knife? 10 or 15?

[europeman]

I'm a pgy2 and no one can tell me why the knife is numbered.


like a ten blade as opposed to a 15 blade.... where does the number come from? ahh now i'm mixed up which one is the little one? anyway, i understand french w/chest tubes.... but blade numbers? anyone know?

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[Dr.LeoSpaceman]

Numbering is based on the size/shape of the blade.

 

[Buzz Me]

Maybe the confusion arises from the arbitrary numbering system (e.g. why is a #10 blade bigger than a #15, but smaller than a #20)?

 

[Winged Scapula]

Maybe the confusion arises from the arbitrary numbering system (e.g. why is a #10 blade bigger than a #15, but smaller than a #20)?

I know it contributes to my confusion on the topic. Has anyone used a #12? What is that barbaric thing for?

 

[JackADeli]

...Has anyone used a #12? What is that barbaric thing for?

I have used it numerous times. It is real useful getting under a tight suture loop when removing sutures.... i.e. ER tied down chest tube. The blade hook allows you to not have to tug on the suture. They actually come in nice disposable versions with plastic handle and all.... good for office suture removal... especially when the suture was put by someone else and again, tight and embedded.

 

[Winged Scapula]

I have used it numerous times. It is real useful getting under a tight suture loop when removing sutures.... i.e. ER tied down chest tube. The blade hook allows you to not have to tug on the suture. They actually come in nice disposable versions with plastic handle and all.... good for office suture removal... especially when the suture was put by someone else and again, tight and embedded.

I can see that as a good use...but what is it designed for?

 

[JackADeli]

I can see that as a good use...but what is it designed for?

I think that sort of "hook cutting" is exactly what it is designed for... though I wasn't on the committee.

http://www.swann-morton.com/product/22.php

 

[Fah-Q]

I can see that as a good use...but what is it designed for?

I use it during parotids. Dissect over the facial nerve and then divide the tissue superficial to it with the 12 blade.

 

[rebel7]

Only used it for removing sutures! it's a claw :|

 

[Buzz Me]

I know it contributes to my confusion on the topic. Has anyone used a #12? What is that barbaric thing for?

We sometimes use it to make an initial incision into a vessel, i.e. for arteriotomies or venotomies.

 

[Winged Scapula]

Huh...ok, thanks guys. I don't recall ever using it - we have 11 blades in the office for cutting sutures and I used those for arteriotomies.

 

[Leforte]

As above, #12 is excellent for parotid surgery. Allows you to cut upwards away from the facial nerve delicately without "painting" the area to be cut as you would with a #15. There are important caveats with that blade, but no more than any other.

 

[Pir8DeacDoc]

In addition to parotid surgery it can also be used to make mucosal cuts on a septoplasty if you desire to do them endoscopically. It's a nifty blade, in the right places.

 

[pnle119]

i've used it as a letter opener

 

[tussy]

I have one to use when my resident places a hemorrhoid band a little too low.

 

[maxheadroom]

The #12 is useful to release the oral mucosa from the nasal mucosa when you're closing a cleft palate. That's the only time I've ever used one.

 

[toxic-megacolon]

WS, have you ever used a #22 for a mastectomy? Its fast, but a bloody mess.

 

[ESU_MD]

what number is the beaver blade?

 

[Winged Scapula]

WS, have you ever used a #22 for a mastectomy? Its fast, but a bloody mess.

I use the 15 to open skin and the Metz and Bovie for dissection; blunt dissection as much as possible in the axilla. The reps used to try and sell me on the Harmonic - too slow. Time is money.

I do not like bloody messes. This is not orthopaedics.

 

[PostLessOne]

I use the 15 to open skin and the Metz and Bovie for dissection; blunt dissection as much as possible in the axilla. The reps used to try and sell me on the Harmonic - too slow. Time is money.

I do not like bloody messes. This is not orthopaedics.

As an idealist medical student, I don't like that statement. That's terrible that you have to consider using bigger knives because you want to speed through a surgery to make more money. I know it's reality, and that if done properly it doesn't endanger a patient, but still it's terrible that time is a concern due to the money involved.

 

[Dimoak]

As an idealist medical student, I don't like that statement. That's terrible that you have to consider using bigger knives because you want to speed through a surgery to make more money. I know it's reality, and that if done properly it doesn't endanger a patient, but still it's terrible that time is a concern due to the money involved.

"Time is money" does not have to be inferred literally. It can also simply be stated to emphasize the importance of being as time-efficient as possible (which improves outcomes, among other things).

 

[PostLessOne]

"Time is money" does not have to be inferred literally. It can also simply be stated to emphasize the importance of being as time-efficient as possible (which improves outcomes, among other things).

Oh. I was thinking she meant "if the operation takes 20 minutes instead of 40, I can squeeze another case in today and collect another few hundred bucks"

 

[MattD]

Oh. I was thinking she meant "if the operation takes 20 minutes instead of 40, I can squeeze another case in today and collect another few hundred bucks"

That's not necessarily UNtrue, but also consider that a.) extended anesthesia time is worse for the patient, and b.) in many situations, the cost of OR time is charged by the minute, so by doing the case in half the time, yes in theory you can do twice the cases, but perhaps more importantly the cost of the procedure is significantly reduced if it is done more quickly.

 

[PostLessOne]

That's not necessarily UNtrue, but also consider that a.) extended anesthesia time is worse for the patient, and b.) in many situations, the cost of OR time is charged by the minute, so by doing the case in half the time, yes in theory you can do twice the cases, but perhaps more importantly the cost of the procedure is significantly reduced if it is done more quickly.

But insurance reimbursements are based on the procedure you did or on a fixed cash price that the patient agreed to pay ahead of time. They are not based upon how much it actually cost you to do the operation. So if the O.R. cost $10/minute, then every extra minute is -$10 directly from your pocket?

 

[maxheadroom]

I think a Beaver Blade is a #64, but I couldn't find a reference.

What's wrong with time being money? If I can be more efficient in the OR and do more cases in a day, shouldn't I be able to enjoy the reward of more money? Furthermore, the Harmonic is a relatively expensive piece of equipment, especially compared to a knife, Metz, and Bovie.

Chung Mee: Opium is my business. The bridge mean more traffic. More traffic mean more money. More money mean more power.
Lawrence Bourne III: Yeah, well, before I commit any of that to memory, would there be anything in this for me?
Chung Mee: Speed is important in business. Time is money.
Lawrence Bourne III: You said opium was money.
Chung Mee: Money is Money.
Lawrence Bourne III: Well then, what is time again?

 

[PostLessOne]

I think a Beaver Blade is a #64, but I couldn't find a reference.

What's wrong with time being money? If I can be more efficient in the OR and do more cases in a day, shouldn't I be able to enjoy the reward of more money?

Yes, but it creates a conflict. What if being 'more efficient' requires that you take a few shortcuts. Now, let's assume the net effect of your shortcuts is that you increase the rate of complications from 1% to 1.1%. You'd never even notice a difference. Still kind of disturbing, especially to a patient.

 

[Fah-Q]

But insurance reimbursements are based on the procedure you did or on a fixed cash price that the patient agreed to pay ahead of time. They are not based upon how much it actually cost you to do the operation.

Yes, they are.

I would suggest some reading on the relative value unit (RVU) - http://www.acro.org/washington/RVU.pdf

Oh. I was thinking she meant "if the operation takes 20 minutes instead of 40, I can squeeze another case in today and collect another few hundred bucks"

I agree. This is probably what she meant. I fail to see a problem with this.

I applaud your admission of being an idealist. Your next step should be recognizing that it might be inappropriate to assail the patient care decisions and motivations of a well-respected surgeon and moderator.

More on topic, I have also used the 12 blade for palate surgery. I would love to get my hands on that 22 blade for raising huge anteriolateral thigh or latissimus flaps.

 

[Winged Scapula]

As an idealist medical student, I don't like that statement. That's terrible that you have to consider using bigger knives because you want to speed through a surgery to make more money. I know it's reality, and that if done properly it doesn't endanger a patient, but still it's terrible that time is a concern due to the money involved.

You have COMPLETELY misunderstood. No where did I say I used a bigger knife to speed through a surgery, more money or not.

I was asked if I used the #22 for mastectomies. I responded that I did not, that I used the SMALLER 15 blade.

Secondly, no where did I say I chose to do use the knife to "speed through surgery to make more money". I said I used the knife on the skin and then the Metz and the Bovie on the deeper tissues - these are SLOWER than using a knife for mastectomies. There is also less bleeding which is better for the patient.

Thirdly, I mentioned the use of the Harmonic (which was, up to a few months ago, a hot item hustled by the reps for use in breast surgery) and said that I didn't use it "because time is money". This refers to the fact that:

1) the use of this equipment is more time consuming
2) more time in the OR means more expense to the patients and their insurance
3) more time under anesthesia
4) a *very* expensive tool which will be billed to the patient/their insurance

When you consider the above, the fact that the equipment is not necessarily better (ie, I have seen no real evidence that it actually reduces post-operative seroma which is what they were selling it for), and the fact that if I take more time to do a case than is necessary, then someone else has to wait for their surgery. I try to get my patients into the OR as soon as possible; the more time I take *than necessary* for each patient, the fewer cases I do per day, the longer someone has to wait.

Finally, I see nothing wrong with wanting to make more money. If that was my motive I wouldn't have chosen this specialty, nor would I be in the OR - believe it or not, I make more for an office based biopsy than I do a mastectomy.

 

[skiz knot]

what number is the beaver blade?

I'm pretty sure the "beaver blade" is No. 69.

 

[gudog]

I can see that as a good use...but what is it designed for?

Traditionally, the 12 blade is used for ureterolithotomies and pyelolithotomies. No other blade opens a ureter or renal pelvis as well.

 

[Dimoak]

I thought beaver blades were measured in mm?

 

[Cruzinman]

No. 24 blade works best for the Y-incisision for autopsies. And we use electric cast cutters to remove the breastplate, not the hedging shears you see on Dr. G.

 

[MattD]

But insurance reimbursements are based on the procedure you did or on a fixed cash price that the patient agreed to pay ahead of time. They are not based upon how much it actually cost you to do the operation. So if the O.R. cost $10/minute, then every extra minute is -$10 directly from your pocket?

It was for the cash cosmetic procedures our plastics guys did (according to them anyway). One of the attendings was constantly talking about how much unnecessary anesthesia time cost him. I don't know much about billing so I just took his word for it, maybe they do things differently from people elsewhere.

 

[Winged Scapula]

It was for the cash cosmetic procedures our plastics guys did (according to them anyway). One of the attendings was constantly talking about how much unnecessary anesthesia time cost him. I don't know much about billing so I just took his word for it, maybe they do things differently from people elsewhere.

That's odd...our guys will quote separately for procedure, OR and anesthesia. Perhaps your guy quoted a flat fee for surgery at an ASC and they paid anesthesia out of that fee (so if the time was longer, the fee paid to the gas provider was higher).

 

[JackADeli]

what number is the beaver blade?

I'm pretty sure the "beaver blade" is No. 69.

I thought beaver blades were measured in mm?

Any reputable/experienced practitioner will tell you a quality "beaver blade" is measured in number of inches over 6".

 

[SocialistMD]

That's odd...our guys will quote separately for procedure, OR and anesthesia. Perhaps your guy quoted a flat fee for surgery at an ASC and they paid anesthesia out of that fee (so if the time was longer, the fee paid to the gas provider was higher).

I think what was meant (by the attending who made the statement, not necessarily how it was understood) is that the lag in anesthesia time throughout the day meant 1-2 fewer cases could be done each day (as in, "I could do 8 hernias in this 9 hour day, but I'll only get through 6 because anesthesia keeps dragging their feet!")

 

[MattD]

I think what was meant (by the attending who made the statement, not necessarily how it was understood) is that the lag in anesthesia time throughout the day meant 1-2 fewer cases could be done each day (as in, "I could do 8 hernias in this 9 hour day, but I'll only get through 6 because anesthesia keeps dragging their feet!")

Yeah, it's entirely possible I misunderstood, but he was even quoting numbers like "it costs me $x/minute of time wasted under anesthesia", which is why I interpreted it the way I did. Who knows?

 

[SocialistMD]

Yeah, it's entirely possible I misunderstood, but he was even quoting numbers like "it costs me $x/minute of time wasted under anesthesia", which is why I interpreted it the way I did. Who knows?

I don't really know what your attending meant, either; I just know I have heard attendings complain about the same thing and they were talking in terms of what I mentioned.

 

[Winged Scapula]

I don't really know what your attending meant, either; I just know I have heard attendings complain about the same thing and they were talking in terms of what I mentioned.

In residency and fellowship there was always "MAFAT"; out in PP anesthesia goes home when I go home, so they are sometimes waiting for me while I'm eating some choice physician's lounge chow.

 

[Guile]

In residency and fellowship there was always "MAFAT"; out in PP anesthesia goes home when I go home, so they are sometimes waiting for me while I'm eating some choice physician's lounge chow.

Ahhh yes, mandatory anesthesia eff around time. Surgery has the best acronyms.

 

[Bill59]

I thought beaver blades were measured in mm?

BD makes a bunch of different Beaver blades. The common ones are:
#63 -- pointed tip, sharp on both sides
#64 -- rounded, sharp on one side
#65 -- looks like a small Bard-Parker #11
#67 -- looks like a small BP #15
#69 --straight with curved tip, sharp all around

The numbers are arbitrary (based on BD catalog #)