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Do people do nail surgery single handed?

Discussion in 'United Kingdom' started by foot rott, Mar 13, 2014.

  1. foot rott

    foot rott Banned


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    hi need some help in an question please.

    as have only ever worked in NHS always had assistant in nail surgery.

    Is it a requirement in private practice or is it ok to do nail ops single handed?

    Thanks guys in advance
    Ed
     
  2. blinda

    blinda MVP

    Hi `Ed`

    I tend to use both hands, I find it easier that way.

    My glamorous receptionist will occasionally come into the treatment room, to distract/put at ease any nervous patients, but she doesn`t assist in any other way.

    Cheers,
    Bel
     
  3. Hannahcullen89

    Hannahcullen89 Welcome New Poster

    I work for a company PP and theres always two of us
     
  4. Tim VS

    Tim VS Active Member

    I have an assistant during planned PNAs/TNAs but use LA in my routine daily practice frequently without assistance.

    Hope that helps.

    Regards

    Tim
     
  5. Mike Plank

    Mike Plank Active Member

    I feel it is always best practice to have someone (receptionist, colleague) within ear-shot when doing a PNA/TNA should any clinical emergency arise. It would be difficult to call 999 and look after the patient at the same time!
     
  6. Nat

    Nat Active Member

    I do it solo. I lay out everything I might need before I start, all within arm's reach.
     
  7. W J Liggins

    W J Liggins Well-Known Member

    No reason why not provided you have emergency contact available per Bel's posting 2. However, life will be safer and much more comfortable and interesting if you can come to an agreement with a local colleague on the basis of (s)he carries out the L.A. whilst you deal with the surgery, and then you reciprocate when (s)he has nail surgery patients.

    All the best

    Bill
     
  8. JB1973

    JB1973 Active Member

    The second person comes in handy when you are using phenol in terms of timing and handling it. You can do it yourself but it's easier with 2.
    Cheers
    John
     
  9. Nat

    Nat Active Member

    I've done it solo enough times that I really am quite comfortable not having an assistant standing there with me for a toenail procedure. I would rather have my employees doing something else with their time. With a little planning it's a one person job. You lay everything out on the Mayo stand or countertop where you can reach it.
     
  10. anthony watson

    anthony watson Active Member

    apart from the rare fainter, anyone seen any reactions to LA?
    I haven't and am happy to do single handed.

    Bit of a pain if the patient faints though, dilemma-do we wait for them to come round and carry on or start again on another day?

    (men worse then woman!)

    Thanks
    Anthony
     
  11. Nat

    Nat Active Member

    I haven't seen any physiologic reactions to local anesthesia. I've seen some emotional reactions though...

    Early in practice I had one patient faint but I saw it starting and immediately put her into Trendelenburg. You can't really continue working while they're out since their limbs spasm (unlike in the movies where they just lay still), but once she came around I took a minute to explain to her what happened and let her get her bearings. Once she had collected herself we finished the procedure.

    Now I lay the patients into Trendelenburg to begin with unless they specifically ask to remain upright. I tell them that if they start to feel lightheaded they should tell me right away so I can lay them back.
     
  12. Deborah Ferguson

    Deborah Ferguson Active Member

    Hi All

    I only book my nail surgery patients on a saturday morning when there is another practitioner in clinic ( I share with a chiropractor).

    Although the risks are very low I much prefer to have A.N.Other present. Sod's law dictates that the patient WILL have an allergic reaction if I am solo.

    Regards


    Deborah
     
  13. Kaleidoscope

    Kaleidoscope Active Member

    I absolutely agree with you Sarah and Bel et al re. 2 people in room!

    Obviously it is not always possible especially since LA can be used routinely BUT I am usually in a clinic with others around whether receptionist or sports therapist (who has also called me in when a Diabetic patient of theirs had a hypo, feinted and bumped head) and I too have other colleagues in (all good for CPD) so that we can discuss tx ideas. I often have student Pods or newly qualified pods wanting the experience and (with Pts consent) are very happy to assist - I also assist other Pods on occasion.

    Re. Above poster from USA who sets everything out first - its NOT the procedure that I need another person to 'help' with as obviously everything should be set out beforehand! Its purely that if things can go wrong they often do when working solo!! Someone needs to stay with the patient (preferably) whilst the other sounds the alarm and waits to direct the ambulance etc. They dont necessarily HAVE to be in room but nearby should anything untoward happen!

    Also having seen another Pt 'fitting' on a chair (a heavy-set man with un-regulated epilepsy) it is difficult to physically keep them on the chair and an extra person really comes in handy here!!!!

    And YES!! I have seen someone react to LA (thankfully when I was a student and assisting another seasoned Pod) thankfully also it was in a hospital! They had had LA previously (but only once) and had an allergic reaction to the drug and their blood pressure went way down (despite being in reclining position) they were seen promptly but the experience has made me very aware of how quickly things can escalate....

    Since now in PP more and more of our patients are diabetic or with multiple health problems I believe it is clinically unwise to perform an invasive procedure solo, insurance-wise also, as this may well leave us open to criticism for not ensuring the pts safety at all times..... just my two-penneth's worth!

    cheers
    Linda Russell
    Darenth Foot Surgery
     
  14. Kaleidoscope

    Kaleidoscope Active Member

    To AW

    Like Foot Root said above when I was working in NHS there was always 2 people for TNA/PNA ops. - doesnt your Trust have the same guidelines? Solo-working such as this leaves the Pod open to being sued should anything go wrong and it is after all the Pod that will get all the flack!

    Frankly I can't believe you even asked whether to carry on performing the op when a Pt has feinted!?? It is imperative that the patient is fully aware and awake (!) whilst having a simple procedure like this, and should they experience any such reaction the Pod should ensure everything is indeed ok before continuing??

    Linda Russell
     
  15. anthony watson

    anthony watson Active Member

    hi Linda

    I am with our US colleague on this.
    if the patient has a simple vasovagal faint and regains composure and is happy to continue why not (no medical reason not to?)

    NHS have policy to follow and it usually donates two people but not always.
    full medical history should rule out any potential medical problems.

    I have found over the years a general fear by many UK pod in using LA.
    podiatry LA is a safe and general risk free,but I understand that problems although rare can happen and patient safety is paramount.

    I would always have staff or help in earshot during any podiatry clinic as it is not safe working in isolation regardless of what we are doing.( home visits aside
    Good points in you thread and this is a good post to provoke discussion.

    Thanks
    Anthony
     
  16. anthony watson

    anthony watson Active Member

    ah Linda
    although tempting to work on patients when out cold i was joking!!!

    You did not think i was serious did you?

    thanks
    Anthony
     
  17. sandra.jones

    sandra.jones Member

    Like a number of colleagues posting I have performed nail surgery single handed for a number of years and it's been a long time since I've experienced any sort of reaction from a patient, be it a faint or anything else.
    Like Nat I make sure everything is laid out close to reach.
    There is always someone in reception, when nail surgery is scheduled, who I have had to call for on occasion, usually because the patient feels nauseous and wants some water; now I keep a bottle of water in the room too!
     
  18. anthony watson

    anthony watson Active Member

    hi guys
    what is your opinion to this taken from the scandonest 3% plain web site and its ref to Oxygen?RISK INFORMATION
    Reactions to Scandonest® are characteristic of those associated with other amide-type local anesthetics. A major cause of adverse reactions to this group of drugs is excessive plasma levels, which may be due to overdosage, inadvertent intravascular injection or slow metabolic degradation. Scandonest® is contraindicated in patients with a known hypersensitivity to it or to any local anesthetic agent of the amide type or to other components of mepivacaine solutions. Local anesthetics should be employed only by clinicians who are well versed in diagnosis and management of dose-related toxicity and other acute emergencies which might arise from the block to be employed, and then only after insuring the immediate availability of oxygen, other resuscitative drugs, cardiopulmonary resuscitative equipment, and the personnel resources needed for proper management of toxic reactions and related emergencies. Scandonest® 2% L contains potassium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. Please see package insert for prescribing information.
     
  19. Kaleidoscope

    Kaleidoscope Active Member

    I did NOT say I wouldnt carry on with the procedure (!) (see end of post), just that I would make absolutely sure the Pt was still ok to continue. So yes of course I am also with the US poster (Nat) regarding continuing the procedure, but just because we have written and verbal consent - we do still have to make sure that post-fainting (apologies for previous 'e') the patient still wishes us to continue, as my consent form gives the patient that ongoing right to 'refuse treatment'.

    AW.
    Im not sure it is a subject I would wish to debate in a teasing way, and neither do I feel this subject warranted your telling us that UK pods are afraid to use LA and then proceed to tell us how safe it is? I use LA in my everyday practice confidently, as Im sure others do, and I dont wish to dwell on the negatives here as it behoves no-one.

    The OP just wanted to know whether in PP it is generally something we Pods undertake solo or not, and clearly it provoked a mixed response, and depends on clinic set up etc. None of which necessarily means we UK pods dont feel able to perform this procedure solo, but rather we endeavour to make sure we have backup if needed to ensure patient safety.

    Regards
    Linda Russell
     
  20. Let's see, I've done about 10,000 local anesthetic injections over the past 30 years into the feet and ankles of my patients and never had systemic complaints from patients during those injections, other than pain.

    In addition, I don't think too many podiatrists here in the US worry about systemic reactions from local anesthetics, such as xylocaine (Lidocaine) or bupivicaine Marcaine), which are the only ones I use. In fact, I don't know of any podiatrists who have ever had any patients develop a systemic reaction to local aneshetic injections into the feet. It can happen, of course, but it is quite rare.

    Also, I can do nail surgery either with or without an assistant, but I am a little faster with an assistant. Once you gain more experience, these injections and surgeries all become a easier over time. The best way to get better is to go and spend a day with a podiatrist who is more experienced in these injections and procedures and you will undoubtedly come away with tips and pearls that will improve your skills for the rest of your practice career.

    Hope this helps.:drinks
     
  21. anthony watson

    anthony watson Active Member

    sorry Linda

    do I know you?
    you seem very peeved with anything I write?

    Thanks
    Anthony
     
  22. anthony watson

    anthony watson Active Member

    hi
    Kevin

    Do you have Oxygen in your surgery as routine?
    what other emergency drugs do you hold as routine in the US?

    Thanks
    Anthony
     
  23. foot rott

    foot rott Banned

    As I work in the NHS we tend to follow policy.
    when i started we used LA in routine clinics and just booked 2 slots out for PNA/TNAs.
    sometimes we had assistants sometimes not.

    However like all work we used to do as general Chiropodists/podiatrists it is all been hived off into "specialisms"
    So now the patient is seen and assessed in the routine/general clinic then is referred off to some other location for nail surgery.
    Usually some pods Band 7 role! to organise.

    It is not uncommon to meet pods in the NHS who have never done a LA since Uni !

    I do envy the pods in private practice as it must be great to use and work with all the things we have been taught to do.

    May leave the NHS soon but worried about getting enough patients to make it worth it.

    Thanks
    Ed
     
  24. None. Is oxygen required to give local anesthetic injections in the UK?

    And by the way, I give all my injections with the patient lying down flat either supine or prone depending on the area of the foot I am injecting.
     
  25. anthony watson

    anthony watson Active Member

     
  26. phil

    phil Active Member

    You people worry too much.

    I've done innumerable solo PNA with phenolisation procedures. What do you need an assistant for? 60 seconds to H block a toe, procedure takes 15 mins tops.

    Never had a vasovagal or systemic reaction to LA.

    It's not brain surgery. It's removing a tiny piece of toenail.
     
  27. Little Sesamoid

    Little Sesamoid Active Member

    Hi all,

    I can understand that the procedure is pretty straightforward and that it can easily be done alone, however, how do you maintain sterility without having to change your sterile gloves and re-scrub 2 or 3 times?

    Just interested how sterility is maintained when you do it alone.

    LS
     
  28. phil

    phil Active Member

    Don't use sterile gloves
     
  29. gdenbyUK

    gdenbyUK Active Member

    Re: Is oxygen required to give LA injections?

    I am a UK private practitioner and always have my receptionist available during LA procedures, in case of any clinical emergencies. I was taught that this is good practice and it makes sense to provide the best patient care you can. Charge accordingly.

    Availability of oxygen is a good precautionary stand-by in case of any fainting, as is a supply of adrenaline in case of anaphylaxis. Oxygen under contract in the UK can be expensive when outside the NHS. A one-off 'diposable' option for emergency use only might be considered. Consider Oxyfit (intended for physiotherapy) at http://www.oxyfit.co.uk/Oxygen-in-a-can-15-Litres-with-breathing-mask-and-tubing/P1082 This can provide 2 litres of oxygen per minute for upto 7.5 minutes, but will require an assistant. A one-off cost of £30, everything shrink-wrapped in plastic and sitting on top of the lockable LA cabinet.
     
  30. Peter

    Peter Well-Known Member

    Weve just been looking at our systems for potential anaphylaxis, and the Advanced Life support advisors stipultaed that Oxygen wasn't necessary to be available in clinic, so long as adrenaline was. (on the proviso that adrenalin is given and the ambulance alerted)
     
  31. anthony watson

    anthony watson Active Member

    hi peter
    when your assessments were done did they look at the manufactures recommendations?

    I think for Scandonest it is suggesting that immediate access to oxygen and resuscitation drugs is needed.
    Is this a thing we need to do as advised by makers?

    The only problem with oxygen is I think it is a prescription only medication usually under a Patient Group Directive.

    I think we don't have this on our POM list.

    You guys in the US and AUS may be able to use oxygen but I dont know.



    So if the manufacture states access to oxygen and resuscitation drugs are advised
    do we need to follow it or not?

    great answers I am enjoying and learning from this post

    :D
     
  32. W J Liggins

    W J Liggins Well-Known Member

    As in so many of these cases, it's really a matter for the practitioner. In the unlikely (but not impossible) event that a case of anaphylaxis occurred, immediate emergency call for an ambulance, appropriate treatment with adrenaline and resuscitation skills would probably suffice to satisfy most requirements. However, if the manufacturer recommended availability of O2 and it was not available then the practitioner would have to support that in court. The BNF suggests regarding O2 as a drug but it is not immediately apparent that it is a POM. In any case, no medical practitioner would state that the treatment was inappropriate - providing of course, that it was. I suspect that the Bolam principle would be the major factor.

    Bill Liggins
     
  33. Little Sesamoid

    Little Sesamoid Active Member

    Hi Phil,

    Thanks for your reply.

    So what you're saying is just open all the packs with non-sterile gloves and then go scrub up?

    How do you open your sterile sheet to put all your instruments on? Do you open everything, then scrub up, open the sterile sheet, place everything on it, prep the pts foot and then go and scrub up again?

    Thanks in advance.

    LS
     
  34. Peter

    Peter Well-Known Member

    On the enclosed literature for our injectables (Marcaine; Depo-Medrone with Lidocaine and Kenalog), no recommendation is given for access to Oxygen. Our current oxygen cylinder didn't need a PGD (whereas we have for the corticosteroids and adrenalin).
     
  35. anthony watson

    anthony watson Active Member

    hi peter
    Can you do me a favor if have time.
    Could you look at the instructions on the Scandonest site and let us know how you read them.

    Its just to me it seems to indicate Oxygen and resuscitation drugs ?

    In recent NHS work there is always an oxygen bottle and adrenaline available did ask about the POM thing and the nurse told me the Doctors need to initiate Oxygen therapy.

    A few years back did have to do PGD for Oxygen.

    Thanks in advance
    Anthony
     
  36. W J Liggins

    W J Liggins Well-Known Member

    It may be the case that a nurse requires a Dr of Medicine to initiate O2 therapy; however, you are an independent practitioner and you do not (please see BNF). (Some nurses are prescribers and would not anyway). The other point is (and I am serious), would you let a patient die because '(a) nurse told (me) that the Doctors need to initiate Oxygen therapy?' The chances of anaphylaxis occurring are remote, and if true anaphylaxis did, then the patient would probably die if immediate Advanced Resuscitation facilities were unavailable BUT (emphasis not shouting) you have taken the responsibility for that patient and I ask: do you let them die or do you do everything within your power to prevent that happening, even if some person, or some politician or some document has informed you that a specific action might be considered improper?

    Bill Liggins
     
  37. anthony watson

    anthony watson Active Member

    this is from one of the NHS policies on O2



    • In the emergency situation oxygen prescription is not required. Oxygen should be given to the patient immediately without a formal prescription or drug order but documented later in the patient’s record.

    • All peri-arrest and critically ill patients should be given 100% oxygen (15 l/min reservoir mask) whilst awaiting immediate medical review. Patients with COPD and other risk factors for hypercapnia who develop critical illness should have the same initial target saturations as other critically ill patients pending the results of urgent blood gas results after which these patients may need controlled oxygen therapy or supported ventilation if there is severe hypoxaemia and/or hypercapnia with respiratory acidosis.

    • All patients who have had a cardiac or respiratory arrest should have 100% oxygen provided along with basic/advanced life support.

    • A subsequent written record must be made of what oxygen therapy has been given to every patient alongside the recording of all other emergency treatment.

    • Any qualified nurse/ health professional can commence oxygen therapy in an emergency situation as indicated in the management of the acutely unwell patient.


    seems a fair statement
     
  38. Peter

    Peter Well-Known Member

    I don't use scandonest Tony, so am reluctant to look. I'll take your side of events, but in reality, our Advanced Life Support decision makers in our trust have said they are happy for us to have access to adrenalin alone ( we are going to update our oxygen though, as the clinicains have told the decision makers that we want it, and they have agreed).

    I'm lucky though, I work in a big primary care centre only 2 mins drive away from A+E via ambulance.
     
  39. anthony watson

    anthony watson Active Member

    hi peter

    Do you guys use Marcaine for nail ops?
    just ask as long lasting and not recommended in kids.

    I only ever use it when longer pain reduction needed.

    Thanks
    Anthony
     
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