MSK (Fluoro/Ultrasound) Procedures

THE DAY BEFORE

1. Check your schedule the day before on Epic, look up relevant history and images, put necessary notes on the schedule on Epic, and load images on Visage (MSK Procedures conference folder - we will show you how to do it).

2. Checklist for each patient:

a.  Prior imaging, especially for cervical nerve root blocks and lumbar epidural injections. No MRI or CT before a cervical nerve root block? Reschedule the patient (lumbar injections may be variable - discuss with the attending the day before)

b.  Make sure to check "Order Comments" when reviewing requests on Epic

c.  Allergies – especially to contrast (iodinated, gadolinium) and latex

SOMETIME BEFORE THE PROCEDURE

d.  Quick review of medical history

i.  Diabetes - take note to explain to them the likely hyperglycemia that could last up to a week.

ii.  HIV – certain medications can precipitate a steroid crisis – so a dose reduction may be warranted.

iii.  Anticoagulation - Aspirin, Plavix, Coumadin, Eliquis. Double check with the patient (will usually be checked by Donna)

iv.  If the patient has had a recent infection and/or is on antibiotics, double check with the patient that they have finished the course of treatment (Donna also usually checks this)

e.  Plan needle length – Check patient body habitus, for spine injections remember to record the needle length if it is greater than 3.5 inches for lumbar spine and 2 inches for cervical spine (only if patient had priors, you can find that info on reports from previous injections too).

ON THE DAY OF...

1. BE READY AND PREPARED TO START SETTING UP FOR CASES BY 7:50 AM AT THE LATEST. The 8am patient should be in the room and on the procedure table AT 8AM.

2. Donna will print a schedule for you but you can also use the template below to help you keep track.

3. When you change the patient, ask:

   1. About allergies to latex and contrast

   2. Whether the patient is driving themselves home

4. INTRODUCE YOURSELF as the fellow and THE ATTENDING (by name) you are working with. Also mention that the Attending may be coming in and out of the room so that the patient will not be surprised if/when he or she appears mid-procedure.

5. Consent the patient. You can use the stamp in the procedure area to make your life a little easier.

6. Prepare your tray

7. Take heed!! If the staff says "advance the needle this way, slowly", that means: advance the needle this way, slowly. Please note: slowly means slowly. This applies to biopsies as well. We are particularly sensitive to needles being advanced abruptly in delicate areas.

8. The ordering clinicians are very specific about what they request. Try to follow the request as close as possible – if it seems very far from our norm, talk to your staff. You can identify some of these by reviewing the cases the day before. If we need to make a major change (e.g. convert from RF to CT, change site or side of injection) then we need to talk directly to the ordering physician. If it is a minor change (e.g. the level of an epidural steroid injection), then include a statement at the beginning of the TECHNIQUE section of the report that explains the rationale, e.g. “The MRI from 3/5/2015 was reviewed. There is a paucity of epidural fat at the L4-5 level. Therefore, the L3-4 level was selected for injection.”

9. For arthrograms, ask about symptoms, including onset, history of trauma, history of surgery, etc. Ask anything that might be helpful for reading the arthrogram, unless you have already gleaned that information from the orthopedic note.

10. For aspirations, if you get pus, you're done. Send the sample for micro and cell count. If you don't get an aspirate or the aspirate isn't clearly pus, inject a little contrast to document that you are in the joint. Also please try to core the synovium using the 20 gauge needle.

    2. • For now, these will need SEPARATE orders in Epic (yes, 2 sets - sorry i know, a pain)

       • If you are unsure how to core the synovium or to send samples, please ask the attendings. 

       • For SYNOVASURE requests, please see the instructions below.

       • Lab specimens – go up to the 7th floor via the North stairway (the side furthest from Cambridge street), knock on room 7-826 (the door is labeled “Oncology Lab”), and they will show you where the specimen drop bin is. If no one answers at that door, take a right and a left around the corner – go to the first door and knock – usually they can see you better from that entrance

11. Ask all women for fluoro and CT guided injections – “Any chance you could be pregnant?”

12. You and staff will read the arthrograms you injected once the procedures are over.

DICTATIONS - see special tab with detailed instructions