Snohomish County Medical Assistants “Medical Office Surgery Instrument Identification” CEU Correspondence Program # 8854-PRG7 Course Participation: September 1, 2008 – December 31, 2008 Contact Credit: 2 Units – Category Clinic

Program Evaluation

After reading the enclosed text, please answer the exam questions so we may assess your participation in this program. After completing the assessment, please send it by email to [email protected] or mail your completed information form with the appropriate fee, and a self-addressed stamped envelope to :

Snohomish County Medical Assistants 205 E Casino Road Suite B-16 PMB#81 Everett, WA 98208

Allow 4-6 weeks for processing the return of your completion grade notice and certificate of program participation. You must receive 70% or better of correct answers to qualify for the CEU units to be awarded. All responses must be postmarked no later than December 31, 2008 to qualify for this course registration on your transcripts for January 2009. Payment can be made by check or money order only. No cash or credit cards can be accepted please!

If you should have any questions, please contact the Snohomish County Medical Assistants Education Chair at [email protected] or call PH# 425-513-2946 before 9:00pm PST.

PLEASE PRINT:

NAME ______

ADDRESS ______

CITY ______STATE ______ZIP ______

Email: ______Phone ______

FEES: AAMA MEMBER $15.00 NON-MEMBER $25.00

AAMA MEMBER? YES ______NO ______

*IF YES, PLEASE PROVIDE AAMA MEMBER NUMBER ______

*IF NON-MEMBER, PLEASE PROVIDE SOCIAL SECURITY NUMBER #______

*Your Program CEUs cannot be posted to your AAMA transcripts without the required information.

1 “Medical Office Identification ” By Sheri R. Greimes CMA PBT RMA RPT

The healthcare industry has made so many advances in the past few decades, even within the past few years, so that surgery is not restricted to hospitals only anymore. Surgeries performed outside the hospital are known as Ambulatory surgery or Outpatient surgery and are easily outnumbering the total inpatient surgeries performed today. This has been a culmination of 30 years of change that has lead to significantly lowered costs and increased patient convenience in having minor surgical procedures done within the doctor’s office.

Surgery is defined as a branch of medicine that treats diseases, injuries, and deformities by manual or operative methods. Surgeries normally take place in hospitals, but more and more are occurring in doctor’s and dentist’s offices as well and specially designed “Surgical Suites”. These surgical suites are built with the conveniences and full complements of surgical equipment and facilities, but with low overhead and costs for the provider-owner. The in-office surgeries allows the physician to schedule surgeries according to their personal preference or needs, provides a convenient and low-cost alternative to high surgical service costs for the patients, and easy access for providers and patients alike.

There are various types of surgery that take place in a provider’s office, such as; laceration repairs, cyst and lesion removals, biopsies, wound debridement, tumor removal, vasectomies, circumcisions, dermatology procedures, minor cosmetic surgery and minor orthopedic procedures.

The responsibility of the medical assistant in assisting the provider during any of these surgical procedures is to be educated and informed on all aspects of the surgical preparation, the patient preparation and the equipment preparation. There are set-up procedures and prescreening procedures that must be followed to ensure that the patient is properly informed, has consented to have the procedure, and is properly prepared for the procedure. The procedure set-up has to be 100% correct in preparation in order to prevent errors and delays during the procedure.

It is the medical assistant’s duty to verify that every possible equipment and supply needs are ready for the provider before the procedure starts so not to delay the surgery or cause delayed treatment to the patient. It would be quite alarming if a person was undergoing an office procedure and the provider had to stop at a critical point during the procedure in order to allow the medical assistant to leave the room to obtain the proper equipment and supplies.

Another part of the medical assistant’s duties are to identify and know the function of medical equipment and most importantly, how to care for the expensive and costly equipment properly. Instrument Identification

2 Instruments are named by their function, their design, or by the surgeon who designed them. More detailed or descriptive names are given for procedure specific or specialty specific instruments, such as a Sims Uterine dressing . This instrument was designed by Dr. J. Marion Sims, a well-known American gynecological surgeon, for the specific use of introducing dressings into the uterine cavity. Specialty instruments are designed to meet specific needs within specialty practices; GYN, ENT, Surgical.

Identifying features are ring handles, rachets, serrations, blades, grooves and other defining features of the instrument. Ring handles are featured on most instruments used for grasping and cutting, the fingers secured within the center of the rings and providing a controlled grasp on the instrument. Rachets are located between the ring handles and are ridged teeth that are designed to “lock” and hold the ring-handles together, providing a firm grip on tissues or objects they are grasping.

The blades of the instruments may have grooves or “serrations” which allows for a tighter hold of the item being held, providing a “non-slip” surface. The box lock is a special design for medical instruments that has the hinge pins contained within the inside of the instrument hinge and not the outside, which if outside they could cause tissue damage or become snagged on items within the surgical site.

Some are named for rather obvious functions, such as a skin rake or , whereas others may be named for a specific use and used for something totally different, such as a Bachaus towel being used during vasectomies to isolate the Vas Deferens.

Instruments are categorized by their function: 1. Clamping, grasping 2. Cutting, slicing 3. Probing, dilating

When identifying instruments, look for special characteristics of the instruments to remember what they are used for, the inventor’s name, or the specific function they were designed or developed for.

There are literally thousands and thousands of different instruments that are available for minor office surgery, some looking all the same with subtle differences. A general overview will be given of the most commonly used minor surgical equipment and instruments to provide education at a common level of instrument identification and care.

Forceps

Forceps have multiple designs and functions, used to grasp and hold tissue or dressing are the most common use. There are forceps that resemble common “tweezers” and forceps that look like . Some people may refer to forceps as “pick ups’, , and drivers, but all having a

3 function of their own. The ring-handle type forceps come in various lengths of shafts and may be straight or curved in design. The thumb blade designs come with specifically design blades for specific uses and range in various lengths of blades.

Hemostatic forceps are designed to clamp blood vessels to stop blood flow and Kelly hemostatic or Crile hemostatic forceps are widely known. Kelly and Crile are design almost alike except Kelly forceps feature half-blade serrations, Crile have full-blade serrations. The handle shafts can be designed to different lengths starting at 2 inches and up to 9 inches. The forceps have ring handles with rachets to lock in place for stopping blood flow within the blood vessels.

Crile hemostatic forceps

Mosquito hemostatic forceps are formed almost exactly like Crile forceps, but are much smaller and delicate in shape and size. The small size of the forceps allows for greater control and maneuverability when grasping the thinnest layers of tissue or most delicate tissues, or working in a smaller surgical site. Mosquito hemostatic shafts can range from 1 inch to 6 inches in length. The blades have full serrations and are very light in weight. Care should be taken not to bend the small, thin shafts of the forceps.

Tissue forceps can have either ring handles with ratchets or be designed as thumb blades with teeth to “bite” into the tissues they are holding and prevent the tissue from slipping during surgery. The tissue forceps most used are the Adson tissue forceps and the Kocher tissue forceps. The teeth are shaped to penetrate into the tissues without causing the tissues to be torn, performing a clean puncture. Teeth are placed on both blades and may number in one to four teeth. They resemble a tooth and sometimes are referred to “rat-tooth” forceps. Allis tissue forceps are designed differently and resemble curved ‘hands” that are used to lift delicate vessels and tissue. 4

Dressing forceps are designed to hold or place gauze sponges and dressings during the surgery procedure. The instruments can resemble the ordinary “ tweezers” shape that contain two blades or ring- handle forceps. The design of the forceps can be very specific for its use.

The specially designed forceps have been developed for use in handling specific tissues or in performing specific procedures, such as the ear forceps. There are two types commonly used; the Bayonet ear forceps and the Duckbill or Alligator ear forceps.

The Bozeman uterine forceps and Foerester sponge forceps are used during gynecological surgeries and procedures, proving long shaft handles that allow insertion deep into the vaginal cavity

5 and pelvic space. Shaft handles range in lengths of 6 to 10 inches. The Foerester sponge forceps are also used to transfer and move items within a sterile surgical tray during the operative procedure.

The Virtus splinter forceps, Physician’s splinter forceps, the Walter splinter forceps, though used for removing splinters or small foreign objects from the tissue, were designed with subtle differences.

Needle holders look very similar to hemostatic forceps, but they are of a heavier design so to provide support when holding the suture needle and forcing it through the tissues. Some physicians call the instruments needle drivers. The or driver is designed with ring handles for controlled movements, rachets to lock and hold the needle, and serrated blades to provide a non-slip surface for grasping the needle. The Mayo-Hegar or Mayo needle holder is commonly used, the Crile-Wood needle holder provides a hole in the blade for the ligature material to slide through. One type of needle holder is the Olsen-Hegar needle holder and suture scissor, containing cutting edges on the blades for cutting the suture after tying.

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Scissors

Scissors are used for cutting material and tissues and most often have ring-handles for precise control and pressure of the cut. The scissors have multiple designs for specific procedures, the standard Operating scissors, the Dissecting scissors, Lister bandage scissors and Iris Ophthalmic scissors are the most commonly used.

Operating scissors come with different blade edges for defining the type of cut for the tissues being operated on. The finer the blade edge, the more delicate the tissue being cut which results in a “clean-edge” cut. Operating scissor blades are defined as Sharp/Sharp, with both blades having sharp edges, Blunt/Sharp, with one blade sharp and the other blunt, and then Blunt/Blunt, both blades having a blunt edge. The shafts range in length from 4 to 7 inches, have ring-handles and come either straight or curved.

Iris Ophthalmic scissors being designed very small and delicately for surgeries on the eye, are used in other minor office procedures. The size of the scissors can range from 2 inches to 6 inches in length. Care must be taken when cleaning to not bend the thin blades or shaft handles.

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Dissecting scissors have beveled blades with a blunt cutting surface that allows the user to separate rather than cut the tissue layers. Metzenbaum Dissecting scissors feature extra long handle shafts for use in deeper cavities and smaller blades for more delicate tissue dissection.

Mayo Dissecting Scissors ← Metzenbaum Dissecting Scissors ↓

Suture scissors feature one blade that has a half-moon cut out which allows the blade to be slipped under the suture being cut without lifting or pulling the ligature. Lister Bandage scissors have a blunt end that allows the blade to slide under the dressing without a sharp point accidentally puncturing the skin beneath the dressing.

8 Other Surgical Instruments

Scalpels are used to cut the tissue for removal or to create an incision in the tissues. The blades are available in different shapes such as curved or straight, convex or concave and in sizes ranging from 10- 23, with only the inside edge actually cutting the tissues. Standard require a handle that attaches to the blade for use or more commonly, disposable scalpels used with a plastic handle permanently attached to the blade that are thrown away after use.

Scalpel handles and blades

Disposable punch and Tischler Cervical punch. Biopsy punches are used to cut small “bullets” of suspicious tissue or organ surfaces. They range in sizes of 2mm to 25mm. Most are disposable, but some are of specialty design and are cleaned and sterilized for reuse. Some reusable biopsy punches are the Uterine or Cervical punches.

Towel clamps are used for just that, clamping towels and surgical draping securely around or above the surgical field. The two most commonly used clamps are the Jones towel clamp and the Backhaus towel clamp. As mentioned earlier, the Backhaus towel clamp is used in minor surgical procedures to isolate vessels and secure them for cauterization or surgical lacerating. The fine points on both types of instruments are very sharp and care must be taken when using in a surgical procedure.

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self-retaining retractor

Skin rakes or retractors have various design differences, used to retain tissue or hold an incision open wider for surgical access to the site. Self-retaining retractors are available and allow the freedom of not having to hold the retractor in place.

Some procedures require a used to hold a cavity open for access to the tissue or surgical site. The scopes are placed within the cavity and locked into an open position. Vaginal speculums are used in the vagina for gynecological procedures. They range in sizes from petite or pediatric to large. The slopes of the blades are designed for the vaginal cavern, some wider blades are called Graves speculums, or thinner blades for smaller cavities require the Pederson speculums. Anoscopes are used to hold the rectum and anal cavity open for viewing or insertion of instruments. Vienna Nasal Speculums are used to enlarge the nasal opening or the nares for viewing the sinus passages or cavities.

10 Sounds and are probing instruments used to penetrate and stimulate a sphincter muscle in the entry to a cavity to gain access to the site or to probe the cavity for determining the depth and size of a cavity. Two examples of probing instruments are the Sims Uterine sound and Hegar or Pratt Dilators. The dilators are inserted in gradually increasing sizes to stimulate the cavity opening, such as the cervical os. The Sims uterine sound is made of pure silver, which makes it maleable and able to be curved to insert easily into the uterus.

Probes and directors are used to probe for depth, clear obstructions or fluids. Many have a groove down the center that allows fluid to be channeled away from the operative site. The probes or directors can be made of plastic, non-flexible steel or rubber.

Curettes are loops of metal attached to a long handle with one side sharpened to remove or cut away tissue or debris. The various types range from ear , dermal curettes to uterine curettes.

Probe and Grooved Director

11 Bucks Ear Sims Uterine curette

Many more instruments are available for use in surgical procedures and may be viewed online, having just reviewed a few of the most commonly used instruments. When looking at the instruments in catalogs and online ordering services, be aware of the actual costs of these specially designed instruments. They are not cheap in the quality and design and your provider may have thousands of dollars invested in purchasing high-quality instruments for use. Care should be given to ensure that the proper cleaning solutions, proper cleaning procedures and proper storage conditions are used. The finer the quality of metal, the less chance of damage or metal breakdown occurring. There are economy level instruments that are easily affordable and also available are disposable surgical packets that are ready for use. Keeping in mind the overall investment in the instruments is vital in understanding the requirements for maintaining the functionality and performance of the instruments.

There are ten basic rules when caring for and using instruments during medical procedures that will ensure care in use and longevity of the instrument:

1. Handle instruments by the handles or grips – this prevents equipment damage or bending of the handles or blades, it also prevents accidental cuts and sticks from the sharp edges or points of the instruments. 2. Take care when removing instruments from the surgical tray or field – the surfaces may be slippery from blood or antiseptic solutions and care must be used to not drop the instrument. 3. Do not allow any blood or protein matter to dry on the instruments – rinsing all visible matter off before the contaminants dry ensures that the instrument surfaces are free of any debris that would inhibit complete disinfection or sterilization of microscopic organisms. 4. Rinse instruments in warm water – the warmth keeps the debris from jelling or coagulating onto the surfaces. Cold water causes shrinkage of the debris and makes it harder to remove. 5. Prevent bending and chipping of instrument surfaces by placing the instruments carefully into the sanitizing or disinfecting solution – piling instruments on top of smaller or more fragile instrument can cause damage to the tips, blades, shafts or hinges of certain instruments. 6. Use the proper cleansing solution for the equipment – the wrong solution can cause metal surface pitting or the finish to become dulled and chemically abraised. Reading the directions of use on the label can determine if the solution being used is the right solution. 7. Allow the proper length of time for instrument exposure to the cleaning solution – In order for the cleansing process to be performed effectively, the required length of time for the instrument to be exposed to the solution is required. Again, thorough understanding of the instrument use and care instructions and reading the cleansing solution label will help ensure that proper exposure times are being met. 8. Use the right cleansing tool for cleaning the instrument surfaces – using the wrong instrument brush on a metal surface, such as a metal brush rather than a soft nylon brush, can cause scarring and penetration of the metal surfaces. This can lead to rusting and cracking of the instrument.

12 9. Inspect each instrument after cleaning, but before sterilization for bent shafts or blades, dull cutting edges, chipped blades, or tips not meeting on locking forceps. Damaged instruments do not function as anticipated or expected and can cause pain to the patient if working poorly. 10. Lubricate the instrument – lubricating the instrument helps to keep the surfaces smooth and the finish intact, hinges gliding freely and easily, and blades smooth to cut with. The typical lubricant “milk bath” is not rinsed off the instrument, but is allowed to dry on the instrument and safe to use on instruments that will be going through the sterilization process.

Surgical instruments come in so many different varieties, categories and designs. Many are very expensive and must be used for and cared for properly. In learning more about proper medical surgery instrument care and use, you are helping your provider give quality care to the patients of your medical clinic or office. Knowing the correct names and functions of the instruments helps you be a better medical assistant to your provider during critical times of care. Your provider will be able to work in a setting that is properly prepared and ready to use, saving valuable time, effort and money.

Bibliography:

Young Alexandra, P., Proctor Devorah B. “Kinn’s The Medical Assistant: An Applied Learning Approach”. Saunders; 10 th Edition, 2007.

Lindh, Pooler, Tamparo and Dahl, ”Comprehensive Medical Assisting”; 4th Edition 2005.

Sklar Surgical Instruments; Online Catalog, http://www.sklarcorp.com

13 ENCLOSE THE FOLLOWING EXAM WITH YOUR PROGRAM REGISTRATION FORM, THE REQUIRED FEE AND A SELF-ADDRESSED STAMPED ENVELOPE.

“MEDICAL OFFICE SURGICAL INSTRUMENT INDENTIFICATION” – EVALUATION FORM

NAME ______

Please identify the following instruments (these have all been reviewed in the text content:

1.______2.______

3. ______4. ______

5.______6. ______

14 7. ______8. ______

9. ______10. ______

11. ______12. ______

13. ______14. ______

15 15. ______16. ______

17. ______18. ______

19. ______20. ______

21.______22. ______

16 23. ______24. ______

25. ______

17