How sharp is a "sharp scratch"? A mixed methods study of verbal warnings issued before venipuncture.

OBJECTIVES: Health care providers frequently issue a verbal warning before venipuncture. Communications that induce negative expectations in patients can lead to the "nocebo" response, defined as experiencing greater pain. But is this also true for "sharp scratch"? METHODS: The study was conducted across 4 U.K. hospitals. Two separate surveys of health care providers and patients explored the prevalence, phraseology, rationale, and reaction to verbal warnings before venipuncture. Blinded adult patients already attending an outpatient department during a 2-week period were randomized to hearing a "sharp scratch" or the verbal cue "ready?" immediately before venipuncture. They were also asked to rate their pain (the primary outcome). RESULTS: 77% of 117 health care providers surveyed issued a verbal warning before venipuncture; 73% used "sharp scratch". Of 62 patients surveyed, 56% agreed that "sharp scratch" accurately describes venipuncture, and 64% agreed that they prefer "sharp scratch" to no warning. With increasing age, a preference came for an alternative warning to "sharp scratch" (P = 0.039) and to be distracted by conversation (P = 0.002). Of 192 patients in the randomized study, there was no difference in pain between the "sharp scratch" and "ready" groups. The numeric rating scores were 0.74 SD 1.06 vs. 0.88 SD 1.18, respectively. (P = 0.493). CONCLUSIONS: Most health care providers use the verbal warning "sharp scratch" before venipuncture. Most patients find this acceptable and prefer it to no warning. An exception may be elderly patients, who may prefer to be distracted by conversation. "Sharp scratch" makes no difference to the pain experienced compared with a verbal cue.

Once Burnt, Twice Burnt: The Vulnerability of Insensate Flap Reconstructions.

The occurrence of a burn injury in the same region as a previous burn is unusual outside the context of deliberate self-harm. Accidental burn injuries sustained to insensate flap reconstructions have previously been well reported in autologous breast reconstruction. Reports of such injuries in distant flap reconstructions of the hand and forearm are however unusual. This case report describes a 40-year-old man who required a pedicled groin flap to reconstruct a burn injury on the ulnar border of his hand. Three years later, he suffered a burn to the same area whilst using an oven. This case highlights the importance of counselling patients with insensate reconstructions regarding increased care and vigilance against inadvertent injury.

Five Simple Techniques to Enable Rapid Elevation and Donor Site Closure of the Anterolateral Thigh Flap.

We describe five technical notes to facilitate rapid elevation of the anterolateral thigh flap for extremity reconstruction. We highlight the advantages of (1) a lateral approach; (2) identification of the perforator with the shortest intramuscular distance; (3) deroofing technique with cutting monopolar for pedicle dissection; (4) taking a cuff of vastus lateralis in some cases to avoid unnecessary long perforator dissection; and (5) closure of large donor sites with a modified keystone flap. Using the sequence reduces flap-raising times to 60 to 90 minutes and improves theater usage while achieving excellent outcomes.