Always strive to improve patient care

Six years ago, I listened to a presentation on “Wide Awake, Local Anesthesia, No tourniquet” (WALANT) surgery.  When the speaker (Dr. Don Lalonde) advocated the use of lidocaine with epinephrine in the hand as a method to deliver high quality and economical patient care, I thought this was preposterous and immediately disregarded the notion of utilizing this in my practice.

Luckily, the concept of WALANT hand surgery remained in the deep neural synapses of my brain.

A few years after that fateful introduction to WALANT hand surgery, I found myself struggling with limited patient access to hand surgery in my practice.  Due to OR allocation issues and a high volume of trauma in my practice, many patients who required elective hand surgery had to wait up to 2 months for a surgical date.  It was heartbreaking to inform a patient with a painful, locked trigger finger that had failed multiple tendon sheath injections that they would need to suffer with this condition for 1 to 2 months until an OR became available for a 10-15 minute case!  Since WALANT hand surgery can be performed without any anesthesia support, I was able to add on many wide-awake hand surgery cases at odd hours into ORs that were underutilized for the day.

For a while, I was very content with performing wide-awake hand surgery in the operating room and noted all of the benefits of WALANT such as improved patient education, enhancing surgical outcomes, and the efficient OR turnovers.  However, the perioperative process seemed onerous to me from a patient prospective.  Imagine seeing a patient who you have diagnosed with carpal tunnel syndrome, they have exhausted all non-operative measures, you counsel them on their options, and they elect to have surgery under wide-awake technique. Yet, they still need to spend the entire day to meet with their primary care physician to get cleared for surgery that involves blood work, ECG, chest x-ray, and modification of their medications for a 10-15 minute surgical case!  In addition, to have the hassle of checking into pre-op for surgery an hour before their surgical time and... “recover” in the post-anaesthesia care unit when they have been completely awake without any medication! It is absurd.

At that point, serendipity afforded me a procedure room in our orthopedic clinic that served as a glorified storage room and a department chairman who was supportive of my endeavors…thus, my clinic-based wide-awake hand surgery practice was born.  Seeing the incredible benefit to the patient by delivering clinic-based WALANT hand surgery, my eyes were opened to the incredible cost differential in performing the wide-awake hand surgery in the OR versus the clinic.  A preliminary cost analysis revealed to me the tremendous cost savings in performing theses procedures in the clinic compared to the OR.

Therefore, my passion in educating and promoting WALANT hand surgery was emboldened.

You might be reading this while perusing this website because you are already performing WALANT hand surgery and want to improve on your delivery of this concept.  Or, you have considered it but have not tested the waters yet.  Regardless of where you are in your journey with WALANT, I would encourage you to be inquisitive and always ask how you can improve patient care or the economical delivery of hand surgery.  A great example of surgeons who have promoted a decrease in medical waste and total cost related to hand surgery or therapy are those recipients of the American Association of Hand Surgery’s Lean and Green Award, of which I am honoured to be the 2018 recipient of this award.

The Lean & Green Award - AAHS

The Lean and Green award is given yearly by the American Association for Hand Surgery to a person who has made a significant impact by presentation(s), publication(s), or other action  in causing:

1) A decrease in the amount of garbage generated by any activity related to hand surgery or therapy at their home institution or elsewhere
2) A decrease in the total costs of any activity related to hand surgery or therapy at their home institution or elsewhere

Any presentation(s), publication(s), or other action that had a significant impact on reducing the garbage production and/or costs of any activity related to hand surgery or therapy at home institution or elsewhere.

For those with access to the ASSH archive:

Please review the presentations that were given by the 2016 (Dr. Mark E. Baratz), 2017 (Dr. Robert E. Van Demark), and 2018 (myself) recipients of the Lean and Green award promoting WALANT hand surgery and its applicability in your practice.  In addition, an enlightening presentation from Dr. Lalonde sharing his pearls in performing WALANT hand surgery.  Hopefully one of you will be a future recipient of this prestigious award while enhancing patient care.

2016 – Mark Baratz, MD

2017 – Robert E. Van Demark, MD

2018 – Peter C. Rhee, DO, MS

Pearls for Delivering WALANT Hand Surgery – Don Lalonde, MD

American Association for Hand Surgery – Lean and Green Award


About the Author

Peter Rhee is a hand surgeon at the Mayo Clinic and one of the editors of Walant.Surgery.