Regional Block Safety
Re: "The Path to Regional Success" (October, page 47). Regional nerve blocks are wonderful for post-op pain management and are far safer for our patients — provided we don't circumvent the protocols that keep patients safe in the first place. While I agree with most of Dr. Rice's approach to performing more regional nerve blocks, I have great concern about administering a block before the surgeon arrives. Blocks are usually done on sites that have laterality, meaning someone must first identify the right or left side. While the patient, circulator and anesthesia provider play a part in this identification, the surgeon must be the one to mark the site. If you give a block "cold turkey" without benefit of anxiolytics or amnesics, the surgeon hasn't participated in site identification. If your providers slip the patient a little Versed "Mickey" to help with relaxation, that prevents the patient from actively participating in site identification with the surgeon. This is a very dangerous practice if medications are given that could in any way alter a patient's mentation or thought processes.

Glenna Montgomery, RN, BSN
Director of Surgical Services
Yavapai Regional Medical Center East
Prescott Valley, Ariz.
[email protected]

Let's Call Equipment By Proper Name
Re: "6 Steps to Clutter-free ORs" (August, page 67). This article brings up a pet peeve of mine: We need to stop referring to medical devices and supplies by the manufacturer's name (think Coke or Kleenex). The author uses the term "Bovie machines" to refer to an electrosurgery unit. Some other brands of this type of device are ValleyLab and ConMed, so calling it a Bovie machine is not entirely accurate. Similarly, when someone says, "bring the Stryker in," it's unclear if she means the tower, the monitor or some other device.

Karen Hausteen, RN
Director of Nursing
Rancho Mirage Surgery Center
Rancho Mirage, Calif.
[email protected]

Blame Game
Re: "Pointing Fingers Sinks Everyone's Ship" (October, page 28). While I strongly agree with Tyler Smith's warning that defendants pointing fingers at each other is almost always a winner for the plaintiff, I must equally as strongly disagree that the surgeon is the captain of the ship in the operating room. The doctrine of "captain of the ship" is one purported by plaintiff's attorneys and is invariably refuted by surgeons nationwide when confronted with shared liability for an anesthesia mishap. Although plaintiffs often advance this claim in an effort to broaden the spectrum of liability, the bottom line is that each provider bears an individual responsibility for his own actions, regardless of the negligence of others.

Charles M. Bauman, CRNA, JD
Bauman Law Firm
Auburn, Mich.
[email protected]

MDA-CRNA Debate Rages On
Re: "8 Ways to Make Anesthesia Safer" (October, page 38). Dr. O'Neill provides outstanding, useful information in a succinct, readable format. However, the section in which he recommends hiring a board-certified or board-eligible anesthesiologist is lacking. Since about 30 million anesthestics are provided by Certified Registered Nurse Anesthetists (CRNAs) each year in the United States, many of them in outpatient surgery centers, these advanced practice nurses should have been mentioned right alongside their physician colleagues who provide anesthesia. On top of that, when you hire CRNAs, you can rest assured that they're "board certified" — they have to be in order to practice. Thank you for the opportunity to share this important point with your readers.

Christopher Bettin
Senior Director, Communications
American Association of Nurse Anesthetists
[email protected]

Your polling and sensational headline in E-Weekly proclaiming CRNAs to be more cost effective demonstrates your respondents' ignorance to the reality of anesthesia billing. Nearly every third-party payor pays the unsupervised CRNA the same as the physician anesthesiologist. A medically directed CRNA receives 50 percent and the anesthesiologist gets 50 percent of the payment as if he had done the case himself. Clearly the value of med school and residency is discounted in the payors' eyes compared to a two-year post-graduate CRNA's education, so actually the anesthesiologist is more cost effective.

Jonathan Radin, MD
Bay Area Anesthesia
Bardmoor Outpatient Surgery Center
Largo, Fla.
[email protected]

What About Hissing Nurses?
Re: "Wild Kingdom of the OR" (September, page 96). Paula Watkins showed great restraint in not describing a snake nurse. I have been in surgery for 30 years. Thanks for having a sense of humor. So many of our colleagues do not.

Susan King, RN, BSN
Co-owner and Director of Nursing
Elm Place Ambulatory Surgical Center
Abilene, Texas
[email protected]

Is Ankle Synovectomy Separately Billable?
Re: "When to Report Synovectomy Separately" (September, page 26). We see a lot of synovitis in the ankle where the surgeon is doing a synovectomy along with many other procedures in the ankle. When there is a separate diagnosis — and the synovectomy is for more than visualization — is this billable?

Kathy Giem, CPC, CPC-ASC
Grand Valley Surgical Center
Grand Rapids, Mich.
[email protected]

G. John Verhovshek, MA, CPC, replies: Whether you can code separately for arthroscopic ankle synovectomy (29895) depends on your payor. The national Correct Coding Initiative (CCI) prohibits separate billing for arthroscopic synovectomy of the same ankle when performed with limited (29897) or extensive (29898) debridement, regardless of pathology or area of the ankle joint. For Medicare and other payers who observe CCI guidelines, therefore, you may not report the synovectomy separately in these cases. The American Academy of Orthopaedic Surgeons (AAOS), however, states that synovectomy, when performed for more than visualization, is a separately billable procedure with debridement procedures 29897 and 29898 or a loose body removal (29894). For third-party payers that accept the AAOS recommendations, a separate synovectomy may be allowable under the appropriate circumstances.

For the Record

• Here's the proper way to start a painless IV. Holding the needle perpendicular to the skin and injecting next to the vein, not over it, avoids stimulation of sensory nerves that lead to pain. A needle depth of about 2cm targets below the papilla layer, which lets the local anesthetic affect the nerve. The photo that accompanied Robert R. Jirgl's tip on painless IV starts (September, page 18) demonstrated an improper way to inject a needle. A flat angle through the skin sets off many nerves and causes the subsequent "ouch."
• The Joint Commission's National Patient Safety Goals call for the surgical team to verify the availability of implants or any special equipment needed for a surgical procedure in the preoperative area and in the OR. "Zero Tolerance for Wrong-site Surgery" (October, page 36) only stated that this step should take place in the OR.
• The word "spores" was omitted from this sentence in "ABC's of Surface Disinfection" (October, page 71): "Most disinfectants don't affect bacterial spores."