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Walant – A Paradigm Shift?

WALANT – On the Track of a Paradigm Shift

By Egemen Ayhan

Orthopaedic Surgeon at Diskapi Training and Research Hospital, Turkey

A paradigm shift can be described as “fundamental change in an individual's or a society's view of how things work in the world”. 

I want to invite you to a short trip on the history of WALANT and follow together how the WALANT goes forward for a paradigm shift. Is the paradigm shift one step beyond or are we far away from it? You will decide. Also, you will recognise the reward after a long pursuit of faith.

In 1962 the well-known scientist Thomas Kuhn published his book, The Structure of Scientific Revolutions. Describing a simple cycle of progress (below), Kuhn opposed the current conception of science, which was a steady progression of the accumulation of new ideas. He changed the way many scientists think about their work and advocated that science advanced the most by occasional revolutionary explosions of new knowledge, each revolution triggered by introduction of new ways of thought. He named those ways as paradigms.

(More information: The Kuhn Cycle - Thomas Kuhn's Brilliant Model of How Scientific Fields Progress)

For a better understanding, let me describe the cycle step by step:

Normal Science: 

Kuhn reported that scientists have a guiding model of understanding (field's paradigm) and scientific revolutions remain most of the time except when their paradigm undergoes a cycle of paradigm revolution.
More information: http://www.thwink.org/sustain/glossary/NormalScience.htm

Before WALANT, the field’s paradigm was that epinephrine cannot be injected to fingers because of the risk of digital necrosis. We, the doctors, all have learned in medical faculties that epinephrine cannot be injected to fingers because of the risk of digital necrosis. If we are not particularly interested, we have forgotten most of our medical knowledge after specialisation in a field, but I can make a bid that most of the doctors, even though they never perform local anaesthesia (e.g., microbiologists, radiologists, …), will all remember the famous myth of epinephrine and digital necrosis. It is a dramatic event to lose a finger after local anaesthesia and that is why that knowledge is recalled easily. But, was it true?

Model Drift: 

Model drift from Normal Science is caused by what Thomas Kuhn called anomalies. An anomaly is an unexpected discovery one's paradigm cannot explain, which includes discovery of problems the paradigm cannot solve.
More information: http://www.thwink.org/sustain/glossary/ModelDrift.htm

It is the model drift step that the first seeds of WALANT spread. Dr. Lalonde realised the 100-surgeon years of clinical safety in the practices of Drs. Shoemaker, MacFarlane, Fielding, and others who routinely injected epinephrine in fingers. He has read the milestone review of Dr. Denkler in 2001, there was not one case of epinephrine with lidocaine causing finger necrosis throughout the medical literature from 1880 to 2000 years.

Model Crisis: 

In this step a field's model of understanding has drifted so far the field is thrown into crisis by discovery of too many anomalies.
More information: http://www.thwink.org/sustain/glossary/ModelCrisis.htm

For the WALANT, it was the years between 2005 and 2015. With the first multi-centre prospective study of 3110 consecutive cases of elective epinephrine use in the fingers, Dr. Lalonde et al reported that epinephrine has not produced any instance of digital tissue loss in 2005. As you can realise, it is over ten years that several high-level fundamental studies were published via great efforts of Dr. Lalonde. The paradigm revolution was on its way forward to support WALANT.

Model revolution:

In this step a field's model of understanding is undergoing revolutionary change. The old model failed, which caused the Model Crisis step. The Model Revolution step begins when one or more competing new models emerge from the crisis.
More information: http://www.thwink.org/sustain/glossary/ModelRevolution.htm

For WALANT, it starts with 2015 and continues up-to-date. Dr. Lalonde’s efforts were welcomed by many surgeons throughout the world. Several papers about WALANT (replantations, distal radius fractures, foot and ankle surgeries, …) were published by different surgeons. That was the award after a long pursuit of faith.

Paradigm shift: 

Earlier steps have created the new model of understanding (the new paradigm). In the Paradigm shift step the new paradigm is taught to newcomers to the field, as well as to those already in it.
More information: http://www.thwink.org/sustain/glossary/ParadigmChange.htm

What do you think? Are we prone to a paradigm shift with WALANT? With your support, we believe that most of the hand surgery operations will not be different than going to dentist all around the world. Join us!

The history of WALANT and its road forward for a paradigm shift. Is the paradigm shift one step beyond or are we far away from it? You will decide. You will recognise the reward after a long pursuit of faith.

Awake patients are receptive patients

Why talking to patients during the operation will help to reduce your complication rate afterwards.

By Don Lalonde - Co-Founder of Walant.Surgery

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;

They are your captive audience.

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”.

“Treat your hand like a sleeping baby!"

"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”.

Carpal tunnel under Walant and using field sterility. Perfect time to educate.

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!)?

"I am trying to heal in here and you are screwing it up!!! Stop that!@#$#."

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.

The bandage is called a Hollywood bandage because it is only there for visual effects!

“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.

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