Monday, January 29, 2007

Local Hero




I said in a recent post that I liked doing office surgery, somewhat parenthetically implying as well that I could do a mean local anesthetic. It's true, of course. More than just lumps and bumps, I did lots of breast biopsies in my office under local, revised mastectomy skin flaps, took off a few humongous lipomas, excised gynecomastia; and I did more than a couple of simple mastectomies under local in frail ladies (not in the office.) (Also not in the office, I repaired many a hernia under local.)

Per a request from a commenter on that post, I hereby share some tricks of the trade. None, I'd say, is original; but I'm not sure that by the time one finishes training, all of these pearls -- if that's what they are -- have been assembled in the same part of every graduate's brain. Realizing it's the ultimate in surgical esoterica, I hope non-medical readers might also find it interesting, if in a useless sort of way.

"Vocal anesthesia" is the term for when a local isn't working out. "Hold still!!... It can't possibly hurt that much!!... I've never had to inject this much local!!..." That sort of thing. The aim is to avoid that scenario. And whereas it's not quantifiable or even supportable, I think step one is establishing some rapport and a measure of emotional comfort. No point dwelling on it, since it's probably condescending: but I really like light banter, joking when appropriate, taking the time to establish a little calm and relaxation. And, of course, letting people know what's going on every step of the way. (There are, strangely, some people in whom no amount of any kind of local seems to work. I've not seen articles about it -- I bet there are some -- but I've had a few patients in whom I simply couldn't get them to the point of adequate numbness, no matter what. Extremely uncommon; but real.)

It's all in the wrist: making a really rapid (but controlled) flick with the back of the wrist is the way to make the first stick. Right through the skin and into the subcutaneous fat. Many times, after saying "OK, here comes a little poke," and flicking the needle in in a nanosecond, I hear "you mean that was it??" Save infiltrating the skin for the very last: once through the skin with that quick move, first fill the subcutaneous area. The idea is that if you get the nerves to the skin from below, when you finally inject the skin itself -- which is otherwise the most painful part -- it's barely felt. It's often helpful to pinch the skin before poking it: first, of course, telling people you are going to do it. A gently increasing pinch is a familiar sensation which isn't frightening; and it'll mask the poke. Pay special attention to dermatomes; that is, infiltrate the upstream subqu, innervationally speaking, before the target area. Like a mini-field block, essentially. And one thing that's important and which I don't recall hearing during training is the need to infiltrate separately around blood vessels before cutting them. Even when the area seems otherwise numb, people often feel pain on cutting a vessel. This is particularly true doing hernias under local; also with breast biopsies. In the breast, I came to do most dissection sharply, with a scalpel, finding it to be less uncomfortable than using scissors. I didn't like to use cautery on awake patients except when absolutely necessary. Because of the smell. Suture and ligate.

[Super-esoterica warning] There are classic articles about local anesthesia for hernia repair, and I can't improve on them other than to say the simple approach is simpler: I didn't find it necessary to try the regional block at the ilium. Do the skin and subcu as I already described. Pop below the fascia and fill that layer up before starting. Pay attention to blood vessels. Infiltrate the base of the sac when you see it. And that's about it. Except: I used long-acting anesthetic for the skin and muscle/fascia, and short-acting for the subcu and the sac. Partly to avoid nearing the limit, and partly, in the case of the sac, in case some local leeches to the femoral nerve: in which case, it's nice not to have a gimpy patient for twelve hours.

In medical school, I was allowed to remove a bunch of sebaceous cysts (plugged up oil glands in the skin). The people teaching me challenged me to remove the cyst intact, without disrupting its wall. It wasn't until many years later that I figured out that meant making a much larger and more noticeable incision than necessary. After a (perfect) local, make a little stab into the cyst, squeeze out the goop, and the cyst sac will follow it out. A little dissolving stitch or two, a steri-strip, and that's it.

Anyone who's bonked their head knows how well-vascularized the scalp is. Anything with that much blood is going to heal more or less no matter how you handle it. So with scalp cysts, I shaved little or not at all: taped hair out of the way, did my thing. People really appreciate not having to walk around looking like they were treated for ring-worm. And never put in a stitch that needs removing, unless you need it for hemostasis. Big pain in the rear to remove them amongst all the hair.

I hardly ever did the bicarb trick (mixing it with local anesthetics raises the pH and lessens the pain of infiltration, especially of the skin. Since I saved that part for last, I didn't think it made a difference.) I did find the thankfully rare patient in whom no flavor of local seemed to work, no matter what I tried. If I couldn't achieve comfort, I quit and scheduled for the surgery center.

Long run, as they say, for a short slide. Less here, maybe, than I thought. Guess you had to be there.

26 comments:

scalpel said...

You can learn a lot about a person by how they respond to a local anesthetic and the process of applying it. The difficult patients who "don't get numb" are the same ones who tend to freak out about the very first needlestick and who scream and flop around with every microliter of injection. In reality, a needlestick with a 27 gauge needle in a given location and the injection of lidocaine at a given rate are standardized pain stimuli. How patients react to them are far from standardized.

Alice said...

Thank you for gathering all of this together. I'll try to remember for next year (although I think the "wrist flick" has to be seen to be understood).

Bohemian Road Nurse... said...

Once, an ER doctor I used to work with asked me to flirt with his patient so that he could quickly reduce a dislocated finger without doing the local. It worked.

Anonymous said...

Plastician's trick for working in the scalp -- use bacitracin ointment to grease the hair out of your way. Or you can sterilize some metal barrettes.

You can also use injectable Benadryl as a local anesthetic for people with an allergy.

Sid Schwab said...

I like the ointment idea!

Kathleen said...

Dear Dr Schwab, This is totally off topic, but I really wanted to comment on your book. Some of it I read twice, the whipple, I read 3x so far. One could write an entire book on the whipple. Having served in the Army, I laughed when you wrote about the AF. I thought it was absolutely hysterical. Funny in a way that only people whom have served this great country can fully understand and appriciate. I always feel bad when people suffer, no matter if it was self inflicted or not, though, I had the most empathy for the sick and not so much those with lead poisioning. I think about all of the internist whom I used to have a relationship with. Your book made me think about why I hate docs but love surgeons. I have thought about every surgeon whom has ever cut on me, helped me, those whom truely hoped I would get the help I needed. I wonder if I have impacted their lives as much or as little as they have impacted mine. I believe surgeons and docs have learned from me in the past and I believe they will contiue doing so. I am not sure if your book "helped" me, persay, but I am glad to know that some docs bond with patients as we patients bond with our surgeons. It is so true. It is a huge leap of faith. As a patient, I spent much energy seeking out the best, the best surgeon, the best chance to not only survive this disease, but to thrive. I thought about how the student made a mistake and the attending said to him , "you just killed my patient". I know patients become a sea. That part really reaffirmed so many things I have always believed. All and all, I am deaply moved by your book. Thank you so much for spending your energy to write it, to share it.

Sid Schwab said...

Kathleen: praise like that is never off topic! I appreciate it enormously. And I can assure you that it's a mutual thing: the effect patients have on their surgeons is lasting and important.

A girl said...

I just found your blog. Great read. I am a new fan...

Anonymous said...

I have had a deep look into this blog and it's given me an urge to practice medicine. Preferably as a surgeon. You make it sound all so simple Doc!

The Independent Urologist said...

Great post. As a urologist, I do many vasectomies in the office, all under local. And the little "tricks of the trade" that you mentioned go along way. Now I do the following, in order: forewarn, pinch, inject, massage in local with simultaneous banter, start case. A truly painless, stressless vas experience for all involved.
Nice blog. I'm thinking of buying your book. You are a terrific writer.

rural_obgyn said...

Thanks for this post. Now I can stop trying to find bicarb (which can only be obtained by getting 50 vials of it!) and concentrate on injecting the subcu before the skin.

And while we are on the subject of your book, I am reading it now for the second time and enjoying it even more. Having been at SFGH myself (the new one, of course), makes it even better. "Bullitt" provides my only images of the old SFGH. The tunnels were still there during my time, and the ER was still referred to as the "Mish" and I regularly saw female patients in the Male Ward.

Please keep writing! Thanks again from your loyal fan...

Sid Schwab said...

rural ob/gyn: thanks. I love hearing things like that. Bullitt was filmed not too long before I got there. One of the residents (by my time, an attending) played the surgeon in the scenes they filmed in the OR. (Bob Allen, in case you might have known him.) And, of course, all the trauma room scenes were in the real spaces, in which I spent many a day. The mish. Great place...

Eric said...

Dr. Schwab:

There's substantial genetic variation in the metabolism and efficacy of lidocaine; (p450 2D6 is highly polymorphic - about 10% of the population is a lousy metabolizer, about 7% are really efficient). This can account for some people getting very short duration of anesthesia from typical amounts of agent.

In another area, Edward Liem at the University of Louisville has done some research in the area, testing the observation that natural redheads need more anesthetic. He found substantial differences in anesthesia between dark- and red-haired women with various painful stimuli.

There also seems to be some differences in kappa-opioid analgesia in redheads, which are probably somehow linked to Mc1r mutation. Thus, it's entirely possible that you had patients with odd little genotypes that make effective anesthesia and analgesia challenging.

Did you find it useful to pre-medicate patients with a low dose of a benzo, for example, before attempting procedures under a local? I would think that anxiety about the procedure (no matter how obviously skilled the practitioner) might contribute to perception of pain, and that a mild Surgeon's Little Helper might be of benefit.

(And now for the obligatory Dr. Schwab Fawning:

My mom was one of the young women with breast cancer that is mentioned in _Cutting Remarks_; the good doctor performed a modified radical mastectomy in 1984, for breast cancer that was Stage IIIa at diagnosis, when she was just 39.

My mother had a very effective recovery. Her oncologists, primary care physicians, radiologists and physiotherapists have all commented the elegance and aesthetics of her (non-reconstructed) results. My mom recovered without a hint of the lymphedema, diminished sensation or circulatory problems that are known to plague women with similar surgeries. In fact, my mom resumed her golf game just a few months after completing chemo and took about six strokes off her game. She does not recommend this method to other players looking to reduce their handicap.

On the downside, the doctor was still fond of "atrocious" ties at that stage of his career. Mom was not suitably impressed and has often wondered aloud as to whether he ever discovered the fine Talbot products at better menswear retailers.)

Eric, geeky amateur pharmacogeneticist.

Sid Schwab said...

Eric: what a treat to read your post. I reveled in the "smart" stuff as well as the "fawning" stuff. Mainly, it's great to hear about your mother. Thanks in the extreme!!

Chrysalis Angel said...

When I learned to give injections, we were trained in the "wrist flick" method. It was over before my patients knew it. They'd say, "that's it?"

As a patient, I wondered how long should you wait for local anesthetic to take? My surgeon injected me with a local, for a breast biopsy, and then literally turned around after grabbing this thing that looked like an ice pick and drove it in.

I held as still as could be, knowing how important it was he get that tissue, but I wasn't numb until it was over. Yikes! The assistant in the room darn near fainted. We were more worried about her.

Hed Taggard said...

Forgive me if this is mentioned, though I didn't see it:

The rate of injection of local anesthetic is usually proportional to pain produced during the injection. Starting with a slow speed of injection is crucial, especially when you are near the dermis.

Sid Schwab said...

Absolutely correct, and I should have mentioned it. Thanks!!

Peekay said...

This post has inspired me to comment after lurking and enjoying your blog for ages!

I'm one of those patients who doesn't respond to local anaesthetic, regardless of how much is put in. I always thought local anaesthetic was just a lousy pain killer until being diagnosed with Ehlers Danlos Syndrome and discovering that it's so common for people with EDS, particularly those with EDS III or the hypermobility type to be resistant to local anaesthesia that in the UK it's part of a checklist that 1 of our 2 specialists uses when diagnosing patients. I really doubt that it has anything to do with being a difficult patient, freaking out or poor pain tolerance as any procedure I've required that should have been done with local anaesthesia over the past couple of years I've simply skipped the local and gone ahead without finding it all together more comfortable and less stressful (for me though not always the doctor!) to take the brief bout of acute pain. The most recent example I can give you was refusing any pain relief/sedation in A&E whilst they attempted to reduce a full shoulder dislocation (not that that would have required local as I understand it)

There are articles on available on this subject that I can post links to if you would like? To start you off here's a link to a very brief article on the US EDS site to aid physician awareness about this issue
http://www.ednf.org/medical/content/view/328/38/

I hope the address has posted ok, I'm no technical expert and thanks for your blog!

Sid Schwab said...

peekay: it's indeed useful. Thanks for the comment )and for coming out of hiding. I love getting comments and hearing from readers!)

scalpel said...

"Some of the women reported no pain alleviation of local analgesics when they were sutured after episiotomy. They were commonly characterized as hysterics. We have definately (sic) proved that this is not the case."

Who did the study, Lindsay Lohan? I'm not sure the methodology was "adequite."

LOL.

Sid Schwab said...

The episiotomy thing brings up an excellent point, and an important trick I wish I'd remembered to have included in the post:

When an area is inflamed (as in an abscess) or other wise engorged with blood (as in the labia in the above situation), anesthetic tends to wash away very fast. I was even told, in training, not to bother infiltrating in either situation. But what I did was to infiltrate with one hand (using an epinephrine-containing local) and simultaneous make a stab with the other, into the blanched area -- which will persist as long as you continue the injection. Once the stab is made, and pus is released, you can infiltrate the rest of the area through the stab, and the anesthetic seems to stay around a little longer after the pressure's off.

Lynn Price said...

As long as we're talking about your book (we were?), I just ordered it because I love your writing style and write medical fiction. My main problem is that I have to wait impatiently for it to arrive.

Anonymous said...

Your mention of Bicarb reminded me of a goof I made as a first yr anesthesia resident. Having placed one of my first epidurals I decided to add bicarb to my mixture of Ropivacaine. After numerous alarms from the infusion pump that there was a blockage in the line I reluctantly pulled the catheter and found that my mixture had crystalized in the catheter..the 2d catheter worked fine. I still add bicarb to lidocaine when its available though.

Anonymous said...

As a patient who has recently had a stereotatic biopsy in both breasts, the lidocaine and other "caine" locals don't work well. I had 5 injections in one area of my left breast and all of it was excruciating. The right breast, uncomfortable but not as bad. I have to have 3 more biopsies- was diagnosed with DCIS in each breast and now the other areas are to be biopsied. I am terrified. I am not wimp...have had two children without any drugs at all and long deliveries. I also don't fare much better with oral sedation of versed and the other drug they use for EGD and colonoscopy...I still felt the EGD scope big time! And remembered it all. Is it my Irish ancestory and the red-head gene theory that Eric posted or am I just weird? By the way, I am a blonde. Any help would be appreciated!

Scott said...

Dr. Schwab...I do surgical hair transplants and the local anesthesia is always the worst part of the procedure for the patient (and myself). Do you know of any topical for the scalp that can be applied first to the injection sites that might decrease the pain to the patient for the initial needle stick and possibly decrease the "burn" of the Xylocaine also? Without a mucus-membrane to work with I've been at a loss for an answer to this question.
Also, I've run into a patient (for the first time) that may possibly be truly allergic to Xylocaine and the other "caines" in the amide group. Not only does he get vaso-vagal with N/V but he gets SOB and a rash. Most of the above can easily be attributed to anxiety and associated responses but the rash is a little more disconcerting. True, the rash could be an anxiety-associated response too but what if he is trully allergic to Xylocaine and it's amide cousins? We're not an ER and I would hate to try this class of medicines on him just to see if it's only an anxiety attack. Do you know of another class of local anesthetic that could be used for the scalp that is not in the "caine" family?

Thanks for your time,

Scott
drscottmd@yahoo.com

Sid Schwab said...

Scott: the burning of lidocaine can be significantly diminished by mixing with sodium bicarb (10:1 local:bicarb). I agree topical applications are pretty much useless for skin. As to the allergy: I suppose you could have him tested to see if it's really an allergy....