Morbidly obese patients present a clinical challenge for anesthesia staff performing subarachnoid punctures. Difficulties arise due to anatomic changes that obscure landmarks for guiding needle placement in the lumbar subarachnoid space. Here's an innovative technique you can use for placement of a continuous lumbar spinal catheter using a Touhy epidural needle with an open-ended epidural catheter. We call it the Sharpie Technique.

• With the morbidly obese patient in the sitting position, place a standard-size Sharpie permanent marker measuring 5 3?8 inches in length at the sacroanal fold and rotate it toward the head so that it's parallel to the vertebral column (Fig. 1 [for illustrative purposes, we taped a Sharpie in place]).
• Draw a horizontal line at the superior pole of the Sharpie, approximating the L3-L4 interspace. As illustrated by the photo, it was virtually impossible to reliably palpate the iliac crest due to the increased subcutaneous adiposity.
• Aseptically prep and drape the patient's lumbar region (Fig. 2).
• Insert a 24-gauge, 4 7?8 inch Sprotte spinal needle through a 19-gauge introducer needle in a cephalad direction at approximately 10 to 30 degrees (Fig. 3). A Sprotte spinal needle will decrease the incidence of a postdural puncture headache. Slowly and steadily advance the needle until you pierce the dura mater and obtain heme-free cerebrospinal fluid.
• If a paresthesia is elicited, you need to redirect the needle in a midline direction away from the side of the paresthesia. If the tip of the spinal needle encounters an osseous structure, withdraw the needle and redirect it. If the cerebrospinal fluid contains heme, withdraw the spinal needle and reinsert it at the next superior interspace.
  
  

Randall W. Klotz, CRNA, MEd, MSN
Anesthesia Services Network
Miami Valley Hospital
Far Hills Surgical Center
Germantown, Ohio
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Robert Miller, DO
William Jennings
Bryan Dorn
Veterans Hospital
Columbia, S.C.
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Staffing Continuous Care
Whenever it's possible, we assign one nurse to follow through an entire case: calling the patient back to pre-op, circulating in the OR and monitoring his recovery. "One nurse, one patient" provides a good continuity of care, plus the patient gets to see the same smiling face all the way through his visit. Compare that with having a procedure done in a hospital, where you're constantly shifted from one face to another and you can't remember the name of anyone who provided care.

Granted, we're a relatively small, single-specialty surgery center - on our busiest surgery days, we'll do eight operations in our one OR - so we can specialize in a way that wouldn't be expedient for large, multi-specialty facilities. And while it might not be the most efficient use of personnel, this continuity is what's best for the patient. When you ask on your patient satisfaction surveys if anyone stood out, and people can name the nurse who provided their care, that's really an accomplishment.

Dick Farr, OPA-C, CASC
Director
Outpatient Orthopedic Surgery Center
Statesboro, Ga.
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Ask for Post-post-op Evaluations
How do you know how well your facility is serving its patients? Why not invite a recent patient and her family to your facility to discuss their experience with you, face to face? With randomly selected visitors once a month or once a quarter, you can learn more about their views of your facility. What did they notice? How did the patient and the family feel about their time there?

The idea is to be more open. In the outpatient setting, staff tend to run people through: This could expose issues instead of covering them up. It also lets your community know you're willing to discuss issues with your customers. Ask patients when they arrive for a procedure if they'd be willing to participate in such a program - before they're prepped and anesthetized for surgery, of course, and when they're with their families, for support.

Jack Neary, CRNA
Director of Anesthesia
Cottage Hospital
Woodsville, N.H.
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It's Not Lost, It's Scanned
Lost operative permits were a big problem in our facility. Without these, surgeons couldn't begin their cases, so they'd have no choice but to wait until they were found, which greatly disrupted our schedule.

Instead of having the paperwork follow the patient, we decided to instead have the information follow the surgeon: The document is scanned in the surgeon's office and the image is expedited to the OR suite as part of the patient's information package. Now, there is no paper to lose and the permit is clearly visible.

Thanks to this system, we've seen a remarkable reduction in missing permits. More operations are beginning on time, and no one has to waste time tracking down the paperwork.

Maureen Harders,MD
Director, Anesthesia for Ambulatory Surgery
MetroHealth Medical Center
Cleveland, Ohio
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Who's Who In a Code?
The last thing you need during a patient emergency is confusion over who's doing what. Here's a quick guide that delineates staff roles during a code. You might want to tape this list to the side of your crash cart.

• Anesthesiologist or CRNA. Runs the code.
• PACU RN(s). Administers medications, starts second IV access and assists with ventilation.
• OR RN. Performs compressions.
• PACU or OR RN. Readies the defibrillator and places leads on patient.
• Nursing assistant. Runs for supplies.
• Front office staff. Calls 911, answers phones and controls foot traffic.
• Administrator. Coordinates staff,documents all events and keeps the patient's family informed.
  
  

Monica Ziegler, MSN
Administrator
Physicians Surgical Center
Lebanon, Pa.
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