My Working Day in Mohs Surgery Quiz / Test | Sci / Tech

Quiz Answer Key and Fun Facts

1. As the clinical support worker for the team I get into work at 07:15 and change into my scrubs. I put my uniform in my locker and enter the unit. What is the first thing I do?

Answer: Start cleaning the surgical bays and trolleys

We clean the surgical bays and trolleys with a mixture called 'Chlor Clean'. This is to ensure that everything is cleaned properly and effectively, ready to start setting up for the day.

2. Now that's done we can start preparing for the procedures. We have nine patients today and one of them is a joint case, which means they are going to another hospital afterwards to be repaired. The assistant practitioner puts a pair of strabismus scissors on the trolley. What does the consultant need these for?

Answer: To cut near the eye

The patient is going to the eye hospital to be repaired by the ophthalmologist. As the eye is delicate, these scissors will see some use as their shape allow easy access in that area.

3. We've set up all of our trolleys, everywhere is tidy and we are ready to call our patients through. The nurse calls one patient through and she finds out that this patient is on warfarin, but has not taken it for 14 days. Can Mohs be performed on this patient?

Answer: Yes

If a patient is taking any medication that thins their blood such as warfarin or aspirin, they should immediately let the nurse know as they are prone to bleeding. The nurse should then immediately let the consultant know so he is aware of this. It is sometimes acceptable for patients to still take their medication, but are told beforehand.

This also means that if they need to stop their medication, they can be notified of when they need to stop taking it prior to surgery. This is because some anaesthetics also thin the blood.

4. The consultant has anaesthetised the patient with local anaesthetic and left them with the nurse for a few minutes for it to kick in. The nurse will now wash the patient's face, but she has to put sterile gloves on first. She has called me in to open up the gloves ready for her to put them on. Which of these will she do first?

Answer: Wash her hands

As I am opening the gloves up ready for her she will wash her hands. Once her hands are dry she will put her apron on then wash her hands again then put the gloves on, making sure not to touch the palms or fingers as she will be touching the patient with those.

The nurse will be following the ANTT procedure (Aseptic Non Touch Technique) which is a practice that ensures safety for both patients and clinical staff in relation to infection control.

5. The consultant will now scrub up as well, and he picks up an instrument to use. What will he typically pick up first?

Answer: A curette

He will curette the lesion first before cutting around the tumour. Once he has finished, he will cauterise the area with the bipolar to stop any bleeding. A curette is a spoon-shaped instrument that cuts away at the lesion. A scalpel is a blade that is used to slice around the area. Monopolars and bipolars are different types of forceps used for cauterisation. We use bipolars in Mohs surgery.

6. The consultant will now take the tumour to the lab to be processed by the technician. What machine does she use to process the removed skin?

Answer: Cryostat

The cryostat will freeze the sample so it can be cut into thin slices (If the layer is very fatty, the cryostat will freeze the skin at -30 degrees Celsius). Once thin enough, the technician will gently place it onto a slide then dye it (This is so the consultant will be able to see any visible tumour under the microscope).

7. Our patient is clear first time round, so there is no tissue left from the BCC. We ask the patient to get into a gown and we wait for the consultant to decide what repair he will do for the patient. He says that he will do a transposition flap. Which of these best describes a transposition flap?

Answer: Manipulating the skin so that it 'jumps' into the wound and can be stitched

The way the consultant taught me about different repair flaps was through chess. He described an advancement flap (The sliding skin) as a rook/castle as it will only move in a straight line. He described a rotation flap (simply rotating without jumping into a new area) as a bishop as it moves diagonally, and a transposition flap (the answer) as a knight as it can jump over other pieces.

The answers which involved cutting off skin and placing it on the wound were types of grafts.

8. The nurse will now dress the closed wound and has asked the patient to get dressed. She then goes through the aftercare instructions with the patient. They ask her who discovered this form of surgery and she replies "Mr. Mohs." What was Mr. Mohs' first name?

Answer: Frederic

Frederic E Mohs created the Mohs technique back in 1938. It is a highly accurate procedure with a 97-99% success rate. There are only a dozen Mohs departments in the UK, and the busiest is in the North West England. Mohs surgery is only performed on the face and other sensitive areas; if a tumour is found anywhere else on the body a wide margin of skin can be taken and repaired but this is not the case with the face.

The most common skin cancer we deal with in Mohs surgery is basal cell carcinoma which are also known as 'rodent ulcers'. Though these very rarely kill you like other cancers can, it is best that they are removed as they can destroy local tissues.

9. All of our Mohs patients have gone home for the day, but we have a wound check patient arrive to be seen by the consultant. He complains that he is feeling a tingling sensation around the wound which is by his mouth. The consultant says he has nothing to worry about as this is just the nerves knitting back together. How fast do nerves grow?

Answer: 1mm a month

As he explains to the concerned patient, when he cut the tumour out, he had to cut some nerves as well. The tingling sensation he is currently feeling is the nerves reforming under the skin.

10. Just before I can get ready to leave for home, the nurses ask me to call the last patient through for a wound check. I call them through and notice that they have a skin graft. I quickly observe the nurse removing the dressing from the graft and see that it is a very dark pink/red colour. Is this a good colour for a skin graft to be?

Answer: Yes

This means that the borrowed skin is getting plenty of blood supply so it can attach nicely to the rest of the skin. Skin grafts require specific care instructions as they are more sensitive compared to the other repairs we see.
A skin graft works by cutting another piece of skin from a 'donor site' which matches the texture and colour of its new site. It will then be stitched on and secured with a dressing which is also stitched.
Another skin graft we see is a Burow's Graft, which involves the wound being cut open more and the skin that is left will be preserved in saline. The pieces of skin will then be reattached, closing the wound up as well. This type of graft is usually done in a diamond shape, as two triangular pieces of skin are removed and replaced.

Source: Author poptart21

This quiz was reviewed by FunTrivia editor WesleyCrusher before going online.
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My Working Day in Mohs Surgery Quiz

So I work in Mohs Surgery in Dermatology, where we remove basal-cell carcinomas (BCCs for short) from the face. Follow my day at work and see if you know just as much as I do about this procedure.

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