HOW TO BOOK A DAY OF FIFTEEN OR MORE ELECTIVE CASES

With good planning and coordination with staff, it is possible to schedule 15 or more elective cases per day that one surgeon, one nurse, and one receptionist can accomplish in the office or hospital minor procedure room in the clinic.

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  For the first three cases, schedule simple procedures: carpal tunnel or trigger finger repairs. Ask the patients to come at 7:45 AM, 7:50 AM, and 7:55 AM.

  
  
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  Schedule longer cases and trauma cases with less predictable lengths later in the day in the event that those procedures run overtime.

  
  
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  Inject the first three patients with local anesthetic.

  
  
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  Inject patients while they are lying down on a stretcher. They are less likely to faint (vasovagal reaction) if they are lying down.

  
  
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  As soon as patients feel well after the injection, they can be asked to sit in a chair to liberate the stretcher so you can inject another patient. Two stretchers and an operating table to inject patients are ideal in the event you encounter a patient who faints and needs to remain lying down for a while. However, if necessary, one stretcher and one operating table will suffice for local anesthetic injections.

  
  
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  After you inject the first three patients, complete their paperwork.

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  While you inject the first three patients and do their paperwork, the nurse sets up the first patient on the operating table and opens the tray of surgical instruments.

  
  
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  We perform most clinic and office surgeries safely with field sterility, which greatly increases efficiency (see Chapter 10).

  
  
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  After you finish the first operation, inject the fourth patient and do paperwork while the nurse sets up the tray for the second case and brings the second patient into the minor procedure room.

  
  
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  The nurse can put on a pair of gloves and perform retraction if needed during part of the surgery. The rest of the time, the nurse circulates. You get your own instruments off the tray.

  
  
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  Always try to inject one or two patients ahead of the one you are operating on so the lidocaine and epinephrine have at least 30 minutes to work optimally. It takes an average of 26 minutes for maximal vasoconstriction to peak after 1:100,000 epinephrine injection in humans.1

  
  
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  Do not inject the patient and make an incision immediately after. The site will bleed less if you organize your time as described to allow an adequate interval for the epinephrine to work. The lidocaine component also increases its effect over 30 minutes and lasts over 4 hours in the hand when you block the median nerve as part of tumescent local anesthesia2 (Chapter 18). Numbness in the finger lasts 10 hours when you inject lidocaine with epinephrine.3 (See Chapter 1, Atlas, for specifics on injection placement, timing, and duration.)

  
  
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  You can conduct most of your communication with the patient while you inject the local anesthetic and as you operate (see Chapter 8).

  
  
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  If you are working with medical students or residents, first teach them how to give local anesthetic injections in a minimally painful fashion (have them read Chapter 5 and look at the videos first), and have the patients score their injection technique. When they amaze patients with minimal pain injections, the patients will be much more comfortable about allowing them to participate in the surgery under your direction.

  
  
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  Clip 14-1 demonstrates that three carpal tunnel procedures can be performed per hour at a relaxed pace by one surgeon and one nurse.