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My Many Pearls

By Kathleen A. Robertson, MD

PEARLS:

1) THANK GOD each day for your talent and your ability to help people. Keep “helping others” at the forefront of your mission as a surgeon and person and your capabilities will be boundless.

2) THINK CHANGE
Never be afraid to change the way you do something!
*Open carpal tunnels and ECTRs for me are now open releases with a more ulnar approach and release of epineurium from the transverse
carpal ligament and from the flexor tenosynovium deep to the nerve. I used the WALANT technique on veterans at a military temporary operating trailer post Hurricane Katrina and they reported better finger extension; most likely due to correction of the neurodesis.
*Ulnar nerve releases at the elbow for me are through a small incision using a nasal speculum and long instruments, basing transposition on nerve perching after arcing into flexion. Transpose the nerve in a straight line with no “kink” points.
*LRTI and variants for me have switched to trapeziectomy and suture suspensionplasty whith faster rehab and lower complications.
*Oblique release of the A1 pulley for trigger fingers carried into the base of A2 if needed allows the tendons to glide easier under a wider oval opening.
*First extensor compartment release for me is opened far dorsal between 1st and 2nd compartments with retinacular flap used as a septal wall blocking volar subluxation of tendon slips; beware of all nerve fibers in this region!

3) THINK NERVE
Nerve injuries are probably the most painful, and the most difficult to rectify. Surgery about nerves of the upper extremity are places where we need to slow our aggressive surgery prowess and be ever-vigilant. A big factor is the individual, as nerves in different patients seem to tolerate more retracting or dissection while others develop a pain that they did not have prior to surgery.

4) THINK INFECTION
Infection changes a patient’s life, especially if you cannot resolve a serious infection or a virulent bug. Always anticipate infection and treat it early, be aggressive. A key PEARL for me has been from my Charity Hospital days (New Orleans) on the wards with tough general surgeons. A wound will not really be helped by wet to dry NS, but 1/4 or 1/2 percent DAKINS solution can keep the area sterile. Remove all excess fluid from the gauze and apply this as “BARELY DAMP TO DRY.” Second to VAC System, this can give you the fastest granulation tissue growth, even faster if you increase the number of dressing changes per day. This is very inexpensive and works! A commercial brand PH balanced called Vash is now available. BEWARE of Staphylococcus lugdunensis that acts like MRSA: if your lab is not culturing for it, you will miss it.

5) THINK NUTRITION
Nutrition should be reviewed, especially in the elderly population, RA patients, and for those whose wounds dehisce with minimal trauma. Supplemental nutrition such as Glucerna, Ensure, or Boost to drink for their meals in addition to whatever else they want. Juven is a flavored powder that has no calories but contains amino acids to build protein. Also add Vitamin C, zinc, and iron for the anemic patients.

6) THINK WALANT
Walant surgery should be part of our armamentarium, as you can help those patients that are concerned about general anesthesia or are on anticoagulants. This can really cut on costs of surgery in many ways. The patient does not get nauseated and can actually leave without being under adverse effects of general anesthesia preventing falls as they leave or once they get home.

7) THINK COMPLICATIONS
Complications teach us many things. For those training students, residents, and fellows, it is important the residents are taught the complication possibilities so they will think and know how to get out of the complication; this will make them much better surgeons.

8) THINK LEAN
Lean thinking will be forever important going forward. We need to think about cutting costs and a great way is to start lean. Update preference cards. Minimize the things that are opened on the back table. Have them available in the room but not opened, cutting waste.

9) THINK TIMEOUT
Timeout is so important and should be observed by all in the room. Respect for the patient is needed !!! PEARL: state diastolic blood pressure and base the tourniquet pressure at 150 above that value. A pre-timeout with the surgical assistant(s) to review the basic instruments and suture and what’s different about this case versus the other ones like it is a great time to inform them of their importance in helping you help the patient.

10) TEACH AND INSPIRE
Teach and inspire your patients, as this will make all the difference in their care. Patients appreciate the HEP instructions, and the key items I give them at each post-op visit to progress their own therapy at home. Doctors’ words of instruction are so important upon discharge; the patient needs to understand how to keep and get their pain under control, how to prevent and or recognize a problem or complication, and how to start their own therapy at home. Medicare and some insurers do not readily approve therapy and surely not by post-op day 3 or 4 when swelling and inflammation are on the decline. Other patients cannot afford the copay for therapy and are at a loss without your instruction and will return with a stiff and edematous hand.

11) THINK EDUCATION
Seek out the great teachers and orators and continue to learn from their lectures and videos. They are the best people to learn from as they are excited to teach, explain, and inspire you!!!

FINAL PEARL
Continued issues after carpal tunnel release, lateral epicondylitis debridement, and other surgeries could be coming from higher nerve entrapments causing weakness and therefore perpetuation of a cycle that does not allow the resolution of symptoms. I highly recommend that you attend the ICL at the ASSH meeting pertaining to these other nerve entrapments. Learn pertinent Physical exam findings that help in diagnosing these issues so that they can be addressed. It is hosted by an outstanding international panel.

Comments (2)
Scott Brandon
November 9, 2018 1:06 am

What a great list of pearls from someone who is obviously constantly analyzing and refining their practice.

Reply

nanak sarhadi
December 14, 2018 12:40 pm

Excellent thoughts Dr Robertson, How best to be helpful to our patients with reflective life long learning and the flexibility to admit the need to change and the ability to do so

Reply

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