it like you would treat the same seriousness and the same attention and care and support the way that we do for hypertension or diabetes. We can make a care plan. We can have them come back. You know what I mean? Anyway.

Yessica Salazar:
You don't have to throw everything at once, right?

Liz Rohr:
Yes, totally.

Yessica Salazar:
Because that's something else that I've seen. When you throw all these things at them, they don't know where to start or what's the best approach. The patient, understandably so, is going to get overwhelmed and just give up, because oh my God, I can't do this.

Liz Rohr:
Totally.

Yessica Salazar:
I've gotten very funny answers from my patients, assistive devices, right? Easy, like a cane. A lot of my female patients don't like that and my male patients either because they don't want to be seen that somehow they're not 100% all right. Because when you see a cane, there's also that judgment, but definitely the cane. Then also teaching the patient how to use the cane is-

Liz Rohr:
Oh, my God. Yes.

Yessica Salazar:
... so essential, because I've seen my patients with a cane and they're using it on the side that hurts them the most. No. If they do that, if they use the cane on the side that is their worst side, they're actually putting even more pressure on that side. So, they have to use the cane on the side, the contralateral side opposed to the one that they're having pain.

Liz Rohr:
Totally.

Yessica Salazar:
So that's how it'll work because they'll off load the weight, right? So that they can ambulate better and have less symptoms. That is another trick, another thing, another tool on the toolkit or the toolbox like I call it to utilize when it comes to treatment.

Liz Rohr:
Totally. I think it's so important that we don't underestimate ourselves whether we're new or experienced NPs, how many options we have. I think that there's a component of, I don't want to say selling, because that sounds super weird. I mean it's just communication. I feel like I have to sell people on physical therapy and I have literally no agenda aside from helping them. I get no financial gain. So, I don't even want to use that word. But at the same time, it's almost like you need to talk to patients about, "Hey, this actually can be helpful for you. Here's how it works. Let's try it." I think that so many popular conception is like, "Oh, I need a medicine. I need this medicine in particular."

Even we think that too, because I think that there's so many algorithmic approaches to medical care that it's like, "Okay, just choose this med first or do this thing next." If we don't fully embody and believe the things that we're telling patients, look at the research and seeing, okay, this intervention actually can be helpful, because I feel like that comes up a lot with pain management in general where everyone just wants to go straight to opiates. Nobody wants to, but everybody wants to. It's like, "Oh, let's talk about heat packs and cold packs," and so many people dismiss that. Well, there's evidence, there's research. We have to try things.

Yessica Salazar:
That's actually a very good thing when it comes to the infamous back pain, right? You just mentioned that heat packs, heat therapy. But I think when it comes to back pain, because I know that a lot of the questions were related to back pain is patient counseling and back pain could be a scary thing. I've had back pain and it's debilitating, right? You think, "Oh, my God. I cannot get out of my bed. I have to stay here." No, absolutely not. On the contrary, you actually want to get some exercise on. But the main thing with patient counseling with back pain and also as a clinician, the understanding should be that 90% of that acute back pain, it's going to get better. It's going to take time, probably six weeks or a little bit more, but it's going to get better.

So, having that understanding, it equips you as a clinician and also equips patients to be patient with the healing process and not jump right away to the opioid or something else. There's so many other things, like you said, heating pack, acupuncture, massage. There's gun massagers out there that you can definitely utilize and all of that can be done. The NSAIDs, actually when it comes to treatment plans for back pain, especially for acute, I like diclofenac because that one actually works faster and better for the acute episode. That is better than throwing the opioid or the tramadol, which I so often see.

Liz Rohr:
It's like a little baby step into opiates. I think people are just like, "Oh, just a little tramadol, little codeine." Can we not though? I would love to talk to you forever. I think we do have to wrap unfortunately, but I think two places to leave off, I think one is resources. People are asking about resources. Whether or not they want to become a nurse practitioner in orthopedics or if they just want to improve their orthopedic care in primary care, what resources would you recommend?

Yessica Salazar:
Yeah, so I think I mentioned it to you when we were talking earlier. I actually created an entire resource for free. It's an orthopedic nurse practitioner guide with my top resources. This I developed when I was doing my board certification in orthopedics. There's so much out there. Some of it is paid, some of it is not. But definitely, if they go and or if we can link the resource guide, they can download it and I have all the links right there that they can utilize and get their hands on that.

Liz Rohr:
Cool.

Yessica Salazar:
Well, we don't really have a UpToDate ortho.

Liz Rohr:
I was going to say, is there an app or what that thousand page book was? I'd love to read it.

Yessica Salazar:
That was another thousand page book when I came into... It's so funny when I came into the specialty, of course, I mean I did my own research and that's the book that I found, I bought it, I read it. That book was way too much for what I should have gotten. So, the book that I recommend is... I can't remember exactly the name, but it's musculoskeletal and it's the one that is recommended for when you're getting your board certification. It's by the AAOS.

Liz Rohr:
Cool.

Yessica Salazar:
Definitely a great guide. If you want to learn about physical therapy, it has all the physical therapy you can imagine and even how to teach it and pamphlets that you can give to your patients.

Liz Rohr:
Totally. Yes, I love that. Just personally speaking in primary care, I am obsessed with UpToDate and DynaMed is another resource too. There's nothing that's specifically orthopedic in there, but I think in terms of that diagnostic approach of knee pain, what location, what are those differentials? What are the next steps for imaging and the right imaging? I've not been as successful with maybe, but that's another way that I've done it is through looking up knee pain specifically differentials that way for people. But I'm very excited for them to utilize your resources. So, my last question is, where can people find you and learn more from you? Because you have a lot of things coming. You can share whatever you want to share or not.

Yessica Salazar:
Sure. Thank you. So, yeah, so I have decided that I really want to do this. So, I created my website, www.npinsiders.com. So, they can go there. They can click at the bottom. I have the orthopedic simple course that I'm generating and I'm creating. That's super exciting. That is in the works. Then they can download there also my ortho NP guide. Also, if you just go to my Instagram and it's @NPInsiders. There, you can see all the resources as well. I have all the links in the link in bio and I am definitely planning to get serious with this whole teaching my NP colleagues on social media.

Because I think there's such a need and I think this collaboration is amazing, right? Because there's no better feeling that having all this amassed knowledge and be able to give it away and share it with all the NPs that I know or even that I don't know or that just happen to find me on social media because it makes a big difference in their lives as clinicians and in their patients' lives.

Liz Rohr:
Absolutely.

Yessica Salazar:
So I think that this will be something nice and positive for everybody.

Liz Rohr:
Yes. I can't wait. Thank you so much for being here. You know so many things and I can't wait to learn more from you. Yeah, thank you so much.

Yessica Salazar:
No, you're welcome. It's been my pleasure. Thank you so much again for everything that you're doing. Anytime you want to have me back, I'll come back.

Liz Rohr:
Awesome.

Yessica Salazar:
More than happy to.

Liz Rohr:
Awesome. That's it for today. If you haven't grabbed the ultimate resource guide for the new NP, head over to realworldnp.com/guide. You'll get these episodes sent straight to your inbox every week with notes from me, patient stories, and bonuses I really just don't share anywhere else. Thank you so much for watching. Hang in there and I'll see you soon.