Efficient Techniques for Managing Fingertip Injuries and Reducing Opioid Use
A detailed presentation by Dr. Orrin I. Franko, focusing on effective methods for treating fingertip injuries, particularly open fractures, with an emphasis on minimizing opioid usage. The presentation covers steps such as block, examination, reduction, and potential specialist interventions. Dr. Franko shares insightful tips and guidelines for healthcare professionals dealing with musculoskeletal patients.
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Fingertips & Reducing Opioid Use in Musculoskeletal Patients ORRIN FRANKO ORTHOPEDIC & HAND SPECIALIST
Disclosures Owner/Founder: www.TopOrthoApps.com Owner/Founder: www.SurgiSurvey.com No relevant financial disclosures related to the topic of this presentation.
Orrin I. Franko, MD Childhood: Palos Verdes, CA Undergraduate: UC San Diego (2005) Medical: Harvard (2009) Orthopedic Residency: UC San Diego Hand Fellowship: Cincinnati, OH Moved to East Bay in August 2016 Wife (Katie), 2 boys: Ari (4 yrs) & Asher (3 yr) Hobbies: Tech and mobile apps in medicine www.TopOrthoApps.com Automated Surgical Outcomes Online Physician Rating & Reputation Management
Fingertips Open fractures (by definition) Ancef + Tetanus Reduce nail avulsions Sometimes salvageable sometimes not Always: Block, Reduce, and Examine (*tips and tricks) Often forgotten, overlooked, or minimized
Step 1 Block the finger 1% lido +/- epi 2-3cc typically sufficient 25g needle SIMPLE Technique Single Subcutaneous Injection in the Middle of the Proximal Phalanx with Lidocaine and Epinephrine
Step 2 Exam, Image and Reduce Look for avulsed nail plates Nail bed lacerations (open fractures) Exposed tendons Dislocated joints (DIP, PIP, MCP)
Step 3 Fix, or Call a specialist Suture with CHROMIC GUT Typically size 4-0 or 5-0 Nail plates need to be removed to repair nailbed lacerations PIP reductions should be easy Temporization: Wrap with moist dressing (xeroform), gauze, and moderate compression (ACE or Coban)
Newest Fingertip Guidelines www.ebhmc.com/ER
Reducing Opioid Use in Musculoskeletal Patients 1990: 4 tons 2009: 39 tons Patients want to have little postop pain Veterans Administration 1999 fifth vital sign JCAHO 2001 rigorous pain standards Physicians responded by prescribing opioids 99% used in the US
Opioid Epidemic Patients want to have little postop pain International Association for the Study of Pain (IASP) Veterans Administration 1999 fifth vital sign JCAHO 2001 rigorous pain standards Physicians responded by prescribing opioids Opioid Epidemic Hydrocodone (Vicodin) most widely prescribed drug in the US 100 million prescriptions per year 2007 Legal prescription opioids kill more Americans than heroin or cocaine (CDC data)
Opioid Consumption Following Outpatient Upper Extremity Surgery Journal of Hand Surgery April 2012 Rodgers, et al. Five-member hand surgery group Ten month period, outpatient surgery 287 patients agreed to participate Contacted between 7-14 days post op 250 completed the study 76% soft tissue, 24% bone procedures 92% satisfied with pain management Patients given 30 opioid pills
45% took 5 pills or less Some took none Total unused pills: 4,639 79% were leftover California: 3,039 orthopedic surgeons 3,382,407 unused pills
Oxy + Tylenol Hydro + Tylenol NSAID + Tylenol Codeine + Tylenol
My Experience Started practice in Sept 2016 and gave Rx how I was trained Norco 5mg with every surgery #10-15 for carpal tunnel/trigger finger #20-40 for bone procedures (distal radius, finger fractures) Often #20-30 for fractures not requiring surgery Signed 5-10 prescriptions each week Signed 1-2 refill requests each week
Summer 2017 Started reading the current literature in depth Adopted a protocol created by another hand surgeon Modified our patient education materials Created an Epic Smartphrase Effect: Currently hand out 1-2 opioid prescriptions per week (75% reduction) Almost ZERO refill requests (90% reduction) Patients are just as satisfied Patients occasionally THANK ME for not giving them opioids
(Watch this video) https://www.youtube.com/watch?v=Tt52qS5Zttk#action=share
Nursing Education Pain is Normal Worst pain is in first 24 hours Reduces by 50% after 48 hours After 72 hrs it should be manageable *Don t use the pain scale (if possible) Encourage distractions Talk to friends/family Walk around the hospital, cafeteria, go outside Play games / watch sports Breakthrough medications are strictly for Assistance with sleep Pre-/Post-therapy exacerbation
Summary Non-opioids are effective and safe Reduced dependence/addiction Improves pain management and patient satisfaction Requires re-educating surgeons, hospitalists, nurses and patients Encourage distractions, activity, and mobility
