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Getting Walant off the ground

How I got WALANT surgery off the ground At UConn Health

By Anthony Parrino M.D.
Assistant Professor of Orthopaedics

In starting my practice, I had the unique opportunity to return to my residency program as faculty. In fellowship, WALANT was a common practice and I wanted to utilize it in my practice. I was returning to an institution and geographic area where it was hardly utilized and would be a culture shock. My dilemma was how to get this off the ground and who I needed to convince that this was a great benefit to patients.

Myself

The most important person I needed to convince for WALANT was myself. If I didn’t fully believe this was for the better of the patient, then it was doomed to fail. I came up with discussion points with patients why this was better for them, and with time my presentation to them became smoother with infrequent hesitation from them to proceed in the manner. I also started with simpler cases (open carpals, triggers) but considered which procedures I would transition to WALANT as I demonstrated safety and outcomes.

Partners

Strength in numbers. If I could have my hand partners on board with a WALANT room then it would be easier to tailor the room. I didn’t need them to do the same exact cases utilizing WALANT, but if they supported it, then when there was pushback from other personnel then it would make the implementation easier. It was also helpful in problem solving and looking at it from different viewpoints.

Chairman / Chief

For an academic center, change can be hard to come by. I utilized my chairman as my big gun. At first when I brought up my desire to implement WALANT in my return, his response was ‘sure’, although I don’t think he fully understood it. As I started, it was my first topic I brought up in our meetings and he soon realized both the small and larger benefits to WALANT if implemented correctly. As I started WALANT, he was crucial to have in my corner when issues began with nursing and anesthesia and concerns they had. With literature to support me and the chairman in my corner, small hurdles that make a big difference (in my view) were overcome. Now nearly two years into WALANT, we are demonstrating the larger benefits, decreased complication rate and cost savings, that the hospital can utilize with insurance companies.

Anesthesia

This may not apply to all. This arose as I did not have the setup for office utilization and anesthesia ran the daily operations of the surgery center. The first concern was for patient safety and comfort. This concern was calmed with studies that support the safety of WALANT and also demonstrating good outcomes and comfort in the first several weeks of WALANT. Other comments that did throw me off guard were “you are taking away my easy cases” or “did I do something wrong”. I hadn’t considered their viewpoint when implementing WALANT. My response was that these are cases that can be done safely without anesthesia, and that their (anesthesia’s) skill set good be better utilized for tougher cases. Also, my transitioning these cases out of an operating room, and into a procedure room, hospital and staff resources could be better utilized. Slowly, they have appreciated its usefulness, especially in patients whose medical conditions could lead to adverse outcomes with general anesthesia or sedation.

OR Staff

This is the biggest factor for you, the surgeon. Identifying a nurse and surgical tech you work well with and enjoy talking to patients is key. This will make your day in the OR much more enjoyable and the patients more at ease. I didn’t want to have a nurse or tech that didn’t want to be in the WALANT room as no one would benefit from that. I made it clear to the supervisors that it was critical to have to same staff in the room each time and has made WALANT days the most enjoyable part of my practice. They know the procedure, my usual discussion points with patients during surgery, and can calm those with anxiety.

In the end

Looking back at starting WALANT at my academic center, I can say that there were some bumps in the road, but persistence is key. For me, I have now increased case complexity utilizing WALANT and I look forward to continue evolving. This is for the better of patients and as more and more patients go through procedures comfortably and have great outcomes, then those around you will appreciate its benefits…and maybe even seek it out for their own care.


Check out how to start Walant in your Hospital or Clinic at Walant.Surgery.

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...

...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.

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
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.

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

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