Being a Surgeon Can Be Dangerous to Your Health

NEW YORK (Reuters Health) – In a survey of occupational injuries in oncologic surgeons at the University of Texas MD Anderson Cancer Center, 90{d3f6bf636dd0cfcc6b6abf6b418bf47c67e9ef114d0af9c178a3c3b139ba13ad} of the surgeons reported musculoskeletal symptoms and 28{d3f6bf636dd0cfcc6b6abf6b418bf47c67e9ef114d0af9c178a3c3b139ba13ad} reported an injury or condition attributed to operating, most of which required some form of treatment.

Based on responses from 127 of 219 surgeons invited to participate in the survey, the most common symptoms were fatigue, discomfort, stiffness, and back pain.

Of the 27.6{d3f6bf636dd0cfcc6b6abf6b418bf47c67e9ef114d0af9c178a3c3b139ba13ad} who reported an occupational injury, 65.7{d3f6bf636dd0cfcc6b6abf6b418bf47c67e9ef114d0af9c178a3c3b139ba13ad} received treatment, according to Dr. Rachel K. Voss, now at the UC San Diego Medical Center, and colleagues. More than a sixth of those treated required surgery for their injury, the researchers note in the Journal of the American College of Surgeons, online September 29.

The team also conducted a two-day randomized cross-over pilot study of intraoperative foot mat use. The use of anti-fatigue mats is recommended by the Occupational Safety and Health Administration (OSHA) to help prevent trauma and pain in the lower extremities in operating rooms.

Of the 20 surgeons who took part in the ergonomic intervention, 65{d3f6bf636dd0cfcc6b6abf6b418bf47c67e9ef114d0af9c178a3c3b139ba13ad} liked the experience and said they would use the mat again; 70{d3f6bf636dd0cfcc6b6abf6b418bf47c67e9ef114d0af9c178a3c3b139ba13ad} said they would recommend the mat to a colleague and 45{d3f6bf636dd0cfcc6b6abf6b418bf47c67e9ef114d0af9c178a3c3b139ba13ad} said it helped reduce surgery-related symptoms.

“Mat use was, however, statistically significantly associated with increased discomfort, with an associated wide confidence interval,” the researchers write in their report.

“Interestingly,” Dr. Voss told Reuters Health by email, “the majority of surgeons said they would use the mat again despite no statistical evidence for symptom improvement. It is important to know however that some individuals did report symptom improvement with the mat even if the group as a whole did not appear to benefit. Foot mats may benefit some individuals but are certainly not a ‘magic bullet’ for improving occupational symptoms.”

In general, Dr. Voss said her “perception is that surgeons have been operating with pain and discomfort and experiencing occupation-related injury for years in relative silence. We need to do better for our own health and for our patients.”

“Institutions and employers could make ergonomic and policy improvements to protect the health of surgeons but initiatives would be more successful with surgeon involvement,” she added. “Surgeons need to engage in better dialogue with occupational hygiene experts and industry experts to push for change. Of course, more research is needed, but being open to changes in the operating room environment and not settling for occupation-related symptoms and injuries is the first step.”

Dr. Voss said that “a surprise finding was that men were more likely to report an injury or chronic condition attributed to operating than women, contrary to prior reports. Furthermore, the rate of injury did not seem to correspond to experiencing occupational symptoms.”

Dr. John Thayer, chief of cardiothoracic surgery at St. Francis Hospital and Medical Center in Hartford, Connecticut, told Reuters Health by email that the “study raises an important issue that is not usually discussed among surgeons.”

“The study points out that over 90{d3f6bf636dd0cfcc6b6abf6b418bf47c67e9ef114d0af9c178a3c3b139ba13ad} of oncologic surgeons experience musculoskeletal discomfort due to the ergonomic hazards associated with operating,” said Dr. Thayer, who was not involved in the research.

“This is an important topic and emphasizes the need for more study and training in ergonomics as applied to the operating room,” he added. “It also reinforces the need for the surgeon to maintain fitness and flexibility despite demanding operative schedules.”

SOURCE: http://bit.ly/2epXIbl

J Am Coll Surg 2016.

US Surgeons Set Guidelines for Proper Attire Both In and Out of OR

The American College of Surgeons (ACS) has issued a statement on proper dress for surgeons, whether in the operating room or interacting with families or the public outside.

ACS Executive Director David B. Hoyt, MD, said the refresher statement is meant to provide evidence-based consensus on appropriate head coverings and when scrubs must be changed.

“Our fellows were concerned they were being told to do things that weren’t necessarily evidence-based,” he told Medscape Medical News. “It just was time for us all to take a step back and say what’s the best evidence, what’s best practice, and let’s all recommit to it.”

The statement was published online August 4 and will appear in the Bulletin of the American College of Surgeons in October.

Guidelines include:

• Change soiled scrubs and/or hats as soon as possible after surgery, and certainly before speaking with family members.
• Change scrubs and hats after contaminated cases, even if clothing is not visibly soiled. Discard paper skull caps at least daily and after every dirty or contaminated case. “Religious beliefs regarding headwear should be respected without compromising patient safety,” the authors explain.
• Do not let masks dangle.
• If wearing scrubs outside the operating room (OR), cover with a clean lab coat.
• Change out of scrubs before leaving the hospital. To enforce this, ACS recommends distinctive, colored scrubs for OR personnel. “I think there’s been a drift of wearing of scrubs into areas where you would not traditionally expect to see them,” Dr Hoyt said. “It does send a message other than that these are things worn for infection control and patient safety.”
• Remove or cover any jewelry on the head or neck that “might fall into or contaminate the sterile field,” before procedures, the authors recommend.
• Cover mouth, nose, and hair during invasive procedures. However, “There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections,” the guidelines authors write.
• Wear clean, appropriate professional attire (not scrubs) during all patient encounters outside the OR. “Physicians need to be reminded of these things, just like anybody else does,” Dr Hoyt said, although he acknowledged some will see it as one more set of rules to follow.

The authors of the guidelines also suggest clothing changes for all OR personnel, including anesthesiologists, certified nurse anesthetists, laboratory technicians, and aides.

The ACS is not the first organization to issue such guidelines. For instance, the Association of periOperative Registered Nurses updated their surgical attire guidelines in 2014 and included rules governing things such as cleaning protective eyewear, cellphones, and handheld devices and what shoes and shoe coverings are appropriate.

The Association of Surgical Technologists released their hand hygiene, surgical scrub, and surgical attire recommendations in 2008.

The guidelines do not add time to OR practice, and in fact support more flexibility in wearing some apparel, Dr Hoyt explained.

“What it doesn’t support is people getting in their car at night and driving in blood-soiled scrubs,” he said.

Dr Hoyt has disclosed no relevant financial relationships.

“Statement on Operating Room Attire.” ACS. Published online August 4, 2016. Full text

Physician Pleads Guilty to Torching Rival’s Office

Anthony Moschetto, DO, a cardiologist on Long Island, New York, had a business problem with a colleague-turned-rival.

It ended up in a court case that was anything but civil.

Dr Moschetto pleaded guilty in a New York State court last month to setting fire to the other physician’s office in Great Neck, New York, and conspiring to have him beaten up by a hireling, which never happened.

It was more complicated than that. Prosecutors said that a police investigation of illegal oxycodone prescriptions written by Dr Moschetto unexpectedly uncovered a murder-for-hire plot targeting an unnamed fellow cardiologist with whom Dr Moschetto had practised for 20 years. He vacillated between killing and merely assaulting the other physician before settling on the latter by the time of his arrest on April 14, 2015.

The ill will stemmed from an unspecified “professional dispute.”

“He wanted to put him out of business so he could get his business,” Nassau County Assistant District Attorney Anne Donnelly said at a press conference last year.

Dr Moschetto had enough tools at his disposal for all sorts of havoc. When police searched his mansion in Sands Points, New York, they found roughly 100 weapons, including rifles with illegal, high-capacity magazines, knives, and a grenade. Many of them were stored in a secret room behind a switch-activated moving bookshelf.

Dynamite, Fire, Fists

Dr Moschetto practised with the other cardiologist from 1994 until roughly 2 years ago. After the breakup, he originally wanted to dynamite the other physician’s office building, but switched to arson, according to prosecutors. The two men he hired for the job were only partly successful. The building’s sprinkler system put out the gasoline-fuelled fire before it had caused too much damage.

His next move was to attempt bodily harm. He offered an undercover detective $5000 to assault the other physician and, for a time, dangled $20,000 for a murder, going so far as to make down payments, prosecutors said.

Dr Moschetto pleaded guilty not only to arson and conspiracy to commit an assault but also to one count of illegal possession of a firearm and one count of the criminal sale of a prescription for a controlled substance. State prosecutors said the plea deal satisfied the original 77-count indictment against him.

His sentencing date is December 16. New York Supreme Court Justice Christopher Quinn intends to sentence him to 5 years in prison, according to prosecutors.

Follow Robert Lowes on Twitter @LowesRobert

WHO Guidelines: 29 Ways to Prevent Surgical Site Infections

New guidance on preventing surgical site infections (SSIs) from the World Health Organization (WHO) recommend that patients bathe or shower before surgery but that they not be shaved, and that antibiotics be used immediately before and during surgery but not afterward.

The Global Guidelines for the Prevention of Surgical Site Infection were developed by a panel of experts who reviewed the latest evidence on preventing SSIs. They include 29 concrete recommendations to be applied in the pre-, intra-, and postoperative periods.

The guidelines are valid for any country and are suitable for local adaptation. They take into account the strength of available scientific evidence, cost and resource implications, and patient values and preferences, the WHO says. The guidelines complement the WHO Surgical Safety Checklist by providing more detailed recommendations on SSI prevention, the agency says.

The new guidelines, if implemented, will save lives, reduce harm, cut costs, and limit the spread of antibiotic resistance, the WHO predicts.

Huge Burden, Highly Preventable

SSI is an issue that “concerns everyone,” Ed Kelley, PhD, WHO director of service delivery and safety, said during a press briefing. “There are no reliable estimates or global database or registry tracking exactly the number of surgical site infections that occur every year, but WHO estimates that millions of patients are affected by surgical site infections annually,” he added.

SSI is “highly preventable,” Dr Kelley said, and the new WHO guidelines are “the most extensive set of global guidelines ever produced on this subject.”

Until now, no international evidence-based guidelines had been published, and there are inconsistencies in the interpretation of evidence and recommendations regarding existing national guidelines, the WHO notes.

The guidelines were published online November 2 in two separate articles in the Lancet Infectious Diseases.

The guidelines say it is “good clinical practice” for patients to bathe or shower before surgery, and they recommend either plain soap or an antimicrobial soap.

With regard to the timing of the use antibiotics, there is evidence that antibiotics given before surgery can prevent infections for certain surgical procedures, but there is no evidence that use of antibiotics after surgery prevents infections, the guidelines say.

The recommendation is to administer surgical antibiotic prophylaxis within 120 minutes before incision and that consideration be given to the half-life of the antibiotic. “Obviously, the selection of the antibiotics, the exact appropriateness of the antibiotic for a given patient is up to the clinician,” Dr Kelley noted.

No Shaving

The guidelines “strongly” discourage shaving at all times, whether preoperatively or in the operating room. The guidelines say that hair should either not be removed or, if absolutely necessary, be removed only with a clipper.

Shaving is something that has “long been assumed was necessary to facilitate skin exposure,” Dr Kelley said. However, after extensive review of the evidence and lengthy discussion, the expert panel concluded that “hair removal can actually increase the risk of causing microscopic cuts or traumas to the skin, and the evidence tells us there is clear benefit to not removing the hair or simply clipping it if it absolutely needs to be done,” Dr Kelley said.

The guidelines also spell out the best way for surgical teams to clean their hands, what disinfectants to use before incision, which sutures to use, and the best approach to the use of drapes and gowns for preventing SSIs.

Although the guidelines are intended for surgical patients of all ages, some recommendations do not apply to the pediatric population, owing to lack of evidence or inapplicability. This is clearly stated in the guidelines.

“No one should get sick while seeking or receiving care,” Marie-Paule Kieny, PhD, WHO assistant director-general for health systems and innovation, said in a news release. “Preventing surgical infections has never been more important, but it is complex and requires a range of preventive measures. These guidelines are an invaluable tool for protecting patients.”

“I really welcome on behalf of doctors this set of guidelines,” Dame Sally Davies, MD, chief medical officer, United Kingdom, told reporters at the briefing. “It’s WHO at its best ― evidence-based, normative guidelines that are straightforward and simple to use. We all know that we’ve got to use our resources carefully, and you tell us when to use them and when not to use them in this, and that’s terribly important,” she added.

The WHO’s next step will be to work with countries and experts to prepare an implementation guide and assessment toolkit, Dr Kelley said.

Lancet Infect Dis. Published online November 2, 3016. Preoperative recommendations, Abstract; Intra- and postoperative recommendations, Abstract

Doctors Beware: Laser Hair Removal Smoke, a Health Hazard

NEW YORK (Reuters Health) – The “burning hair” plume that develops during laser hair removal (LHR) should be considered a biohazard, especially for health care workers,” researchers report.

Numerous surgical procedures involving lasers produce an aerosolized byproduct known as “surgical plume” that contain chemicals such as benzene, formaldehyde, carbon monoxide and hydrogen cyanide, according to Dr. Gary S. Chuang of the David Geffen School of Medicine at the University of California, Los Angeles and colleagues.

Laser hair removal is one of the most popular cosmetic procedures in the world, yet until now, the content of the “malodorous plume and visible particulates” had not been analyzed, they write in JAMA Dermatology, online July 6.

To simulate plume production during LHR treatment, the team collected hair samples from various parts of the body of two adult volunteers. They sealed the samples in glass gas chromatography jars and treated them with a laser.

During treatment, the researchers captured 30 seconds of laser plume, which they analyzed by gas chromatography-mass spectrometry (GC-MS).

Separately, they used a particle counter to measure ultrafine (less than 1 um) particulate concentrations in the treatment room, the waiting room and outside the building.

The GC-MS analysis identified 377 chemical compounds, 62 of which are easily absorbed, 20 of which are environmental toxins and 13 of which are known or suspected carcinogens, according to the researchers.

During LHR, the particle counters documented an eight-fold increase in ultrafine particle concentrations compared with the ambient room baseline level-from 15,300 particles per cubic centimeter (ppc) to 129,376 ppc-even when a smoke evacuator was in close proximity (5 centimeters) to the procedure site.

When they turned the smoke evacuator off for just 30 seconds, the particulate count increased by more than 26-fold compared to baseline, rising from 15,300 ppc to 435,888 ppc.

“These findings establish the concern that the burning-hair plume often present during LHR should be considered a biohazard, warranting the use of smoke evacuators, good ventilation, and respiratory protection, especially for health care workers with prolonged exposure to LHR plume,” the authors conclude.

Dr. Chuang told Reuters Health by email, “Laser hair removal smoke has long thought to be innocuous. This study provided definitiveevidence that surgical smoke may be harmful to human health.”

“Laser hair removal performed by improperly trained personnel or in an inadequately equipped facility will put both the healthcare workers and patients at risk,” he stressed. “Patients should seek laser hair removal treatment in facilities equipped with an adequate air filtration system and a smoke evacuator.”

Risks are likely greater for practitioners who may work eight hours straight, Dr. Chuang observed, although no studies have looked at how much exposure is too much. “It’s similar to estimating the effect of second-hand smoke-very difficult to do. However, it’s important to minimize the risks.”

Dermatologist Dr. Delphine Lee, director of the Dirks/Dougherty Laboratory for Cancer Research and Department of Translational Immunology at John Wayne Cancer Institute at Providence Saint John’s Health Center in Santa Monica, California, told Reuters Health by email, “This is a very interesting study (and) the findings alert us to be aware of potential risks so that we can take precautions.”

“While it is important to know what is generated, and the fact that carcinogens are detected in the plume and in the waiting rooms of the offices, it is important to keep these results in perspective,” she continued.

“It is important to consider how these levels compare to everyday exposures to other carcinogen-laden air, such as an urban environment or a smoky restaurant. For example, one should ask, how do the levels of carcinogens detected in the plume during a hair removal procedure compare to the walking on the street with car exhaust all around?”

“There has been no reported epidemic of increased lung disease or other cancer in technicians or health professionals who perform procedures with lasers, people who visit dermatology offices that use lasers, or patients who have frequent laser hair removal,” Dr. Lee observed.

“However, this landmark study alerts us to consider the consequences and further studies are warranted to investigate the risk of exposure to laser hair removal plume.”

Although the actual risks aren’t yet known, she said, “it is not unreasonable (for both practitioners and consumers) to take some moderate precautions, such as wearing respiratory masks.”

No funding or conflicts of interest were reported.

SOURCE: http://bit.ly/29DQ74N

JAMA Dermatol 2016.