Scenario

Tom Anderson, CMA (AAMA), works for Dr. Sheila Samanski, a dermatologist who frequently performs minor surgical procedures in the office. Tom assists Dr. Samanski with procedures and is also responsible for maintaining stock supplies in the minor surgery room, including solutions and medications, and for cleaning, maintaining, and inspecting the surgical instruments. Because there are no procedures scheduled for today, Tom is planning to compile an inventory of supplies and equipment and perform routine maintenance activities.

While studying this chapter, think about the following questions:

Minor Surgery Room

Surgical Solutions and Medications

Treatment room supplies include standard solutions and medications that are used in minor surgery and dressing changes. Although the solutions and medications listed here are basic, every physician’s office practice has preferred items and methods of applying them. The medical assistant is responsible for their care and for maintaining up-to-date supplies.

Sterile water is kept in two forms. Multiple-dose vials are used as a diluent for medications; larger containers of sterile water are for rinsing instruments that have been in a chemical disinfectant solution.

Sterile physiologic saline solution (0.9%) is also stocked in two sizes. The small multiple-dose vial is used for injection. A larger container of sterile saline is used for rinsing and irrigating wounds. These commercially prepared products are ordered from a medical supply company.

The surgical site on the patient must be prepared preoperatively with an antiseptic skin cleansing preparation to reduce the number of pathogens. Although it is not possible to remove all microorganisms from the skin, it is important to prepare the surgical site to remove transient and pathogenic microorganisms on the skin’s surface and to reduce resident flora. In addition, the surgeon’s hands and those of the medical assistant require disinfection to reduce the chances of wound contamination even though hands will be covered with sterile gloves. Surgical scrub preparations should have a broad antimicrobial action effective against bacterial spores; they also should work rapidly to reduce transient bacteria, show evidence of persistent activity on the skin, and work despite the presence of organic matter such as blood or wound drainage. Research indicates that chlorhexidine (Hibiscrub or Hibiclens) and povidone-iodine (Betadine) are safe and effective antiseptics.

Even minor surgical procedures require the use of anesthetics, which either are injected locally at the site of the procedure or may be sprayed on the skin as a preinjection anesthetic. For patients who find injections of local anesthesia painful or traumatic, the physician may first spray the injection area with a topical anesthetic, such as Fluori-Methane 15%, which is supplied in 3.5-ounce amber glass bottles for either fine or medium spray. Immediately after spraying the site, the physician makes a series of injections around the area with a local anesthetic.

Another topical anesthetic spray is ethyl chloride, a vapocoolant that controls pain associated with minor surgical procedures, such as lancing boils or incision and drainage of small abscesses, by causing localized freezing of the affected area. Because ethyl chloride is highly flammable, it should never be used in the presence of electrical cauterizing equipment, and it requires the application of petroleum jelly to surrounding areas to protect them from the cooling action of the spray. It has a short duration, so all equipment must be prepared and the physician must be ready to perform the procedure before it is applied.

Local anesthetics are injected into the subcutaneous tissue. These produce a temporary cessation of feeling at the site of injection by blocking the generation and conduction of nerve impulses. Many different types of local anesthetics are available, but all share the same suffix, -caine. Those used most frequently include lidocaine (Xylocaine), chloroprocaine (Nesacaine), and bupivacaine (Sensorcaine). Local anesthetics are purchased in multiple-dose vials of 30 to 50 mL and in varying strengths, such as 0.5%, 1%, and 2%. They begin acting relatively quickly, within 5 to 15 minutes; the duration of action depends on the type of anesthetic, but they usually last 1 to 3 hours. When highly vascular areas are involved, local anesthetics containing epinephrine may be used. Epinephrine causes vasoconstriction at the site, which keeps the anesthetic in the tissues longer, prolonging its effect. It also minimizes local bleeding. However, epinephrine is not used in areas where decreased circulation may cause problems with healing, such as fingertips or toes.

All tissues removed, or biopsied, from the patient are sent to the pathology laboratory for analysis. A 10% formalin solution typically is used to preserve excised tissue for specimens. Specimen bottles are purchased with preservatives included and should be part of the supplies prepared for a surgical procedure if a biopsy is to be done. The physician places the specimen in the container, and the medical assistant is responsible for accurately labeling the container with the patient’s name, the date of collection, and the type of specimen.

Sometimes the physician may want to use topical silver nitrate (AgNO₃) solution or coated applicator sticks to stop localized bleeding, such as with epistaxis (nosebleed) or capillary bleeding at the site of a wound. The applicators must be kept in lightproof brown containers, and the most commonly used strength is 20%. The applicator sticks are convenient for use in the mouth or nose.

An instrument is usually named for its use (e.g., splinter forceps, for removing splinters) or after the person or people who developed it (e.g., Mayo-Hegar needle holder). Many general instruments are identified by the part of the body on which they are used (e.g., rectal speculum and nasal speculum).

There are thousands of surgical instruments with multiple name variations. The same instrument may have two or three different names, depending on the physician identifying it or the part of the country in which the practice is located. A physician may ask for a clamp or forceps when a Kelly hemostat is wanted. It is important to learn the physician’s preference in terminology. Learn to recognize the distinctive parts of instruments and the reasons for each part, and you will quickly build a working knowledge of hundreds of instruments.

Classifications of Surgical Instruments