I received a note giving a "clinical rationale" for the denial of standard textbook medical care on patient Donald Livesay from a doctor who is a D.O. in physical medicine and rehabilitation which means he isn't qualified to know the first thing about a complex tenolysis case following major hand trauma and flap reconstruction. He starts by noting two calls he strategically made just before 5 pm on successive days. What he intentionally leaves out of his report in a very deceptive fashion is that his call was indeed returned on 8/15 (this call is documented in the patient's electronic record); a message was left outlining the fact that the surgery that necessitates the requested therapy had already been accepted and also explaining the rationale for requesting the post-operative therapy in advance. He was also informed that I am only here in the office to receive calls from 7:30 am to 1:00 pm, after which I leave to perform surgery. His action of trying to establish documentation of a second effort at 4:45pm on 8/15 is extremely feeble as he was informed that he would not find me in the office at that time. He cites ODG as not providing for the therapy that I have ordered. He cites the section on therapy for an open wound of the hand region. Unfortunately, this is not this patient's problem. This patient needs to undergo post-tenolysis therapy of reconstructed extensor tendons in a bed of tissue scarred by prior infection, under the reconstructed envelope of a free flap. If anyone wants to try to use ODG to determine proper treatment for this patient the only thing that individual would have to do is to find the section in ODG that covers situation as described; unfortunately, that would be an impossibility as there is no such section in the ODG. The reality is that the ODG is far too basic and simplistic to cover this patient’s situation. There is a correct timing for all medical treatments. The correct timing for this surgery was when it was originally scheduled to take place; until the proper post-operative care is guaranteed I am unable to proceed. While people who have no idea about how a case such as this needs to be managed delay Mr. Livesay's care his potential for best final results is slipping away. With time continuing to pass, it only becomes more and more difficult to mobilize his tendon. With respect to FES, the stimulation unit is not being used to control pain; it is being used to induce a more rapid and forceful tendon pull than the patient is capable of inducing himself in this specific clinical scenario. Once again, the citations from ODG are simply not applicable to this case. The discussion given there applies to different clinical scenarios than this one. Patients can't get the right medical care if persons who don't understand the case deny the correct textbook treatment that comes directly from the evidence based literature in the real journals of medical care. The correct methods for rehabilitating scarred tendons following prior trauma and surgery is a complex subject and one that is not even touched on in ODG and is far removed from what any PMR physician does in practice or has been trained on. It is a specific set of knowledge held only by those who actually give care for such patients, meaning full time hand surgeons as specialists and particularly those who further specialize in trauma. The American Society for Surgery of the Hand, in an attempt to better educate its specialist members, seeks out the best experts in the world on specific subjects to write articles in its journal. When they needed the best expert on surgery to correct post-traumatic hand stiffness, I was the expert they recruited to write that article. Therefore, it is clear that my actual peers believe that my proposed treatments are the correct ones and while this was ostensibly a “peer” review, it is quite obvious that those that use their state medical license to profiteer by denying patient care are not in fact peers in any sense.

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