Local Only Hand Surgery, Pearls and Challenges

Chuck and Chris discuss their approach to local only surgery include some basic pearls, building on previous episodes.  They also discuss some local challenges including insurance companies.

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Transcript

Travel Experiences and Sponsor 
Charles and Christopher discussed their recent travel experiences, with Christopher and Chuck mentioning their trips to Italy. The conversation then shifted to thanking their sponsor, PracticeLink.com, for their support of The Upper Hand podcast.

OR Scheduling and Workload Management
Christopher discussed challenges with OR scheduling and workload, particularly due to time constraints from conferences and holiday commitments, as well as adjustments to block time requested by the hospital. He described managing a full day of local-only cases, which he found mentally exhausting, typically handling 4-5 cases across two rooms with pre-blocked schedules. The discussion explored how Christopher managed this workload and share pearls for performing cases under local anesthesia.

OR vs Clinic Surgery Advantages
Chuck and Christopher discussed the advantages and disadvantages of performing local only surgeries in the operating room versus a clinic setting. They noted that the OR provides better support but the facility fee is charged and therefore it may not be ideal for patients. Christopher highlighted the importance of facility fees to cover overhead costs, while Chuck mentioned their upcoming dedicated procedure room in the clinic. They agreed that once the new facility is operational, they could plan to efficiently perform a variety of minor surgeries in-house, potentially with higher compensation.

Challenges of Out-of-OR Surgeries
Christopher and Chuck discussed the cost-effectiveness and practical challenges of performing surgeries outside traditional operating rooms, particularly in response to COVID-19. They noted that while in-office surgeries could be efficient, they often lack the necessary equipment found in operating rooms. Christopher expressed concerns about the quality of disposable surgical instruments, which are more expensive and less effective than reusable ones. They also touched on the differences in surgical volume and efficiency between different medical facilities.

Advantages of Local-Only Surgeries
Charles and Christopher discussed the topic of local-only surgeries, highlighting its popularity in medical meetings. Christopher shared his experience and ideal cases for local-only procedures, including carpal tunnel, trigger finger, and Dequervain surgeries. He emphasized the advantages of local-only surgeries for older patients who may not tolerate sedation and the ease of adding cases during clinic hours. Christopher also noted the importance of marking patients in the office in these situations to avoid unnecessary delays.

Local Anesthesia Surgical Workflow Discussion
Christopher and Chuck discussed their approaches to performing nerve decompression procedures and other surgeries under local anesthesia. Christopher shared his experience with peroneal nerve decompressions and noted that he no longer pushes patients towards local-only anesthesia, instead making it an opt-out option for procedures like carpal tunnel surgery. Charles agreed with this approach and described his own workflow, which involves starting the day with cases requiring anesthesia and ending with local-only procedures. Both doctors acknowledged the benefits of local anesthesia for patient safety and convenience, though they noted some challenges with the process.

Challenges in Dupuytren's Surgery Anesthesia
Chuck and Christopher discussed their experiences with performing Dupuytren's surgeries under local anesthesia, with Christopher expressing a preference for general anesthesia due to the potential variability of the procedure. They also addressed a payer challenge, noting that some insurance providers, including Medicare Advantage commercial, refuse to cover in-office needle procedures for Dupuytren's, which Chuck finds problematic.

Needle Procedures and Teaching Innovations
Chuck and Christopher discussed the challenges of performing needle procedures in operating rooms due to insurance company requirements, highlighting inefficiencies and cost increases. They shared their experiences and techniques for teaching local-only surgeries, emphasizing the importance of exposing residents and fellows to this approach. The conversation also covered suture materials, wound care practices, and the use of running horizontal mattress sutures, with Charles expressing a preference for nylon sutures and Christopher favoring absorbable options. They encouraged listeners to share their insights on office-based procedures and teaching methods for future discussions.