The average emergency instrument tray, even the so-called plastic tray, often leaves much to be desired. The quality of the instruments is such that it interferes with the precision of the repair. The hospital may be accommodating enough to equip several trays with the instruments you want. At some institutions, this arrangement has proven satisfactory but not at others. If the hospital is providing good instrumentation, it is critical to have the emergency room return the used tray to central supply immediately after you finish. Otherwise, many of the instruments tend to disappear. A plastic needle holder with a gold handle makes a great roach clip!

Carrying the instruments you need with you and sterilizing them in isopropyl alcohol is another alternative. The purists may object to this type of sterilization, and I am aware of their arguments, but in 45 years of practice a problem never arose from this routine. The instruments need to be carefully washed after each case and it is a good practice to do this cleansing yourself.

One hospital would complain about my alcohol sterilization technique about every 10 years and would put together a tray with the instruments I desired. Within two or three weeks, the tray would be missing important instruments and I would revert back to alcohol sterilization.

Another alternative would be to carry an autoclaved tray with you. The problem with this approach is that you often have several cases consecutively. Adequate instrumentation is mandatory to achieve maximal results and often unless you carry the instruments you require with you, they will not be available or the time required to obtain them will be inordinate.

The seven instruments I carry with me include a plastic needle holder, a skin hook, a regular Adson forceps, a small, neurosurgical toothed forceps Iris scissors, tenotomy scissors and a number three scalpel handle with a ruler on it. I prefer Storz instruments but any quality brand will do. It is also a good idea to have a couple of good curved mosquito hemostats and two towel clips in your bag. Not infrequently the hemostats the hospital provide are in adequate and extra towel clips can facilitate keeping the drapes stable when the wound is in an awkward position. These instruments obviously can also be sterilized by alcohol immersion.

When fitting the number 15 blade on the scalpel handle, it is helpful to dip the blade into sterile water or saline to provide some lubrication.

Other items you may wish to carry with you include double edged razor blades, a straight Kelly clamp, a nasal speculum, nasal splints, number 15 and number 10 scalpel blades, ¼% ophthalmic topical tetracaine, 4% topical lidocaine, methylene blue, ½ inch Micropore tape or similar tape and an assortment of sutures. In addition, a small container with cough drops, analgesics, antacids, Sudafed, Imodium and Benadryl can come in handy.

The double-edged razor blades and straight Kelly forceps enable you to take a small split-thickness skin graft. The nasal speculum and nasal splints as well as the 4% topical lidocaine equip you to manage nasal fractures and the topical ophthalmic anesthetic helps when dealing with full thickness lacerations of the eyelids. Methylene blue is necessary for marking the red-white junction of lip lacerations and for sketching out flaps and donor sites. Having one’s preferred adhesive tape can expedite nasal splinting and finger dressings.

Carrying at least one of the sutures you frequently use with you can often be a big timesaver. If a particular suture is not immediately available in the emergency room or operating room, you can use the suture you have with you and then have the emergency room or operating room replace it before you leave.

The amount of unused material discarded by the emergency room and operating room is astounding. Clean disposable towels, 4 x 4 gauze, fluffs, Kerlex, greasy gauze, lap sponges and Ace bandages are routinely discarded. By salvaging these items and re-sterilizing them if necessary, one can practically supply his office! As the old saying goes, waste not, want not.

In addition to proper instrumentation, loopes are a must for many types of wounds. An Optivisor with 2.5 X magnification is adequate but more expensive loopes obviously work also.  Optivisors are available with an attached light. Having a light on your loopes often is helpful, particularly when the repair is being done at the bedside. The advantage with the more expensive loopes is that it has a longer focal length but an Optivisor has a wider field. It is convenient to have both types of loopes with you. A longer focal length is desirable in some situations, such as with patients with uncleared cervical spines who can’t be put in a semi Fowler position.