Before surgery, be aware of the patient and the disease process, and develop a treatment/surgical plan. The surgical site must be marked. An accurate consent must be obtained prior to surgery. The consent should include the diagnoses, the site and the side. The consent signature should be witnessed by the pre-op nurse. The patient should be seen by CWC in the preop area. The case is reviewed and the consent is checked.
Surgeons must be in pre-op area before 7 AM.
Medical students should be gowned and gloved prior to draping to expedite the case.
If patient is under general anesthesia, if the local anesthetic volume does not distort the anatomy, I usually inject surgical sites with Marcaine .5% with epinephrine 1:100,000 prior to prepping and draping.. If patient is sedated only, I usually inject surgical sites with Lidocaine 0.5% with 1:200,000 epinephrine prior to prepping and draping and then maybe Marcaine 0.5% at end of case. Do not inject local anesthetic solution with epinephrine into penis. Do not inject local anesthetic solution into the surgical site if the solution will distort the anatomy.
Learn how to do the preferred head and neck surgical prep and draping. Prep inside the nasal vestibule.
I prefer NOT to use elastic bandages as a part of foot, leg, hand and forearm dressings.
If a thigh is a donor site for a skin graft, then shave widely so that all hair is removed at the site of Duoderm placement over the donor site. For most thigh donor site dressings, I prefer Duoderm, 2 Kerlex rolls and a 6 inch ACE wrap.
As a bandage, I usually prefer only Mastisol and adhesive strips on sutured incisions.
For lymph node cases, use a headlight for adequate visualization. In fact, use a headlight anytime adequate light is needed.
Ask me when and where the patient is to be followed up after discharge on a Tuesday at HLM McKinley Campus.
Insert urinary bladder catheter prior to surgery and remove when surgery is completed before leaving the OR. Use sequential compression devices during surgery. Inject Marcaine 0.5% with Epinephrine 1:200,000 into surgical sites prior to prepping and draping. Usually admit for 2 days. On day of surgery, when awake, pt can eat and ambulate with assistance. Head of bed elevated 15 degrees when in bed. Ice on incisions intermittently x 2 days. Check function of Cr N VII and IX each day and document. Oftentimes patients have pain and can not shrug shoulder well. Note character of drainage. Note viability of flaps, +/- hematoma, incision intact. When discharge, give pain meds. Return in 3-5 days on a Tuesday.
Drains- For complete neck dissections, initially the 2 drains go to medium wall suction overnight. Then in AM, separate the drains into 2 different receptacles to medium wall suction. On the next day, usually pull the drain with the least drainage and the patient can be discharged with one drain. Connect drains to bulb suction when ambulating.
I prefer hand ties on sutures that are placed in muscle, deep fascia, superficial fascia, and deep dermis.
When seeing post-operative patients in the clinic and documenting/dictating a note, document the patients age, days/months/years post-op, diagnosis (including depth of melanoma for mm patients), procedure performed, pathology results, and any significant occurrences. DUH!
Give a chronology of events of the patient's illness and important occurrences so that we have enough information at the next visit to make a plan.
When I see the patient in return, I receive only the last note and it should include the above important information. Otherwise then I have to go to the computer and look up the above information.
Initial Office Evaluations:
When completing medical records in the Clinic on Wednesday, please review and sign before Friday at noon. I can then review and sign and the note will be available for the referring physician in a timely manner.