Hi, I'm Dr. Bielfield
from Colorado Dermatology institute.
Today, we're going to talk about biopsies, why they're important and the safety thereof. We do these
every day in the office.
We do them for multiple reasons, but most importantly we use them to detect skin cancers
and abnormal moles.
We do this so that we can get them in an earlier phase.
They do not grow or spread internally.
Now, we're going to talk about safety of biopsies. This is crucially important not only
for the patient, but for our own health status. As you know, if you cut yourself with a sharp
instrument, you can transmit diseases such as Hepatitis C and HIV.
Unfortunately, these are things that can be very deadly to yourself, or make you very sick
for a long term.
So we want to be very safe for ourselves and the patients. When we're doing biopsies,
we want to make sure we have everything visible in front of us.
So there'll be a tray.
It should be clearly organized in a fashion that you know where everything is, and is easily
accessible.
Next, you also want to put the patient at ease. Safety includes putting the patient at ease because,
if the patient doesn't feel at ease, they could get sick, they could pass out, they could harm
themselves, and we don't want any of that to happen.
So, we want to look professional, you want to look prepared, and you want the patient
in good position.
So now you have your biopsy perfectly organized.
We look professional or ready to approach the patient. The patient sees all these movements,
they want to make sure that you are professional and organized, that already puts them at ease.
Next we're going to talk about an example of actually putting the patient into the chair,
and getting them in the appropriate position. And although you think this is redundant,
it's very important because if you put yourself in the patient's position, you want to be comfortable,
and you want to feel stable.
So for example, if you're doing a lesion on the chest, we're going to put them in the chair,
and put them in the number two position, which I like to call the beach chair position.
And the best way to think of that is that you're at the beach, you're leaning back a
little bit, you feel comfy, and you feel stable.
We want to make sure that they're safe, and they're not going to fall off the chair, harm
themselves, or harm us because remember, we have sharp instruments.
So now we have the patient comfortable.
They're confident with us.
They feel that we're professional and organized.
We're actually going to proceed with the biopsy. Now, obviously, I don't have a patient in
front of me, but I'm going to walk you through some certain techniques that are important.
We've now got the patient position,
again, I want to reiterate, can't say enough about safety.
So we want to make sure again they're stable, they're comfortable.
So now we're going to move on to the actual tray here.
You can see I have on my gloves, gloves are multiple purposes.
Number one, safety. Safety for the patient, you're protecting them from anything dirty,
you're protecting yourself from anything dirty, and potentially transmissible stuff through
body fluids and blood. You're keeping it clean.
And this is not sterile.
So sterile is something that's heated up to a very high temperature, and kills bacteria, spores,
viruses.
This is clean.
So biopsies don't need to be sterile again, but when you're grabbing your gloves, you
don't want to have dirty hands, and grab something or have bodily fluids.
You want to make sure everything is, your hands are washed, and you put your gloves on.
The patient sees that, it gives more confidence to them.
So now moving onto the tray.
Let's just do a general overview of the tray.
We're going to start with, we have two biopsies, are going to start with the shave biopsy, and...
I'm going to just use this as my pointer here.
We're going to point.
This is the blade for the shave biopsy. As you can see,
it's basically just a razor blade, and the beauty is that it's flexible. So I can move it.
And the whole point of this is the depth of the shave. Most shaves are pretty much straight
across.
We're not putting a big dip it in there. If we're doing a melanoma biopsy,
we want to take a bigger scoop.
Be careful.
This is sharp on both sides.
Most providers prefer
just one part of the blade, where they crack it.
I actually use both, because it has more stabilization.
Whatever the provider prefers.
I'll put that back down.
The other thing with that is, here notice
I put it at an angle, because it's easier for me to pick up like that, and on the gauze versus
flat on here.
We've also got our anesthetizing or numbing agent.
We almost exclusively use lidocaine with epinephrine, and then you're going to buffer that. What
do I mean by buffer?
You're going to use this right here.
And this is sodium bicarbonate, and we usually use about 10%. So this doesn't have to be exact,
but 10% if we look at this, we look at that black stopper there.
It's at point five.
So another point one CCs. And what that does is it basically balances the pH of the fluid.
So in plain English what that means is, less pain for the patient.
And you can see, you just put it right through there.
We've already got a needle in there, but this needle wouldn't be in there, you would just
open this up, and put your needle in and [inaudible].
Another point, when you're drawing fluid out. Always want to clean the tip of
the bottle again. Can't see it here at this needle here, but you're going to take an alcohol
swab where that blue part
is there where the stopper's going to go through, and you want to make sure it's clean with alcohol.
So and then we also have our Band-Aid here.
We should also have vaseline, which will be readily available to you. Once, see, I like the
MA to have it done.
You can peel this open, have the vaseline on the padded part of the Band-Aid.
So again, you want everything potentially ready.
So we're not fumbling, or hands aren't, we're not rushing. Want to be calm, cool, and professional.
And then finally we have some gauze over here.
There is always going to be a little bit of blood, so we have our guys ready to go. Soon
as you get that box, your specimen in the bottle. We use these cotton sticks for the application
of chemicals to stop the bleeding.
There's multiple types, and I don't have them here.
We'll just talk about them. The most common one we use is TCA: Trichloroacetic Acid.
And again, these are caustic or chemical agents.
You can think of them like chemical cautery.
So you want just a little bit on the tip here. You don't want it saturated, you don't want it dripping.
These things will burn, they will burn you and the patient. You want just enough on there.
I often do this.
I dab it onto this towel here.
So we're not dripping, we have just enough, and then once we're done, I'll talk to you
about how to apply that. So I have that ready to go again right here.
Now there's something I do personally for a safety thing, is I use the back end of this for my
biopsies.
So for example, if I'm doing the biopsy, and notice I'm pinching here,
I've got the specimen, the specimen is going to be on the top of this blade right here.
So I can take my finger and try and get it off, put it into the bottle, or I can do this
more safely.
I can take the stick, push it. So I don't care if the stick gets poked, right?
I just don't want my finger to get poked.
Once the patient is stabilized,
we're going to clean the area with alcohol.
We're going to numb the area, and we never just go straight in, especially with a...
sharp object to a patient.
We warn them, and say, "Now I'm going to numb this area.
It's going to feel like a little pinch or a little bug bite.
Are you okay with that?"
So I'm even asking them consent again, even though we've received that. They're going to
say it's okay.
I'm going to gently brace them, clean the area, and then I'm going to make sure that whatever
way I'm comfortable,
I'm going to stabilize my hands, so that I'm not all over the place, and I'm going smoothly
in and numb up the area.
Once that's done,
I always tell them that's the worst part. It puts them at ease again.
They shouldn't feel anything other than gentle pressure.
So this is the needle, and at the very tip here
there's actually a hollow opening, and that's the hub of the needle where the medicine actually
is going to come out. So you can imagine, this is face up right now.
So I always try to inject and because you guys are going to inject, an anesthetized patient,
face up, because the medicine goes up into the dermis where you want.
It's not going to go down into the subcutaneous fat or somewhere else.
It goes right where you need it.
So it's important to kind of hold it like that.
And then again, there's other videos on the actual biopsy technique, but again bracing
yourself.
So I have one here, ready to plunge.
Dr. Anderson likes to use his little finger.
Sometimes I'll use my hand, whatever it takes so that you have some sort of stability,
so that if something happens when it bumps you, you just look stable. I'm going to demonstrate something
else with safety. After I anesthetize the patient,
this is a [inaudible].
This has been exposed to the patient.
How do I protect you?
How do I protect me?
I put this in here, I use this paper,
I slide it in like so. Now that needle is buried in the paper.
So you would have to deliberately put your finger right there.
But again, awareness. There is multiple potential hazards on this tray. Right here
we have a sharp blade. Right here
we have a needle that again,
it was just exposed to the patient.
We've got that complete.
We're ready to actually do the biopsy. The most important step now from the staff standpoint
is again patient safety, which always comes first, making sure they're calm, bleeding is
controlled. The provider will then take the specimen over to the bottle over there,
and most importantly, we've got to have that label because you can imagine, let's say we actually
sample a melanoma, and I say it's on the right arm and you put left leg, and there's multiple
biopsies. Those have been confused.
We've given them a diagnosis of melanoma and an inappropriate location and potentially even
killed the patient.
So it's extremely important to make sure everything is organized, labeled, provider can go directly
to the bottle of the specimen.
So now we're moving on. We've done our shave biopsy.
This is probably 90% of the time, we're going to do a shave. If we're going to do a punch
to provide our [inaudible] needs to tell you that. And so we will say, "Okay, we need to do a special
type of biopsy." And the way
I say to the patient is, "We're going to do a cookie cutter type of biopsy and I'll show
you why." I say that, but let me show you the tool first for that, which is right here.
There's multiple sizes. This size right here is very small.
This is a two punch. Probably the most common punch
we use is a three. The reason we use a three is, I'm going to turn this just like so.
You can see this is like a little cookie cutter device. A three is just enough tissue usually for
the pathologist to read. A two is a little bit small, two would be used for a tiny little mole
where you just want to punch it out.
And the way this tool is used is I'm rotating it.
Doesn't matter if you do a clockwise, counterclockwise,
we want to stay even. And you can see that basically this whole hub right here,
we want to bury or get to the level that we want to get the specimen. So that's the punch
right there. Pretty simple. And they come in a pack that you actually open up.
So then you're also need the punch kit, and notice that there's deliberately some labeling
on here.
Number one.
What is it?
It's a punch kit.
Number two.
It came from room number seven, so we know which room it belongs to, and where it came from
if there's any question. Number three: Sterilization, cleanliness.
This is absolutely essential.
This does have to be sterile.
"You know, why does it have to be sterile?"
These are instruments we're going to use to retract or receive the biopsy from that punch,
potentially even close or suture it. So these are instruments that are shared among patients.
They need to be sterilized. And what is sterilize mean? It means that they kill, at very high temperature,
bacterial, fungal spores, viruses,
so there's no transmission of any infectious processes.
So on here, it says 12-21-18. That's the day it was actually put through the autoclave. And then,
just as importantly, we have one of our medical assistant's initials here. And she put those
there, she said, "Hey, I quality checked this.
I'm putting my name on here, telling you, I make sure we're caring for the patient and
that this is appropriately done."
So anything blue means it was in the autoclave and sterilized. These stripes here are simply
an indication that this went through the autoclave.
So now I'm actually going to open this. So I'm aware.
I'm looking at the package.
This is something you should do before you open it.
There's no holes in this. Let's say you got this, and there's a big hole in there or something
[obviously] a breach.
You're going to stop. You're going to say, "Doctor or PA,
I need a moment.
I'm going to get another package." And you're not going to make a big deal in front of the patient.
You're just going to do it because you know, it's the right thing to do, because that one
was breached and sterility.
So once we've checked all that, we'll actually release the tape here.
And you can see how nicely folded this is. In reality,
we're not going to have all this all over the place.
But again, I'm aware.
I'm aware of my surroundings.
There is a sharp needle there.
There's a sharp blade there.
I'm keeping my hands well away from there.
Open like so.
And let's take a look at what we got in here.
And then if we're doing this thoroughly, this would be dropped directly on to there. So these
are pickups. You'll see these used in surgery, for excisions, for Mohs.
This is used to pick up tissue.
You can see I can actually pinch these together, pick up what I want. Before we go any further,
there's an actual strip, indicator strip in here.
This is an indicator strip meaning that, "Hey, the color here, teal, turquoise, depending on
how you see that, mean indicator strip,
meaning that it is truly sterilized by this indicator here, at this color, says we're good."
So it gives us another moment to pause.
Doctors, providers, medical assistants should all be really looking at this.
So we have shared responsibility taking care of that patient.
So we move this aside, ready to do the punch. Here is my punch tool.
It's very simple again,
if this is the skin or tissue, I usually hold it tight.
I put it down, and I... once the specimen is ready,
it will usually still stay there.
It's like a cylinder block.
You can't just like pick it up, and you don't want to crush it, because if I squeeze that
together too hard with these pickups, if I just crushed that tissue,
Dr. [inaudible] or whoever's reading that specimen is going to say, "Hey this, this is crushed." And literally
it looks on the microscope like all the cells are mushed.
So we have to be really careful about that.
So I grab that, and I also grab these little suture scissors here.
And so I'm going to demonstrate with the sponge here.
So let's say again, the skin is coming up, the specimen is ready to go.
I pick it up gently.
I'm not manhandling it.
I'm just sort of gently grabbing.
I pick it up and I cut it at the base.
I grab it gently.
I put it in the correct biopsy specimen that you will have ready for us.
And then I'm good to go. From here, if it's a three punch or lower,
meaning three millimeter hole or smaller,
we don't need to close it.
It will close on its own. But often what we'll do is, we'll take a little bit of the TCA or
aluminum chloride, which we didn't really touch on as much before, and I'll reiterate,
we have that on the tip here from our medicine.
And so again, I roll it, so it's not dripping, and let's say again, this is the hole right here.
You simply just apply it to the wound, and only to the wound. Because again, it will burn skin.
If you put it on normal skin. And you roll it back and forth.
So now the biopsy is complete and the patient's going to have lots of questions.
"How do I take care of the wound?"
"How do I know if everything's okay?" And these are all legit questions.
We do this hundreds of times a day.
So it becomes very monotonous for us. Meaning it becomes very boring for you.
But remember for the patient, it could be their first biopsy and it could be the most
important thing that you tell them. We want to go through a couple things, one is what
are we doing?
You're going to be putting a bandage on there.
You'll be putting a little bit of Vaseline.
And most likely a band-aid on there.
Sometimes a pressure dressing.
This is an area
that's a little more vascular, or bleeds more. That is a perfect opportunity, while you're
doing that, to tell the patient,
"Hey, we're putting this bandage on. This is how I'm doing it, and why I'm doing it."
Everybody wants to know why do we put Vaseline on there?
We put a small amount of Vaseline on the wound so that it can quote, granulate, meaning that
it can grow good tissue from inside out.
We don't want scabs, because scabs are dry, and that prevents the skin cells from coming
in and healing. So very simply again,
we're putting Vaseline on, keep a moist area,
so the good skin cells can come in there and prevent scabbing. Period. Once they have that
down you're going to talk about what to expect with a biopsy. They may have a little tenderness,
they should not need pain medication for this. After that,
they're gonna want to know, "How do I know if something's wrong with my biopsy?" We've got
that clearly in our biopsy instructions here, which we'll go through. And basically the body,
once they have a cut or scrape, it senses
there's something wrong. So it sends out inflammatory cells that make a little pink or even a slightly red
halo or circle around the wound. That is not an infection. A very common misconception
both by beginning staff and patients that, as soon as they see a little pink or red,
"Oh my gosh!
I have an infection!" Not the case.
It's actually normal.
So I think it's a very important point you say to them very briefly,
"Hey, you're going to get a little pink or red ring around the biopsy. That's totally
normal body response to the biopsy."
If it's expansive, if it's painful, if it's swollen, if there's drainage of any sort coming out,
we need to know these things. The patient should call us immediately, or if there, we're not available
to seek immediate medical care. And that is essentially the basic steps of the biopsy.
I talked a lot in this video, it's because I want you to think about all these steps as
we go along. When we actually do the biopsy,
it happens very quick, within a minute or so. But if you have it planned in your head, you're
ready to go, you look professional, you look good, and the patient's happy.
Thanks for your time.