For patients, fear of the unknown and anxiety about pain are the two biggest concerns about being awake during hand surgery. However, if we explain the process to patients calmly, clearly, and with confidence, we can quell the fear of the unknown so that most patients are reassured. By gaining knowledge of the procedure, the patient can feel more like an active participant in the treatment process, awake and cooperating. If we inject local anesthetic thoughtfully, as described in Chapter 5, it really does make the local anesthetic injection and surgery pain free, except for the initial pinch with a 27-gauge needle. The patient will be amazed at how brief and minor the discomfort is.

Wide awake surgery is as simple as when you go to the dentist for a filling. We put in the freezing/numbing medicine, we perform the surgery, and then you get up and go home. (When asked, most patients say that it is a more pleasant experience than going to the dentist.)

You will not need to undergo any tests before surgery. That means you do not need to leave work or pay a babysitter to go for tests on a day before your surgery. You just need to arrive the day of surgery.

You do not have to stop taking any medication before surgery.

You do not have to fast before surgery or change any diabetic treatment routine.

No intravenous line will be placed, so there will be no uncomfortable needle in your unoperated hand.

You will be amazed at how little the freezing/numbing medicine hurts when we put it in slowly with a tiny needle. Most people just feel one little needle prick in the hand, and then they feel no pain at all (see Chapter 5).

The needle prick you will feel will be smaller than the sting of an intravenous insertion if we were using a general anesthetic, because we use a much smaller needle.

For those who are especially afraid of needles and therefore request sedation: If you have sedation, you will have two needle sticks with bigger needles than the single prick you will feel if we numb you with a local anesthetic. You get two bigger needles if you want to be asleep: the first larger one is for blood tests, then you get another one with an intravenous line inserted to put you to sleep.

In Clip 7-3 a patient describes the impression of pain of a local anesthetic needle for trapeziectomy versus the pain of intravenous needle insertion. This patient just had 40 ml of local anesthetic to numb up the radial hand, as described in Chapters 5 and 27.

We will not be putting an uncomfortable tourniquet on your arm (for those who have had experience with a tourniquet or have heard about it).

For tendon or bone reconstruction: You will be able to help me get a better result. After I fix your tendon, you can move it to make sure it is working properly. Sometimes I need to adjust what I have done, because your repaired tendon does not want to fit in the tunnel it lives in after I fix it. If you move your broken finger after I fix it, I can be sure that I have it straight. We are more likely to get a good result if you are awake to help me get it right. You cannot move it if you are asleep or sedated during the procedure.

After the surgery, there is no need to wait around in the hospital to recover. You just get up and go home.

You will not be nauseated and you will not vomit if you are not sedated.

You will not have trouble urinating after surgery if you do not receive sedation.

Staying awake is safer than sedation, because the safest sedation is no sedation. This is especially important for you because of your other medical problems [such as your lung problem…].

You do not have to worry about what will happen to you. You can just ask us anything at any time before as well as during the procedure if you have concerns.

You can watch if you wish. Many patients do enjoy watching parts of the surgery. Some tell their friends that watching the surgery should be on their “bucket list.” However, you do not have to watch anything if you do not want to.

You can bring headphones and listen to music during the surgery.

It is very uncommon for anyone to feel pain during the surgery, but if you did, you would just tell me and I would add more local anesthetic.

If you have a sore shoulder or back, let us know and we will help you adjust to a more comfortable position, such as on your side, during the surgery.

Bring a book to read. After we inject the local anesthetic, you need to wait at least a half hour before we do the surgery. It is like putting a cake in the oven: you need to let it bake.

You can ask me any questions during the surgery, and I will be happy to answer all of them.

While I am operating, we can also discuss details about how you should care for your hand after the surgery.

You do not need to get undressed (for patients for whom field sterility will be used, see Chapter 10). You will simply roll up your sleeve and have the surgery. You may want to wear short sleeves or a loose longsleeve shirt so the bandage fits in easily.

You will not need to have someone stay with you the evening of surgery, because you will not have had sedation. It will be safe for you to be alone with your children or elderly parents the evening of surgery. If you were to have sedation, the hospital would tell you that you need to have someone stay with you at home the evening of surgery.