Bunion Surgery in office?

[Hanjason]

Hello guys
I just saw this clip on youtube... I was just wondering how safe is it to do a surgery in office? Is this how it's done normally?..

here's the link

http://www.youtube.com/watch?v=NkTHP7QmIIk

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[Feli]

With evidence based medicine, the standard of care is getting to be more of a nationwide quality level as opposed to local/regional. Bunions in the office have been getting phased out for awhile now. Not sure when that video was taken... 20-30yrs ago, then it's totally within the norm. 10yrs ago, maybe gray area. Today... not so much.

A few experienced docs I've shadowed or rotated with in private practice have an old "surgery suite" room sign still hanging in their office, but it's usually just a relic... most/all have since turned it into another patient exam room or storage room. In-office surgery is being largely replaced with ambulatory surgery centers across the street, down the road, etc. The surgery centers and medical centers have anesthesia providers, more surgical supplies, and more options for pain control, monitoring, possible 23hr admit, basic/advanced life support, etc which the private practice offices would not have. They can just provide a higher level of care; yeah, it's at a higher cost, but in today's medico-legal environment, that's just how it's usually done. Hospitals or major medical centers are where most major surgery F&A is done when a subsequent inpatient stay might be anticipated for post-op pain control, monitoring, assistance with recovery, physical therapy, etc. A lot of private practice docs prefer the surgery centers to big hospitals due to faster turnaround times, easier scheduling, OR staff more familiar with pod surg, etc... but when it's a case that dictates possible multi-day hospital stay, they will usually bring it to the hospital.

Does some in-office surgery still occur? Yeah, a lot of docs will do minor derm surgery, quick hardware removals, nail procedures, or maybe percutaneous hammertoe tenotomies for diabetic/geriatric hammertoes, etc in the office under local anesthesia. However, if you see docs still doing bunions, amps, midfoot, etc surgery in the office, that is starting to fall outside the typical standard of care for today's F&A surgery. There is probably more leeway in rural areas where hospitals and surgery centers might be few and far between. Still, if you see guys doing most/all of their bone and joint procedures in the office under straight local anesthesia - esp in a major metro area where they have many nearby surgery ORs, then I'd sorta begin to question if they are board cert and have hospital operating privileges. JMO

 

[PADPM]

Feli,

Excellent reply/post. In addition to your accurate response, some docs still remove a small bony prominence/"exostosis" or perform a single arthroplasty in the office.

The rationale is often that this 10 minute procedure can often become quite time consuming by the time you drive to the hospital or surgery center, perform the case, complete the paperwork, drive back to the office, etc., etc.

I am NOT advocating that position, but I am simply repeating the reasons I often hear. One of our offices has an approved "O.R.", but the only procedures performed are soft tissue lesions and an occasional ganglion, hardware removal, etc.

I perform ALL my cases in the hospital or surgical center with the exception of nail procedures, superficial soft tissue procedures such as biopsies and simple hardware removal. I do not perform any bone surgery in the office.

 

[Podfather]

When hospital privileges were difficult to obtain (1970-80s) many DPMs did office surgery. Now it is rarely done because of hospital access and the lack of reimbursement by insurers for your costs. Many cosmetic surgeons and some maxillofacial surgeons still do surgery within office suites.
Since anyone can do office surgery one must use caution since there is no credentialing process ( as a hospital would require) to ensure the surgeon is trained and experienced in the procedure they are performing. If sedation is being used, one must be positive that the surgeon has the appropriate monitoring, training, and emergency equipment to handle a medical emergency.

 

[hightower]

This brings up another question in my mind. Is it under DPM scope to push I.V. sedatives like propofol? I know of an older dentist (oral surgeon?) who pushes propofol during wisdom teeth extraction (90% of his practice). I do think he did a anesthesia fellowship or something though. But it seems like a large number of dentists practice sedation dentistry. I'm just wondering if DPM's can do sedation if ever warranted (like a medical mission, unique office situations, etc), or would we need an anesthesiologist on board?

 

[Podfather]

This brings up another question in my mind. Is it under DPM scope to push I.V. sedatives like propofol? I know of an older dentist (oral surgeon?) who pushes propofol during wisdom teeth extraction (90% of his practice). I do think he did a anesthesia fellowship or something though. But it seems like a large number of dentists practice sedation dentistry. I'm just wondering if DPM's can do sedation if ever warranted (like a medical mission, unique office situations, etc), or would we need an anesthesiologist on board?

Many states prohibit DPMs from administering general anesthesia. Inducing a patient with propofol would be an issue in those states. DPMs are permitted to use IV sedation if they want to. I have given this in the ER prior to fracture reduction or in monitored settings as sedation within a OR. Technically it coulde be done in an office. Oral sedation is often used for patients who may require a painful procedure within the office or in anxious patients for even suture removal. The key point is no one of any degree should be administering sedation in the office without the proper training, monitoring equipment, and appropriate emergency drugs/equipment.

 

[Feli]

Propofol, etomidate, IV benzos, etc are something I'd never even consider... big difference between what you "can do" and what you should. Consider your training level and experience with sedation as opposed to other professionals, and know when you are playing with ethical/legal fire. As Podfather said, plastics and maxillofacial might do office sedation, but they also usually have higher training in use of those Rx and what amounts to almost surg center in/attached to the office... AED, crash cart meds, EKG, probably a CRNA or anesthesiologist on site or on call in the hospital across the skywalk/street, etc. Do you have that in your facility?

A valium tablet on the other hand? Maybe that could be dispensed to a healthy, anxious pt prior to a pod office PNA, derm lesion removal, hammertoe or met fracture k-wire removal, etc... depends pt, circumstance, and on the laws. Better also be darn sure your procedure consent is done and post procedure instructions are done prior to administration and the pt has a driver afterwards.

 

[hightower]

Thanks for the replies to my inquiry. I was just curious about sedation scope, not that I want to do such in the future or think other pods should work out of scope or without the proper resources, etc etc. This leads me to another question (sorry I am just very curious about certain things). Have you ever had a patient crash on you during surgery or heard of such happening to another DPM? At that point I assume the anesthesiologist runs the code and you help him in whatever he directs you to do (chest compressions, breathing, etc)?

 

[NatCh]

Thanks for the replies to my inquiry. I was just curious about sedation scope, not that I want to do such in the future or think other pods should work out of scope or without the proper resources, etc etc. This leads me to another question (sorry I am just very curious about certain things). Have you ever had a patient crash on you during surgery or heard of such happening to another DPM? At that point I assume the anesthesiologist runs the code and you help him in whatever he directs you to do (chest compressions, breathing, etc)?

I used to work for a doc who did bunionectomies in the office surgical suite fairly often. He does have hospital privileges, but the main reason he did it in the office was to expedite and simplify the whole process. I assisted him several times and it always scared the heck out of me since there was no backup equipment such as a hospital or surgery center would have. As far as I know, nothing bad has ever happened to the patients other than the usual realm of complications that might occur regardless of surgical venue.

He would use straight local anesthesia and the patient would be completely awake and coherent for the entire case. No sedation was really needed.

It always made me too uncomfortable to operate on my own patients in the office though.


No patient has ever crumped on me during surgery, but in such an event I think our job would be to stabilize the surgical site as quickly as possible (close the incision, apply bandages) while Anesthesia runs the code.

 

[krabmas]

Thanks for the replies to my inquiry. I was just curious about sedation scope, not that I want to do such in the future or think other pods should work out of scope or without the proper resources, etc etc. This leads me to another question (sorry I am just very curious about certain things). Have you ever had a patient crash on you during surgery or heard of such happening to another DPM? At that point I assume the anesthesiologist runs the code and you help him in whatever he directs you to do (chest compressions, breathing, etc)?

Patients that have coded or come close in OR:

1. Patient was in asystole, full code and brought back, circulator did chest compressions, those scrubbed in stayed sterile, wound was closed quickly and pt brought back to OR different day.

2. Pt had rxn to abx in pre-op, taken to OR and full code ran, case cancelled, pt survived.

3. pt yesterday in OR had SBP of 44. He did fine and no code was run.

Those are all I can remember.

But, typically anesthesia runs the code and many people come running into the room when the code is anounced.