Category Archives for "Outpatient operating"

Want to decrease your complication rates after surgery? Who doesn’t? What patient does not want to avoid trouble after surgery.
When patients are sedated or have a tourniquet on their arm, there's no point talking to them because they cannot hear and remember well. When they are asleep, what a waste of time talking to the nurses about the weather, or to the anesthetist about his holiday!
When patients are awake, tourniquet-free, pain-free, and just lying there listening to nice music, consider this;

What a great time to spend talking to them about what to do and what not to do after surgery to make recovery sail beautifully!
During flexor tendon repair, I tell patients that the hand “is on strike” and only does one thing for 3-5 days after surgery until I see them again. “It stays higher than your heart!” “None of this” I say as I pretend to walk with my hand by my side and then cross my hands down like a referee and say “No! None of this” I say as I open and close my hand and then cross my hands down like a referee and say “No! Walking with your hand by your side and moving your fingers will cause bleeding in the wound. Bleeding becomes a blood clot which occupies space. Blood clots take weeks to dissolve and turn to scar”.

"Don’t disturb it! Keep it higher than your heart without moving it until I see you again in 4 days. We will start early protected movement when all the swelling is gone and you are off all pain killers”.

During every operation, I talk to patients about how to take pain killers properly. I start with “What do you normally take for pain; Advil? Tylenol? Nothing?”. If they reply Advil, I tell them that is all they will need for this operation (most procedures except bad fractures and big nerve repairs). I then say: “With every operation, there are 2 kinds of pain; 1) the sting of the cut which lasts for a day or two, and then 2) the pain of “Gee doctor, now it only hurts when I put down my hand or when I try to do things”. I tell them this: “When you get to the point of “Gee doctor, now it only hurts when I put down my hand or when I try to do things”, that is when you quit taking pain killers and listen to your body. We did not spend 2 billion years evolving pain because it is bad for us! Pain is your body’s only way to say to you: “Hey, would you quit that Mary (if the patient’s name is Mary!)?

That is a little voice in your head you WANT to listen to, and you can’t hear it with Advil in your ears. So you stop taking pain killers after a day or two and only do what does not hurt, including putting your hand down. This is called “pain guided healing” or “Common sense” or “Instinct”
After carpal tunnel, I tell them they can get in the shower the day after their surgery without their bandage because fresh wounds love to be washed. I tell them to reapply a “Hollywood bandage” after their shower.

“Bandages do not stop infection or bleeding. All they do is remind you and those around you that you cannot do all the things you normally do. I know you will forget this and go to use your hand when you go to the restroom or get ready for bed tonight. When you go to use your hand to eat, you will see the Hollywood bandage and it is going to talk to you. It will have my annoying little voice and it will say: “What part of keep your hand up and on strike can’t you remember?...!”

You can ask them: “What WERE you planning to do this week” as you pin their fracture or repair their tendon. Then you tell them about their new reality, and how their hand injury will change their life in the next few weeks. Better coming from you than from a complication you could have avoided!

Time invested in talking to your patient during surgery or painless injection of local anesthesia saves time talking to them in the office or recovery room (where they won’t remember any of it).

Try it! You will watch your complication rate go down! You will also have patients who get to know you, respect you, and want to be part of your team that helps them get better faster!!!

Find out more about how to do and use Walant at the Walant University.

I find looking at the guidelines and protocols presented here very daunting. In my case, I came to this technique slowly and organically over many years. When I first started practice, I decided that I wanted to be able to treat some simple things in the office, e.g., finger tip injuries, simple fractures, foreign body and hardware removal, small tumors, and trigger fingers. I purchased two simple instrument kits, and a battery powered k-wire inserter. I appropriated an out of date nitrogen powered tourniquet box when the OR switched to the more modern and safer boxes.

I am old enough to know how to use an Esmarch as a tourniquet (actually the way it was meant to be used).

During my fellowship, we pinned fractures in the emergency room using field sterility and plane radiographs.

So, to me, our cast room was perfectly acceptable. I have since read about the safety and cost advantages of field sterility versus OR sterility and kept this in mind as I expanded my capabilities with office surgery.

Aha Moment #1
I received a call one day from an ER about a seamstress who fell on a sewing needle and it was imbedded in the volar aspect of wrist. The physician said that the thread was sticking out of the skin. I said "just pull it out." He resisted not wanting to break the thread. After another attempt to convince him to try, I demurred and had the patient sent to the office. She came with radiographs on which the needle was present. Sure enough, the thread was visible and I tugged, but nothing happened. I assumed, like a fishhook, that the way to remove this was antegrade. I gave her some xylocaine and made a small incision following the thread. I exsanquinated by elevation and used a forearm tourniquet. Before long and with more xylocaine, I soon found that I was in the carpal tunnel and that the needle was in a flexor tendon. And there I was in the cast room. I then started to think that this was surprisingly well tolerated and maybe I should think of doing CTRs in the right person in the office. I found that forearm tourniquets were well tolerated for about 15 minutes and began doing more things in this fashion.

I usually did these cases before the start of the day as the cast room was shared by up to six physicians at a time and was therefore a busy place.

During my fellowship, we pinned fractures in the emergency room using field sterility and plane radiographs.

The patients liked the simplicity of the procedure. But one day there was an edict saying that local with sedation was acceptable for the ASC, but straight local was not.
At about the same time I was becoming aware of Don Lalonde's writings and wanted to try. I was scared. I had always done most of my cases with a pneumatic tourniquet although digital cases might be done with a penrose drain or tournicot. This was the way I was trained. To overcome my fear, I started performing cases under sedation and local anesthesia (xylocaine with epinephrine). A tourniquet was placed, but not used unless absolutely necessary. I started to get more comfortable. Masses, CTRs, extensor tendon repairs, tenolyses, and nerve repairs were some of my first successes.

Aha Moment #2.
A woman with a ruptured EPL presented for EIP transfer. After arrival in the ASC, she refused all sedation. I was worried about tourniquet discomfort but decided to proceed with WALANT. She did give me permission to use the tourniquet if I absolutely felt it was necessary. Guess what? Not only was it not needed, but the ability to set the tension was enhanced by the patients ability to try things out.

Aha Moment #3
I was getting confident but was still fearful of a bloody field when doing Dupuytren surgery. One afternoon a woman arrived at the ASC. Her driver had a flat, so she took two buses and the Metro to get to the center. The rules of the center were that if she did not have transportation home, then she could not have surgery with sedation. I was not about to send this woman home. I prepared her for WALANT, but she agreed that she could tolerate a tourniquet for a while if needed. Things went very smoothly. I put the cuff up briefly to deal with a spiral cord. Of course, her condition was bilateral and she wanted the other side done. The rules of the ASC were such that I could not schedule her straight local. She lived much closer to my office, so I agreed to do it there. This really opened my eyes to what I could do in an office.

Nuts and Bolts:
I worked at Kaiser Permanente so there were opportunities for institutional support that might not be available in different practice scenarios especially as it relates to funding purchases and sterilization as autoclaves were no longer the standard of care.
Cases were done in an existing procedure room. I created a schedule to do six 45 minute cases in a morning block. Eight basic instrument sets were purchased.

Cases were done on a stretcher with a wheeled hand table. There was a single movable overhead light.

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.

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...

...to “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.

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 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
And/or
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.

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