Monday, January 29, 2007
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.