Mohs Emergency Preparedness Starts Before the Appointment

SAN DIEGO – A man goes into full cardiopulmonary arrest in the waiting room. A patient coughs up pink frothy sputum during a Mohs surgical procedure. Another pops two ibuprofen 20 minutes before a biopsy and goes into anaphylaxis once the procedure is underway.

These aren’t scenarios concocted for an emergency training film, but real-life events that transpired in the private practice of Dr. Alexander Miller, a Mohs surgeon in private practice in Yorba Linda, Calif.

"Stuff happens," he said during the meeting sponsored by the American Society for Mohs Surgery. "You’ve got to be prepared."

Preparedness begins with a preoperative consultation, said Dr. Edward H. Yob, a Mohs surgeon in private practice in Tulsa, Okla., who noted that it’s an "odd week" when he doesn’t find at least one prospective patient with a systolic blood pressure well over 200 mm Hg.

Mohs surgeons who meet their patients for the first time during the surgical appointment might never realize that the patient in his 50s with nitroglycerine on his medication list actually requires the medication 1-2 times a day. Dr. Yob sent this patient for a cardiac consultation, eventually deciding to schedule his procedure in a hospital operating room.

"You have to decide how far you’re going to take this, whether you’re going to monitor patients. In our office, we don’t monitor. We take blood pressure, pulse oximetry, and pulse. [Beyond that], we have our cutoff and say, ‘We won’t operate on this patient in the office,’ " he said.

However, an occasional medical emergency is bound to strike, regardless of how thorough the preoperative workup might be, both surgeons agreed.

For that, planning is the key.

"Designate a 911 caller," suggested Dr. Miller. "[While the staff is] sort of scared and wide-eyed and gaga, [someone needs] to actually call 911."

Likewise, he said, "Train yourself to maintain composure and calmness, and do the steps that are required."

Maintain CPR certification and proficiency, and have the right equipment on hand, he recommended.

Dr. Yob said the extent of equipment required will depend not only on the complexity level of patients accepted for Mohs surgery, but also the practice’s proximity to the hospital.

"How long does it take for an ambulance to get there?" he asked.

At a minimum, an office performing Mohs surgery should have available oxygen, Benadryl, atropine, epinephrine, intravenous supplies, and oral and intravenous dextrose.

An automated external defibrillator is an element of state-of-the-art care, said Dr. Yob.

A review of internet sites found that such units are available for about $2,400 and up, and come with simple instructions designed to be easily followed even in the pressure of an emergency.

Dr. Yob and Dr. Miller reported no disclosures pertaining to their talks.

SAN DIEGO – A man goes into full cardiopulmonary arrest in the waiting room. A patient coughs up pink frothy sputum during a Mohs surgical procedure. Another pops two ibuprofen 20 minutes before a biopsy and goes into anaphylaxis once the procedure is underway.

These aren’t scenarios concocted for an emergency training film, but real-life events that transpired in the private practice of Dr. Alexander Miller, a Mohs surgeon in private practice in Yorba Linda, Calif.

"Stuff happens," he said during the meeting sponsored by the American Society for Mohs Surgery. "You’ve got to be prepared."

Preparedness begins with a preoperative consultation, said Dr. Edward H. Yob, a Mohs surgeon in private practice in Tulsa, Okla., who noted that it’s an "odd week" when he doesn’t find at least one prospective patient with a systolic blood pressure well over 200 mm Hg.

Mohs surgeons who meet their patients for the first time during the surgical appointment might never realize that the patient in his 50s with nitroglycerine on his medication list actually requires the medication 1-2 times a day. Dr. Yob sent this patient for a cardiac consultation, eventually deciding to schedule his procedure in a hospital operating room.

"You have to decide how far you’re going to take this, whether you’re going to monitor patients. In our office, we don’t monitor. We take blood pressure, pulse oximetry, and pulse. [Beyond that], we have our cutoff and say, ‘We won’t operate on this patient in the office,’ " he said.

However, an occasional medical emergency is bound to strike, regardless of how thorough the preoperative workup might be, both surgeons agreed.

For that, planning is the key.

"Designate a 911 caller," suggested Dr. Miller. "[While the staff is] sort of scared and wide-eyed and gaga, [someone needs] to actually call 911."

Likewise, he said, "Train yourself to maintain composure and calmness, and do the steps that are required."

Maintain CPR certification and proficiency, and have the right equipment on hand, he recommended.

Dr. Yob said the extent of equipment required will depend not only on the complexity level of patients accepted for Mohs surgery, but also the practice’s proximity to the hospital.

"How long does it take for an ambulance to get there?" he asked.

At a minimum, an office performing Mohs surgery should have available oxygen, Benadryl, atropine, epinephrine, intravenous supplies, and oral and intravenous dextrose.

An automated external defibrillator is an element of state-of-the-art care, said Dr. Yob.

A review of internet sites found that such units are available for about $2,400 and up, and come with simple instructions designed to be easily followed even in the pressure of an emergency.

Dr. Yob and Dr. Miller reported no disclosures pertaining to their talks.

SAN DIEGO – A man goes into full cardiopulmonary arrest in the waiting room. A patient coughs up pink frothy sputum during a Mohs surgical procedure. Another pops two ibuprofen 20 minutes before a biopsy and goes into anaphylaxis once the procedure is underway.

These aren’t scenarios concocted for an emergency training film, but real-life events that transpired in the private practice of Dr. Alexander Miller, a Mohs surgeon in private practice in Yorba Linda, Calif.

"Stuff happens," he said during the meeting sponsored by the American Society for Mohs Surgery. "You’ve got to be prepared."

Preparedness begins with a preoperative consultation, said Dr. Edward H. Yob, a Mohs surgeon in private practice in Tulsa, Okla., who noted that it’s an "odd week" when he doesn’t find at least one prospective patient with a systolic blood pressure well over 200 mm Hg.

Mohs surgeons who meet their patients for the first time during the surgical appointment might never realize that the patient in his 50s with nitroglycerine on his medication list actually requires the medication 1-2 times a day. Dr. Yob sent this patient for a cardiac consultation, eventually deciding to schedule his procedure in a hospital operating room.

"You have to decide how far you’re going to take this, whether you’re going to monitor patients. In our office, we don’t monitor. We take blood pressure, pulse oximetry, and pulse. [Beyond that], we have our cutoff and say, ‘We won’t operate on this patient in the office,’ " he said.

However, an occasional medical emergency is bound to strike, regardless of how thorough the preoperative workup might be, both surgeons agreed.

For that, planning is the key.

"Designate a 911 caller," suggested Dr. Miller. "[While the staff is] sort of scared and wide-eyed and gaga, [someone needs] to actually call 911."

Likewise, he said, "Train yourself to maintain composure and calmness, and do the steps that are required."

Maintain CPR certification and proficiency, and have the right equipment on hand, he recommended.

Dr. Yob said the extent of equipment required will depend not only on the complexity level of patients accepted for Mohs surgery, but also the practice’s proximity to the hospital.

"How long does it take for an ambulance to get there?" he asked.

At a minimum, an office performing Mohs surgery should have available oxygen, Benadryl, atropine, epinephrine, intravenous supplies, and oral and intravenous dextrose.

An automated external defibrillator is an element of state-of-the-art care, said Dr. Yob.

A review of internet sites found that such units are available for about $2,400 and up, and come with simple instructions designed to be easily followed even in the pressure of an emergency.

Dr. Yob and Dr. Miller reported no disclosures pertaining to their talks.