Should nail surgery be conducted in a hospital or within the community?

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Should nail surgery be undertaken in a hospital setting, either by Orthopaedic or Podiatric surgeons, or in the community setting by Podiatrists?

I think that we should continue to do it in a community setting but wondered what other people thought about it.

Thanks

 

It's a simple enough procedure with, I would hope, low complications, such as infection. It would far more cost effective all around for these to be done in the community rther than taking operating room time and space.

 

Depends on the general health risk category of the patient concerned. In very young patients and certain special needs patients I prefer to do it in theatre so that a general anaesthetic can be given. Problem is often obtaining theatre time which surgeons guard like gold.

 

What would you consider a health risk to move from community to hospital? I agree with the young children, costs more and they generally have to wait longer to be seen but can be a lot better from both patient and practitioner point of view.

 

Maybe I am over cautious but any patient with previous history of allergic reaction to local anaesthesia also those with a history of porphyria (we have quite a few of those in SA). I am compliant with patients wishes where sensible and possible. I work in the private health sector so if patients insist on general anaesthesia rather than local I try to be obliging if their medical insurance gives the go ahead or they are prepared to pay out of their pocket

 

Nails should be done in the office. It's a 5 minute procedure that is already a "dirty". To bring this to an operating room is not warranted.
That being said, if you do nail procedures and just do not have the setup for it in the office (for whatever the reason) and the local hospital has a "minor" room, then I think it would be appropriate to use it.
Allergies to Locals?
I have done literally thousands of nail surgeries in the office using lidocaine and have never had a TRUE allergic reaction.
Never.


Steve

 

Porphyria

http://porphbook.tripod.com/2.html


Jose Antonio Teatino
Licenciado en Podología
Profesor de cirugía
The Academy Ambulatory Foot & Ankle Surgery

 

It would be interesting to do a risk assessment comparing putting a child through a GA as opposed to an LA. I've done nail surgery on kids as young as 6 and frequently in kids from 10 up. Never had a problem.

GA is not a "soft option". For me this puts the patient at unacceptable and disproportionate risk. I would think if they were THAT nervous, IV sedation or entonox for the LA would be more sensible.

 

As in most questions, the answer is 'yes and no'. It depends on the patient and it depends on the nail surgery. If you are referring to Phenol 'matrixectomy' either partial or total then there is no reason that the procedure should not be carried out in a community setting providing the patient is appropriate for that treatment.

I don't agree Robert that the risk of GA is either unacceptable or disproportionate. Many Anaesthetists believe that modern inhalation techniques are less risky than the potential outcomes of IV sedation. Having just dealt with a case of anxiety hysteria with seizure, I know that the patient would have been at far less risk cared for by a qualified Anaesthetist using GA and allowing me to get on with my job - and a qualified nurse was with me. I agree that some very young children can be treated under L.A., but some cannot. It's really a case of 'horses for courses'.

All the best

Bill

PS for 'office' in the USA read 'surgery' in the UK.

 

Care to justify that. 99.9% of nail surgery is currently done in the community in Australia and I have never heard of a problem.

 

this is a crazy thread.

Whether the use of local anesthesia in an office setting is safe IS NOT IN QUESTION.

Of course it is safe.

Literally MILLIONS of procedures are done under local anesthesia yearly without any complications, from podiatry to dermatology to family practice, dentistry....on and on.

Just to ease your mind re: ALLERGIES, most patients that give a hx of an allergy to LA are, in fact, not allergic.
Anyone with a true allergy would be placed in the EXTREMELY RARE category.

When asked, most of these "reactions" are during dental procedures when either lidocaine was absorbed into the blood stream (toxic rxn) or Lidocaine with epi was used and the patient had palpitations or the expected increased BP and pulse from the epinephrine. Many are also vasovagal reactions. At times locals maybe inadvertently injected into a vessel. These are not allergies, just poor technique.

My 2 cents: If you are afraid of local anesthesia you simply are not trained sufficiently to use it.

Steve

 

Steve:

I agree. No one that has good training in local anesthetic use in the foot would do toenail surgery in a hospital setting over an office setting.

 

I am lucky to work with a team of vascular surgeons, if I am uncertain I ask their opinion. I have had one true allergic reaction in a 16 year old girl approx 20 years ago, fortunately I was working in a hospital setting at the time. I have been working in my field for 31 years so I agree it is rare.

 

I tend to agree with many of your points and you are certainly entitled to your opinion, as are others. However, there is absolutely no need to be rude and to'shout'. I too have done probably thousands of phenolisations in a surgery (that is, not an operating theatre) setting with no problems. However, as I mentioned in a previous post, I did have a case of hysteria recently, which, in my view, would have better been dealt with under G.A. - there was no Hx in the consultation. In addition, I think that the guidance and accepted protocols are different in the USA and the UK. If a procedure requires incision to bone level eg. Winograd/Zadeks excisions/simple arthroplasties, then accepted procedure here is to use an operating theatre. Procedures which do not breach the common integument, plus other skin surgery techniques are considered appropriate for treatment in surgery's.

All the best

Bill

 

WJ
I wasn't being "rude" nor was I "yelling"

When I choose to be rude you will know it.

I was making a point. Apparently I was successful.

Steve

 

Steve

I'm afraid that you were being both rude and 'shouting'. It may be that I am incorrect and that you are simply unaware of forum manners. If you type your comments in upper case it is indicative of shouting. To indicate that you believe that the OP's question is "crazy" is, per se, rude.

As I mentioned in my post, you are entitled to make your point and to express your opinion. I can assure you that your view will bear more weight on a scientifically based forum if you are calm and considered rather than rude and arrogant.

Kind regards

Bill

 

FYI: Upper case also means that one is placing extra significance to a selected part of a post or thought.

I think this thread is crazy. That isn't rude it's my opinion. Are you OK with that?
Perhaps I should sent any future posts to you so I can have them edited and checked over for any possible forum incorrectness.

Perhaps you are just overly intolerant or perhaps looking for something to be upset about. It a podiatry forum, lighten up a bit.

And thank you for ALLOWING me (not shouting here!) to make a point.

Very kind of you.

I can't believe I'm even waisting my time responding to you. Let's move on, I'm sure you have more important things to do (I hope so at least)


Steve

 

It appears that most people agree that nail surgery, in this instance I am referring to Phenol 'matrixectomyrather than more invasive procedures, should be conducted in the community setting due to the relative low risk or complications and the high success rate of the procedure.

For those working in hospital settings, does anyone have an idea of how many procedures are carried out by Pod's compared to orthopaedics?

 

Our pod department (2 of us) has only conducted 1 PNA in the 2.5 years I have been at the hosp. Management feel more comfortable for the GP at the treatment room to perform nail surgery, as they are assisted by a nurse. Reason being, they are more equipped to deal with reactions to anaesthetic.

I think this is a crazy idea, and taking away a skill of our profession.

As a uni student I performed heaps of PNAs with no problems whatsoever!

 

Paul,

Where I am all nail surgery (as far as i'm aware) is done by the community Podiatry team. This has been the case in each trust i have worked in. Now i'm not to know if ortho or general surgery get a few tossed there way by their GP friends however i would imagine it be very small.
Working in the Pod Surg department i do get 1 or 2 a week referred by Podiatry as it is "high risk" nail surgery (whatever that means?).

The very notion that a trust would prefer a GP to do it is mad, i know a few dabble in their minor treatment rooms every now and then but for a trust to actually prefer it, beyond belief.

Paul, i have a couple of papers lying around somewhere which look at nail surgery comparisons between Pod's, GP's, ortho and general surgery and shall try and dig them out for you.

(actually as a coincidence, i friend of mine who is a trainee gynae was on a general surgery rotation and scrubbed for a winograd, knowing me he asked the consultant why this had come to him and not a podiatric surgeon. His actually words were, Podiatrists only perform surgery in America, they don't do it here!! :bang

 

& SPAIN


Jose Antonio Teatino
Licenciado en Podología
Profesor de cirugía
The Academy Ambulatory Foot & Ankle Surgery

 

Hi All

I'm going to put the cat among the pigeons now.

I had a pt in last Saturday with Bilateral septic oc/ox slight convolution. Been self Tx for many years now cannot reach / nails too thick to cut ( butcher) herself.

She has had much surgery in her life on her spine and shoulders.

When I was clerking her in, she informed me she was allergic to Lignocaine and had suffered an anaphalactic episode when she was given it for dental Tx which is now performed in hospital under GA.

I Tx with palliative care and sent her off to her GP for onward referral to NHS podiatry. I can only believe what the patient tells me so......
Cheers
D ;-)

 

If a patient told me they'd had an anaphalactic reaction to any LA I would touch them with a 60 foot pole. I definitly would not touch her with LA!!!

 

My feelings exactly Rob, she has been to her GP for A/B's and is returning here for follow up to check the infection has resolved. The GP requested a referral letter which is on my desk for the patient to take personally.

Get here early Friday M8 and you can meet her ;-)

Cheers
D ;-)

 

I wonder what is wrong with this profession at times.

Disposable instruments????:deadhorse:

If you go into hospital to have brain surgery you will have autoclaved instruments.

Dentists also use autoclaves and they are far more invasive than we are. They go into bone every day.

So why do we seem to be going down the single use crappy blunt hopeless instrument route.:deadhorse:

Also dentists administer L/A all day long and they work primarily in PP in their own commercial premises.

So why are we seeking to increasingly make ourselves an impossible profession to treat patients.

I have , as have many colleagues, used LA safely and uneventfully for 25 years.


Good history taking and selection of pts will reduce the risk for pts and ourselves.

When i graduated and joined the nhs in 1986 we used a bucket of piss (chlorhexidine gluconate solution) and 1 set of instruments for 20 pts.

Infection rate to my knowledge was zero.:craig:

So now with single use instruments we will create a catlogue of ruined hands and careers for what appears to be political expediency by managers.

So lets look at what our Dental colleagues do and follow their practice protocols for infection control and decontamiantion and sterilisation of instruments.

Ho Hum

David

 

Hi Dave

I cant comment on the disposable instruments coz I dont use them, but I have seen them and the ones I saw were clumsy cheap rubbish.

What would your reaction be in PP if a Pt told you what my Pt told me ??

The same as Robert and I??


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OR ?????

Cheers
Derek ;-)

 

As i said take a good history.

if the patient informs you of an allergy/adverse reaction to a drug that i was considering administering then i would

Refer to the Hospital setting where alternative drugs could be used, even up to and including a general anaesthetic.

A bit extreme for a procedure that can be safely done in a community setting using a local.

But where the risk is an adverse reaction the decision is easy.

One interesting thing.

i recently worked in Aus for 4 years and in that time used Latex gloves exclusively.

I never met anybody with a latex allergy.

Here in the NHS i used non latex gloves for several years due to the risk of t/t a pt with a sensitivity/allergy.

I sometimes think we go over board with risk limitation/elimination.

There is a trade off in everything, one has to select where that trade off should be.

David

 

Hi Dave

Take a good Hx ? yes I did that but dont you think that as a rule the patients with the known problems ,latex allergies,or any serious allergy are usually giving it loads from the minute they arrive ?? Which reduces the problem even more coz we are looking for the unknown allergy patient that MAY emerge ??

Yes I agree I believe we go over the top on many things because of the million to one chance a patient may react and sue.

I don't know if the accountants have worked out the cost of prevention against the cost of claims ??

We live in a litigious society where the Lawyers are the bain of every professionals life, and that is where the whole thing stems from.

Incidentally I also have had a few patients with latex allergy ( cant use condoms etc) but I keep a couple of boxes of non latex gloves around for them.

Cheers
D ;-)

 

"I wonder what is wrong with this profession at times."

I'm with you.

Steve