W. G. (Bill) Hefner VA Medical Center - Salisbury, NC
Wide Awake Hand Surgery Experience
On Nov. 23rd, 2016, Dr. Jeffrey A. Baker, a hand and upper extremity specialist, introduced a relatively new technique called Wide-Awake Hand Surgery to the Salisbury VA Medical Center. Baker used this technique in his private practice for almost two years before starting at VA.
He was introduced to the technique during a presentation at a University of Florida Hand Fellows Meeting, given by Dr. Paul Gorman from Johnson City, Tenn. Baker later visited Gorman to observe the procedures. After the experience, Baker began performing similar procedures in his office, then brought the technique to the VA.
Wide-Awake Hand Surgery was adapted from the WALANT (Wide-Awake Local Anesthesia No Tourniquet) technique of Canadian hand surgery pioneer Donald H. Lalonde, MD. The procedure does not require general anesthesia for the surgery. Patients can be fully clothed and receive local numbing medication to the affected area. Once it takes effect, the surgery is performed. After the procedure, patient is given post-op instructions and leaves the procedure room unassisted, to go about the rest of his or her day. They also may eat and drink prior to surgery.
Since 2016, the practice has been streamlined to allow about 12 patients to have minor hand surgery, such as carpal tunnel releases, trigger finger releases, ganglion excisions, mass excisions, De Quervaine releases, Dupuytren’s releases, tennis elbow surgery and ulnar nerve releases at the wrist every Friday morning. Most of the procedures take between five and 15 minutes to perform under local anesthesia.
The surgery does not require antibiotics because it is a soft-tissue procedure, and patients do not have to hold any of their diabetic or other medications, except some blood thinners. No IVs or medications are needed prior to the procedure. The environment is very interpersonal, as surgeons and staff talk with the patient throughout the procedure. The use of narcotics is essentially eliminated because the patient is awake and realizes how quick and simple the procedure is.
Using this technique has greatly improved access to care for Veterans. Although the number is growing, few orthopedic surgeons in the private sector use the new technique. Dr. Baker said he believes that we are the first to do so at any VA, especially with this level of access and timeliness. Typical VA system OR procedures allow three to five of these cases in an entire day compared to the 12 Baker completes every Friday morning.
Baker says, "Over the last two years it has been exciting developing the Wide- Awake Hand Program at the Salisbury VA." He was able to perform surgery on 349 Veterans over the last year, with no complications, and Baker anticipates volume to increase. Orthopedic procedure volume in the main OR at the Salisbury VA shared by four surgeons was around 680. He says, "The Wide-Awake Hand Procedure room enables us to service another 349 patients each year, without utilizing the regular ORs."
In 2017, an article by the San Antonio Military Medical Center showed a 75-80% savings (around $393,100) in the cost of surgery for 100 procedures ("Cost Savings and Patient Experiences of a Clinic-Based, Wide-Awake Hand Surgery Program at a Military Medical Center: A Critical Analysis of the First 100 Procedures," Rhee, Fischer, Rhee, McMillan, Johnson). For the almost 350 cases at the Salisbury VA, that would equate to around $1.4 million in cost savings.
Veterans who have undergone Wide-Awake Hand Surgery at the Salisbury VA have expressed extreme satisfaction with the technique. Baker feels strongly that with determination and very little additional cost, the practice could be easily implemented at VA facilities nationwide, tremendously helping Veterans’ access to care.