Appendix EE –Mohs Bleeder Protocol

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Most surgical calls revolve around post-operative BLEEDING, PAIN, and/or INFECTION. Below is
the recommended protocol for how to appropriately counsel patients on these issues and how
to notify the fellow/attending. All phone calls should be directed first to your senior resident
on call and subsequently to the fellow (see below). All phone calls should be documented in
EPIC with a phone note detailing the events, and a cosign by the attending.
BLEEDING
If a patient calls about post-operative bleeding, the first step is to reassure the patient that
most skin bleeding stops with pressure. Instruct the patient/a family member to apply FIRM,
UNINTERUPPTED PRESSURE with a clean gauze/wash cloth/towel to the wound for 20 minutes.
Care should be taken to explain that pressure should be constant, as patients may be tempted
to “peek” before the 20 minutes has elapsed. If they peek, then the 20 minutes starts over
again. This must be reinforced with a little bit of fear (i.e. you will tear off the clot and the
bleeding will start again). Precise directions are important. Ask the patient to localize the
bleeding. If they are unable to do so underneath the thick bandage, instruct him/her to remove
the bandage to locate the bleeding source and apply direct pressure to it. After 20 minutes,
pressure should be relieved and the wound checked for bleeding. If bleeding persists, constant
pressure should be repeated for 20 minutes a total of 3 times (60 minutes).
Quantify bleeding from patient when possible ie

• slow oozing vs brisk
• spontaneous, induced by manipulation (dressing change, slept on it), change in pressure
  (sneezing), or some other activity
  You should start these interventions immediately when the patient calls. Tell the patient you
  will call back in 20 minutes to check on their progress. Once you hang up, call or text the
  fellow with the information. Request a photograph if the patient is able to send one (consider
  getting a Google voice phone number to receive patient photos via text).
  The fellow will determine if it is appropriate to meet the patient at the Des Peres or CSM
  location. Do NOT send the patient to the ER under these circumstances, if possible.
  If the fellow is out of town or unable to come in, make sure the attending is contacted by
  CALLING them (only text if not available by telephone). They are probably not on call and may
  not check a text message at night. If the patient’s attending is not available, contact the other
  attending.

For after hours, the CSM is available at all hours. The Des Peres location closes at 8, but can be
accessed afterwards through the exterior side entrance of Des Peres (nearest the Mohs clinic
space) which has a metal key pad to the right of the outside door with code. The doors at Des
Peres are also open on the weekends until about noon or so. Please ask your senior resident for
the door code.
There is a small grey filing cabinet between the two nursing bays at the Mohs CSM clinic where
there are labelled keys in the top drawer to open the cabinets for sutures etc.
PAIN
Standard recommendations for postoperative pain are as follows. If there are patient issues
with pain, contact either the fellow on call or the attending directly to inform them of the
patient’s concerns.

1. Tylenol q4-6h prn pain, not to exceed 3g in 1 day
2. AVOID aspirin and NSAIDs x 48 h. However, in certain situations (ie Tylenol allergy),
   NSAIDs may preferable to opiods on case-by-case basis.
3. If a narcotic is deemed necessary, the following are the most commonly prescribed.
   These should be discussed with fellow/attending prior to calling in a prescription.
   i. Tramadol 50mg q4-6h*
   ii. Tylenol with codeine #3 300 mg/30 mg q4-6h*
   *Before calling in, make sure patient was not already prescribed a narcotic in clinic that
   day and check allergies.
   INFECTION
   HOW TO CONTAGE JHE SELL Worough history. Ask about increased redness, swelling, pain,
   odor, exudate, and if patient is on antibiotics. It can be helpful if the patient sends a photo of
4. Text or call the tellow, (Nasrodsaa, 63+528-8227)/duringi daytime hourstwith alilture is ideal prior to
   atient calls.
   antibiotics, we may call in antibiotics if warranted. If non-allergic, the most common antibiotic
5. After 10pm, text inessages are OR to quickly convey coitsun laroratidinburia5 Fofalling in any
   assume it will wake ati the recipient.

The following format is requested for text messages:
Identify yourself
Patient initials, XX y/o M/F (use initials to be HIPPA compliant)
Patient of Dr. Behshad or Dr. Aria
s/p (MMS/excision) on (site) (MM/DD) repaired with (repair)
Who called? Patient or spouse/caregiver
What is patient calling about?
What is best call back number?
Any serious medical comorbidities?
Any constitutional symptoms (fevers, chills, SOB, chest pain, N/V/D)?
Any allergies if relevant to antibiotics or pain meds that we might prescribe, what was reaction?
Example:
Hi this is Alex, the on-call resident.
JS called, 77 yo M (Behshad) s/p MMS on scalp 4/15 repaired with complex linear closure. Pt
complains of slow oozing after dressing change. On ASA/Plavix. Bleeding stopped after holding
pressure.