ASA Dues-paying Members only -

Transcription

Exclusive educational opportunity
for ASA dues-paying members
details on page 2 ►
Take Advantage of This Special Offer
for ASA Dues-Paying Members Only
CSFAs: Earn more than 10% of your recertification
requirements for only $1.50/per credit*
For only $15 you will receive:
Targeted Information
∎∎ Authored by experienced surgical personnel—from veteran CSTs, CSFAs,
MDs and PhDs
∎∎ Original articles—not generically published for the mass health care
audience
∎∎ Information that is targeted to You and what you as a surgical assistant
need to know to provide the highest quality care to your patients.
Topics Related to the Advanced Practitioners
∎∎ These articles are written for the advanced practitioners for advanced
practitioners
∎∎ Innovative Instrumentation and technologies
∎∎ Ethical considerations
∎∎ Safety in the OR
∎∎ Trends in surgical patient care
Learning Objectives
Each article includes five learning objectives that have been developed by
surgical assistant practitioners. The objectives highlight the salient points of each
article. You can use the objectives to evaluate your level of comprehension while
reading.
Professional Exams
The tests that follow each exam specifically address the information in the
article and were designed to evaluate your comprehension and retention of the
information presented by the individual author.
Instructions for completing the online booklet
10 CEs
Table of Contents
Hernias of the Abdominal
Wall: Inguinal Anatomy in
the Male . . . . . . . . . . . . . . 3
Hazards of Vaporized
Tissue Plume . . . . . . . . . . 6
Tourniquet safety:
Preventing skin
injuries . . . . . . . . . . . . . . 10
Understanding
anaphylaxis . . . . . . . . . . 16
Electrosurgery . . . . . . . . 20
Blood Clotting
Mechanism . . . . . . . . . . 25
Bioethics in Solid Organ
Transplantation . . . . . . . 30
Maintaining Patient
Confidentiality:
HIPAA Compliance . . . . 36
Radiation Risk . . . . . . . . 46
Birmingham Hip
Resurfacing . . . . . . . . . . 51
CSFAs should download and read the articles; and answer all exam questions.
The interactive answer sheet should be completed and submitted with
payment. If you click the appropriate response on the individual exam after
each article, your answer will be automatically transferred to the answer key.
If preferred, download the answer sheet, fill it out completely. Indicate type of
credit card or include a check. To fax: send it to 303-694-9169. To mail: ASA:
Attn: CE credits, 6 West Dry Creek Circle, Ste 200, Littleton, CO 80120.
CSAs and SA-Cs should follow the policies of the NSAA and ABSA
accordingly.
*Based on 75 CE credits in a four-year cycle for the CSFA.
2
Association of Surgical Assistants ∎ www.surgicalassistant.org ∎ Table of Contents
Hernias of the Abdominal Wall:
Inguinal Anatomy in the Male
by Bob Caruthers, CST, PhD, FAST
Learning objectives:
1. Review groin anatomy.
2. Define the differences between direct
and indirect hernias.
3.Understand the significance of
inguinal ligament.
4.Explain the importance of the
transversalis fascia.
5.List the contents of the inguinal canal.
The surgical repair of an inguinal hernia, although one of
the most common of surgical procedures, presents a special challenge: Groin anatomy remains one of the more difficult topics to master for both the entry-level student and
the first assistant. This article reviews the relevant anatomy
of the male groin.
Major Fascial and Ligamental Structures
The abdominal wall contains muscle groups representing two broad areas: anterolateral and posterior. The posterior muscles, the quadratus lumborum, do not concern
us in this discussion. The anterolateral group consists of
two muscle groups whose bodies are near the midline and
whose fibers are oriented vertically in the standing human:
the rectus abdominis and the pyramidalis. The muscle bodies of the other three groups are more lateral, have significantly larger aponeuroses, and have obliquely oriented
fibers. These three groups contribute the major portion of
the fascial and ligamental structures in the groin area.1,2,3
At the level of the inguinal canal, the layers of the
abdominal wall include skin, subcutaneous tissue (Camper’s and Scarpa’s fascia), external oblique fascia, cremasteric muscle fibers, spermatic cord structures, the transversus
abdominis aponeurosis, the transversalis fascia, preperitoneal tissues, and peritoneum.1,2,3
External Abdominal Oblique Muscle
The external abdominal oblique muscle is the most superficial, thickest, and largest of the anterolateral muscle groups.
The muscle body is found laterally, having a strong, flat
aponeurosis occurring anteriorly. The external abdominal oblique muscle arises from the lower outside border of
the lower eight ribs. Fibers from the bottom two ribs insert
3
in the iliac crest, while fibers from the upper six ribs course
downward obliquely and anteriorly to become the external
oblique aponeurosis. The aponeurotic fibers from each side
interlace with fibers from the opposite side in the linea alba.
Fibers of the external abdominal oblique fuse with fibers
from the underlying internal abdominal oblique to form
the sheath of the rectus abdominis muscle.1,2,3,4
Inguinal Ligament
In the groin area, a continuation of the aponeurosis of
the external abdominal oblique stretches from the pubic
tubercle to the anterior-superior iliac spine. This extension is a rolled-under, inferior margin of the aponeurosis of
the external abdominal oblique and is called the inguinal
(Poupart’s) ligament. This ligament marks, in the groin, the
separation between the abdominal wall and the lower limb.
Hernias that occur immediately above this ligament are
considered to be in the inguinal area, while hernias existing
below the ligament are called femoral hernias.
The more medial of the rolled-under fibers of the inguinal ligament flatten into a horizontal shelf. These fibers
attach to the os pubis, and this continuation of the inguinal
ligament is called the lacunar (Gimbernat’s) ligament. The
spermatic cord, which courses through the inguinal canal,
rests on the lacunar ligament until it turns to exit through
the superficial inguinal ring. Fibers that continue laterally
along the anterior border of the superior ramus of the pubis
contribute to the pectineal (Cooper’s) ligament.1,2,3
Internal Abdominal Oblique Muscle
The internal abdominal oblique muscle—as the middle
one of the three flat abdominal muscles—is a thin, muscular sheet arising from the posterior layer of the thoracolumbar fascia, the anterior two-thirds of the iliac crest, the lateral two-thirds of the inguinal ligament, and the iliacus fascia. Posterior fibers ascend vertically to the inferior borders
of the lower 3 or 4 ribs, while the other fibers spread fan-like
in a forward and medial fashion. The ultimate insertion of
these fibers is the linea alba and the pubic bone.
In the upper abdomen, the internal abdominal oblique
aponuerosis splits at the linea semilunaris, having an anterior and posterior sheath. In the lower quarter of the abdomen, the aponeurosis does not split, but masses to the midline, anterior to the rectus abdominis muscle. The lower
Hernias of the Abdominal Wall: Inguinal Anatomy in the Male
fibers arch over the spermatic cord and insert in the superior border of the pubis. These fibers join with similar fibers
from the transversalis muscle to form the falx inguinalis.1,2,3
Cremaster Muscle and Fascia
The cremaster muscle originates from the inferior margin
of the internal abdominal oblique muscle and forms part of
the coverings of the cord and testis: It underlies the external
spermatic fascia and serves as the middle one of the three
covering layers of the cord and testis.1,2
Transversus Abdominis Muscle
The transversus abdominis muscle is the innermost of the flat
muscles of the abdomen, having an extensive and varied origin in the cartilages of the six lower ribs, the thoracolumbar
fascia, the iliac crest, and the inguinal ligament. The internal
surface of the muscle is lined by the tranversalis fascia.1,2,3
Transversalis Fascia
The endoabdominal fascia forms a continuous lining of the
abdominal cavity. When this fascia lies deep to the transversus abdominis muscle, it is labeled “transversalis fascia.”
When the endoabdominal fascia is intact, no hernia exists;
therefore, all hernias in the groin represent a defect in the
transversalis fascia. This fascia is attached to the iliac crest
and descends upon the iliac fascia, serving as the superior
fascia of the pelvic diaphragm. The internal spermatic fascia
is the principal outpouching of the transversalis fascia; its
mouth is the deep inguinal ring.1,2,3
Inguinal Canal
The inguinal canal is approximately 4-cm long and obliquely oriented; it lies 2 cm to 4 cm above and parallel to the
inguinal ligament. Entrance to the canal is the deep inguinal ring found above the midpoint of the inguinal ligament.
The deep inguinal ring is not truly “ring-like,” but a fingerlike diverticulum of the transversalis fascia. The canal is
directed lateral to medial, deep to superficial, and cephalad
to caudad, exiting at the superficial inguinal ring occurring
above and lateral to the pubic tubercle.
Whereas the superficial boundary of the canal is formed
by the external oblique aponeurosis, the most cephalad wall
is formed by the internal oblique and tranversus muscles,
along with aponeurotic fibers from each. The inferior wall
is formed by the inguinal and lacunar ligaments; the posterior wall—sometimes called the “floor”—is formed by the
transversalis fascia and transversus abdominis muscle.
In the male, the contents of the inguinal canal include the
vas deferens; deferential artery and vein; testicular artery;
lymphatics; autonomic nerves; the ilioinguinal nerve and
genital portion of the genitofemoral nerve; and the cremaster
artery, which is a branch of the inferior epigastric artery.1,2,3,4
4
Inferior Epigastric Vessels
The external iliac arteries supply blood to the legs, and the
internal iliac arteries supply the pelvis and perineum. The
external iliac artery passes under the inguinal ligament at a
point midway between the anterior-superior iliac spine and
the symphysis pubis: At that crossing point, it becomes the
femoral artery. The external iliac artery follows the medial border of the psoas muscle, giving off several branches.
The inferior epigastric artery branches from the external
iliac artery just above the inguinal ligament and has its origin at the medial border of the deep inguinal ring. The spermatic cord passes behind and lateral to the epigastric artery
and vein.
By using three points—the inferior epigastric artery and
vein, the symphysis pubis, and the rectus abdominis muscle
as it reaches the midline of the abdomen—one can create
an imaginary triangle called “Hesselbach’s triangle,” which
is used to determine whether a hernia is considered direct
or indirect.1,2,3
Inguinal Hernias
Several schemes are used to describe hernias: One of the
more traditional distinctions made when referring to inguinal hernias is that between direct and indirect hernias. The
indirect inguinal hernia is characterized by a herniation of
abdominal contents into an unobliterated vaginal process
within the coverings of the spermatic cord that begins at
the deep inguinal ring. The structures traverse the inguinal
canal to emerge at the superficial inguinal ring, and the contents may descend into the scrotum.
The direct inguinal hernia, which occurs one-third as
frequently as the indirect hernia, develops secondarily to a
weakness in the superficial inguinal ring and the abdominal wall lateral to the falx inguinalis. The inferior epigastric
artery lies lateral to the mass; that is to say, the mass occurs
in Hesselbach’s triangle. The covering layers of this type of
hernia are those of the abdominal wall.
The techniques of hernia repair are beyond the scope
of this review, but the Certified Surgical Technologist will
recognize that the various methods of repair tend to make
use of different ligaments to reconstruct an intact and sufficiently strong transversalis fascial plane.1,2,3,4
References
1. Woodburne RT, Burkel WE. Essentials of Human Anatomy. 8th
ed. New York, NY Oxford University Press, 1988.
2. Wantz GE. Open Repair of Hernias of the Abdominal Wall.
Scientific American CD-ROM. Scientific American Inc, 1997.
3. Netter F. A Guide to the Interactive Atlas of Human Anatomy.
Summit, NJ: Ciba-Geigy Corporation, 1995.
4. Sabiston DC. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Philadelphia, Pa: W.B. Saunders Co, 1997.
CE Exam: Hernias of the Abdominal Wall: Inguinal Anatomy in the Male
1. Those fibers of the external abdominal oblique
muscle that arise from the bottom two ribs
insert in the
, while the fibers arising
from the upper six ribs become the external
oblique aponeurosis.
6. The
layer represents the middle one of
the three covering layers of the cord and testis.
A superior ramus of the
pubis
B anterior surface of the
xiphoid process
C iIiac crest
D superior border of the
pubis
7. The deep inguinal ring, the entrance to the
, is described as
.
2. In the abdominal wall, the two anterolateral
muscle groups whose fibers are vertically
oriented are the
.
A pyramidalis and
transverses abdominis
B external and internal
abdominal oblique
C quadratus lumborum and
transversus abdominis
D rectus abdominis and
pyramidalis
3. In the upper abdomen, the internal abdominal
oblique aponeurosis splits at the
, with
a/an
sheath.
A linea alba; anteriorsuperior
B linea semilunaris; anterior
and posterior
C costal margin;
inferolaretal
D margin of the xiphoid
process; superolateral
4. The
ligament marks the separation
between the abdominal wall and the lower
limb; hernias occurring below it are called
hernias.
A pectineal; unobliterated
B Gimbernat’s;
endoabdominal
C lacunar; inguinal
D inguinal; femoral
A transversalis fascia
B external spermatic fascia
C cremaster muscle and
fascia
D internal spermatic fascia
A falx inguinalis;
sickle‑shaped
B inguinal canal;
a diverticulum
C femoral canal; ring-like
D iliopubic tract;
an invagination
8. Three points create Hesselbach’s triangle:
the symphysis pubis, the inferior epigastric
vessels, and the
.
A falx inguinalis
B rectus abdominis at the
midline
C linea alba
D deep inguinal ring
9. The inguinal canal
A contains the elements of
the spermatic cord.
B serves strictly as a
passageway for the
lymphatics and blood
vessels.
C excludes the elements of
the spermatic cord.
D has an inferior wall that is
also known as the “floor.”
10. The type of hernia that occurs in Hesselbach’s
triangle is a/an
hernia.
A indirect
B unobliterated
C direct
D diverticular
5. A groin hernia represents a defect in the
fascia.
A transversalis
B thoracolumbar
C cremaster
D extraperitoneal
5
Hazards of Vaporized Tissue Plume
by Kevin W Gracie, CST, CSFA
1. Summarize the health concerns
caused by laser plume
2. Define and analyze vaporized tissue
plume
3.Identify the chemical and biological
byproducts in laser plume
4.Examine the recommended clinical
practice guidelines
5.Evaluate the methods for removal of
airborne contaminants
While the medical use of cautery for the treatment of hemorrhage and lesions has been documented since 3000 BCE,
it was not until the early 1800s when newly discovered electricity was used to heat a probe for cauterization. In 1936
the first practical electrosurgical unit (ESU) was designed
by WT Bovie and used by the famed neurosurgeon Harvey Cushing. Since the ESU has become recognized as an
invaluable tool in medicine and widely accepted, its use has
been estimated in 90 percent of the 24,000,000 cases performed each year. For the surgical team, the inhalation of
vaporized tissue plume is routine and has been accepted as
part of the working environment. Occasional upper respiratory tract and ocular irritation is expected. Additionally, the
view of the surgical field may be temporarily obstructed by
the plume, causing minor delays.1,7
It was not until laser surgery became popular in the
1980s that concerns grew about the laser plume’s content.
Coincidentally, this was about the same time the true hazards of tobacco smoke became evident to the general public. Research studies were conducted in the early 1980s to
determine the content of plume, as well as the potential
hazard of exposure to the pungent white/gray billow that
emanates from both the laser and the ESU as it cuts and
cauterizes tissue. Researchers were able to identify chemical byproducts contained in the vaporized tissue plume
and noted that particle size in the plume ranged from 0.1
to 0.8 microns. (Standard surgical masks are capable of 5.0
micron particle diameter filtration.)7 Research also demonstrated that exposure to laser plume caused pathological changes in the lungs of rats and that a carbon dioxide
laser could vaporize intact DNA from the human papilloma
virus (HPV).7
6
An increase in the number of procedures that can be performed endoscopically prompted additional research in the
1990s. This research demonstrated that:
∎∎ plume within the abdominal cavity reduced the oxygen-carrying capacity of the blood due to an increase
in methemoglobin.
∎∎ HIV DNA was detected in laser plume in culture on
the 14th day.
As a result of these findings, the National Institution for
Occupational Safety and Health (NIOSH) issued a hazard
control statement that calls for evacuation of plume generated by electrosurgical units and lasers.7
Vaporized tissue plume
Vaporized tissue plume is the term commonly used to
describe the smoke generated when tissue (including
bone) is thermally destroyed and vaporized through the
use of the ESU or the laser. However, when discussing
plume, it is important to include the smoke and aerosol that
is formed with the use of power instrumentation, such as
saws, drills, and reamers, and devices that produce pulsatile
lavage. Even if proper cooling techniques are used, power
instrumentation can produce a vaporized tissue plume,
and aerosol formation is likely with pulsatile lavage devices.
Although, aerosols may not contain the byproducts associated with smoke, they must be considered airborne contaminants and treated accordingly.
Whatever the original source, all vaporized tissue plume
is similar in content.2 The plume has been shown to contain
more than 600 components (Table 1), some of which are
known to be toxic, mutagenic, and carcinogenic. Among
the known hazards is benzene, which is documented as
being a trigger for leukemia.7 Precautions are mandated in
OSHA’s booklet, “Health Hazards of Benzene.” For more
information about the other hazardous components of
plume, refer to www.osha-scl.gov or the hospital’s Material
Safety Data Sheets (MSDS).
One study comparing cigarette smoke to laser-generated smoke, demonstrated that 1 gram of tissue cut with the
carbon dioxide laser was found to have the same harmful
potential as smoking three unfiltered cigarettes.7
More recent studies have been directed toward the possibility of active/viable microbial cells within the plume.
Transmission by inhalation has been reported, and in one
Table 1 Chemical and biological byproducts found in vaporized tissue plume 2,4,5,7,8
∎∎
∎∎
∎∎
∎∎
∎∎
∎∎
∎∎
∎∎
∎∎
Acetonitrile
Acetylene
Acrolein
Acrylonitrile
Alkyl benzenes
Benzene
Butadiene
Butene
Carbon monoxide
∎∎ Carbonized cell
fragments
∎∎ Creosols
∎∎ Ethane
∎∎ Ethene
∎∎ Ethylene
∎∎ Formaldehyde
∎∎ Free radicals
∎∎ Gasses
∎∎ Hydrogen cyanide
case, a 44-year-old laser surgeon developed laryngeal papillomatosis. Biopsies revealed HPV DNA types consistent
with the anogenital condylomas lased from his patients.
Another report involved a patient who underwent laparoscopic resection of an intraabdominal tumor. The patient
later developed trocar site metastasis, suggesting that active
cancer cells in the smoke may have attached to the trocar, which were transferred to the tissue as the trocars were
removed. Also under investigation is the potential build up
of carbon monoxide within the patient’s abdomen and its
potential to reach a toxic level.
As studies continue to pinpoint potential vaporized tissue plume hazards, steps must be taken to protect the surgical team members (including auxiliary personnel) and the
patient from exposure. Patients undergoing laparoscopic
procedures and receiving general anesthesia alternatives are
at highest risk.
Recommended clinical practice guidelines
Recommended clinical practice guidelines, presented
in Table 2, are a combination of recommendations from
the American Society for Laser Medicine & Surgery, the
National Institute for Occupational Safety and Health
(NIOSH), the Occupational Safety & Health Administration (OSHA—US Department of Labor), and the Ontario Ministry of Labour (Canadian Centre for Occupational
Health and Safety).
Please note that these are recommendations, not
requirements. Currently, there are no standards specific
to vaporized tissue plume; however, compliance with specific standards is applied to certain situations.5 Examples
include:
∎∎ Standard Precautions are used in all patient-care
situations in which blood, any body Xuid, secretion,
or excretion (with the exception of sweat), non-intact
skin, and mucous membranes may be encountered.
7
∎∎ Isobuteine
∎∎ Methane
∎∎ Microbial cellular DNA
constituents
∎∎ Organic vapors
∎∎ Particulate matter
∎∎ Phenol
∎∎ Polycyclic aromatic
hydrocarbons
∎∎ Propene
∎∎
∎∎
∎∎
∎∎
∎∎
∎∎
∎∎
∎∎
∎∎
Propylene
Pyridine
Pyrrole
Styrene
Toluene
Trace toxic gasses
Viral fragments
Water vapor
Xylene
∎∎ General Duty Clause 5(a)1 OHS Act of 1970 states
the duties of the employer and responsibilities of the
employee in reference to workplace hazards.
∎∎ OHSA Standard 1910.134(a)(1) Respiratory Protection’s primary objective is to control occupational
diseases caused by breathing air contaminated with
harmful substances. This is to be accomplished
through accepted engineering controls if feasible or
through the use of appropriate respirators. (Note:
surgical masks used to prevent contamination of the
patient are not certified for respiratory protection of
medical employees.)
∎∎ OSHA Standard 1910.1030(d)(3)(i) Blood-borne
Pathogens states that the employer must supply appropriate personal protective equipment, such as gloves,
gowns, masks, and eye protection. This standard would
apply if such items become contaminated with viable
blood-borne pathogens from vaporized tissue plume.
Methods for removal
Two main methods are used to remove airborne contaminants from the operating room.
1. Room-air exchange systems, such as laminar Xow, are
not sufficient to capture vaporized tissue plume at its
point of origin. The surgical team and patient have already been exposed to the contaminants prior to their
removal from the operating room.
2. Local exhaust ventilation offers several methods to capture vaporized tissue plume at its point of origin. Ideally, the local exhaust-ventilation system is composed of
an inlet nozzle or tip, hose, filter, and suction unit.
A.Hand-held wand attached to a suction device. This
technology has been available for more than a
decade and is effective only when the surgical first
assistant is able to hold the device in close proximity to the plume’s point of origin.
Table 2 Clinical practice guidelines
1,4,5,6
1. Vaporized tissue plume (from any source)
should be considered potentially hazardous for two reasons:
A.Presence of particulate matter
B.Presence of infective agents
2. Vaporized tissue plume should be collected by an appropriate mechanical evacuation system at all times. Ideally, the evacuation system will:
A.Have a high flow volume.
B.Be vented outdoors.
C.Contain an appropriate filter (HEPA, highefficiency particulate air, or ULPA, ultra-low
penetration air, used with charcoal) that has
the ability to detect overloading and is subject to frequent filter changes.
D.Allow placement of the evacuator nozzle/tip
as close to the point of origin of the vaporized tissue plume (2-5 cm) as possible.
E. Treat disposable components as biohazardous material, as needed.
F. Have non-disposable components sterilized
prior to reuse, as needed.
G.Be maintained according to the manufacturers recommendations.
3. Personal protective equipment is required
in all situations that vaporized tissue plume
is generated.
A.Appropriate clothing—fluid-resistant or fluidproof long-sleeve apron or surgical gown.
B.Eye protection—sufficient to protect from
splatter.
C.Mask—effective filtration or respirator.
D.Gloves—latex preferred or suitable substitute.
4. Smoke evacuation should be carried out
independently of fluid aspiration
B. An adhesive device attached to the patient’s skin or
the drapes. This new technology does not require
any additional intraoperative handling once positioned and allows for capture, filtration and deodorization of vaporized tissue plume.
C.A device that is attached to the outXow port during
laparoscopy. This is another new technology that
does not require additional intraoperative handling
once positioned. It also allows for capture, filtration
and deodorization of vaporized tissue plume.
The most effective protection against vaporized tissue
plume at this time is a high-Xow smoke evacuator that cap-
8
tures smoke at its point of origin. Currently in use are several systems such as the Stackhouse high-Xow evacuator, the
Sun Medical SFE-200, and the JLJ Medical Devices International, LLC, Plume-Away.
As concern grows over vaporized tissue plume generated during surgery, additional research is necessary, current
methods for evacuation must be evaluated, and new evacuation systems must be developed to protect the patient and
surgical team from exposure.
About the author
Kevin Gracie is a self employed CST, CSFA and has provided surgical assistant services to 11 hospitals and clinics in
the Minneapolis/St Paul metropolitan area since 1994. Previously, he was a surgical assistant for 15 years at the Institute for Low Back Care.
References
1. Longmire A. “Control of Smoke from Laser/ Electric Surgical
Procedures.” NIOSH Hazard Controls. www.cdc.gov/niosh/hc11.
html Accessed 12-1-00
2. Dikes C. Is it Safe to Allow Smoke in Our Operating Room?
Today’s Surgical Nurse—Innovations in Perioperative Nursing.
Vol 21, No 2, March/April 1999.
3. Hallmo P, Naess O. “Laryngeal papillomatosis with human
papillomavirus DNA contracted by a laser surgeon.” European
Archives of Otorhinolaryngology. 1991.
4. Laser Plume in Surgical Procedures. Information Alert Ontario
Ministry of Labour/Canadian Centre for Occupational Health
and Safety. August 19, 1992. www.ccohs.ca/otherhsin fo/alerts/
alert61.txt Accessed 12-1-00
5. Laser/Electrosurgery Plume. OSHA Technical Links.
www.osha-slc.gov/SLTC/laserelectrosurgery plume/index.html
Accessed 12-1-00
6. Smoking Guns—Part 1 and Part 2. The American Society for
Laser Medicine & Surgery Inc.
www.aslms.org/general-smokeguns1.htm and
www.aslms.org/general-smokeguns2.htm Accessed 12-1-00
7. Surgical Smoke Plume Infection Control Newsletter. Vol 5, No 2,
May 1997. www.uhealth net.on.ca/infection/surgicalsmokeplume.
htm Accessed 12-1-00
8. Schultz L, Drogue J. “Unique Devices for EVectively Removing
Surgical Plume.” Viewpoint. Surgical Services Management. Vol 6,
No 4, April 2000.
Additional links
A. The OSH Act Public Law 91-596. 91st Congress, S.2193,
December 29, 1970. www.osha-slc. gov/OshAct_data/OSHACT.
B. OSHA Standards Interpretation and Compliance Letter
4/18/1996—Hazards of Smoke Generated from Surgical
Procedures. www.osha-slc.gov/OshDoc/Interp_data/I19960418E.
C. OSHA Standards—Respiratory Protection. www.osha-slc.gov/
OshStd_data/1910_0134.html Accessed 12-1-00
D. OSHA Standards—Blood-borne Pathogens. www.osha-sslc.gov/
OshStd_data/1910_1030.html Accessed 12-1-00
CE Exam: Hazards of Vaporized Tissue Plume
1. Which is most effective for removing vaporized
tissue plume at its origin?
6. Vaporized tissue plume should be considered
hazardous for two reasons:
A Room-air exchange
system
B Regular suction
A foul odor and eye irritant
B eye and respiratory
irritant
C High-flow smoke
evacuator
D None of the above
C particulate matter and
infective agents
D skin and respiratory
irritant
2. When did plume awareness intensify?
7. Standard precautions are implemented
A 3000 BCE
B 1980’s
C 1936
D 2001
A Only when the patient is
known to be infected
B Only when exposure to
blood is expected
C Only when you touch the
patient’s intact skin
D In all patient care
situations in which blood,
any body fluid, secretion,
or excretion, non-intact
skin, and mucous
membranes may be
encountered
3. The term vaporized tissue plume is used to
describe smoke generated by
.
A electrocautery
B laser
C power instrumentation
(bone saw)
D All of the above
4. Which of the following statements concerning
vaporized tissue plume is true?
A Despite the source, all
vaporized tissue plume is
similar in content
B plume from lased tissue
is the most dangerous
C plume from the
electrosurgical unit is the
most dangerous
D Vaporized tissue plume
poses no threat
5. Why is the patient receiving a general
anesthesia alternative at higher risk for
exposure to vaporized tissue plume?
A They receive 100%
oxygen via the ventilator
B They are closer to the
point of origin of the
plume
C They are breathing
“room-air”
D They are at no higher risk
than a patient undergoing
a general anesthetic
9
8. OSHA Standard 1910.134(a)(1) Respiratory
Protection is concerned with
A Controlling occupational
diseases caused
by breathing air
contaminated with
harmful substances
B Protecting yourself from
TB
C Protecting the patient
D Forcing surgical
from community acquired
personnel to wear
infections
respirators in all patient
care situations
9. Appropriate PPE when exposure to vaporized
tissue plume is expected includes:
A Appropriate clothing
B Face and eye protection
C Gloves
D All of the above
10. Standard surgical masks are capable of
filtering
particles.
A 2–5 cm
B 5 microns
C 0.1–0.8 microns
D Standard surgical masks
do not contain filters
Tourniquet safety
Preventing skin injuries
by James A McEwen, PhD, PEng, Kevin Inkpen, MASc
1. Identify injuries to the patient that
occur underneath the tourniquet cuff.
2. Compare the trial results of five adult
volunteers.
3.Evaluate the cuff and limb protection
configurations.
4.Understand the importance of
maximum wrinkle height.
5.Analyze recommended practices for
limb protection.
For maximum safety, tourniquet cuff pressure and duration should be minimized and skin integrity under the cuff
should be maintained.1 Cuff pressure can be minimized by
selecting the widest, best fitting cuff for the chosen limb
location1,2,3 and by setting the cuff at the patient’s limb
occlusion pressure (LOP) plus a safety margin, typically
recommended to be 40-80 mmHg for a cuff snugly applied
to a normal limb of a normotensive patient.2 Even when
cuff fit and pressure are ideal, however, injuries to the skin
underneath the cuff, such as indentation, redness and blistering, can still occur.4,5,6
Stockinette or cotton-cast padding is commonly used
between the cuff and the skin to help prevent these injuries.
Present recommended practices for the operating room
state, “Manufacturers’ instructions may suggest that a soft,
wrinkle free padding (eg cotton-cast padding, stockinette)
be wrapped smoothly around the limb…” Yet related educational material states, “Do not use cotton-cast padding,
sheet padding, Webril,™ or any other material that may shed
loose fibers; lint from these materials can become embedded in the contact closures and reduce their effectiveness.”7
Some manufacturers make no specific recommendations
about underlying padding, leaving the user with no clear
guidance on the best limb protection technique.
Limb protection sleeves of various types have recently been introduced by other disposable cuff manufacturers;
for example, one brand is supplied with a four-layer, loose
fitting stockinette sleeve, and the user is instructed to “wrap
the area with a stockinette sleeve.” In the literature, there
is currently no quantitative comparison of the severity of
wrinkling and pinching of the skin under different cuff and
10
limb protection combinations, so it is not clear what type of
limb protection minimizes the risk of skin damage, and the
question of which technique to use remains unanswered.
This question particularly concerns operating room staff
who are often responsible for tourniquet application.
To answer this question, we have developed a technique
of making and analyzing an imprint of the cuff-to-skin
interface to quantitatively compare wrinkling and pinching
of the skin under various types of padding or limb protection. We have recently described this technique and reported results on pediatric subjects.8 In this article, we present
the results from multiple trials on five healthy adult volunteers to demonstrate:
∎∎ a first brand of disposable cuffs applied directly to the
bare skin.
∎∎ the same cuffs used with cotton-cast padding.
∎∎ a second brand of disposable cuffs with a built-in layer
of ‘gel’ padding applied directly to the bare skin.
∎∎ a third brand of disposable cuffs used with the stockinette sleeve supplied with each cuff.
∎∎ the first brand of cuffs used with tubular elastic material sleeves matched specifically to these cuffs.
Our hypothesis is that some types of cuff/ padding combinations will cause substantially less severe wrinkling and
pinching of the skin than others.
Method
The University of British Columbia granted ethical approval for this study. To approximate the deformation of the skin
surface in contact with the cuff or padding, we placed a layer
of modelling clay sheet (Model Magic, Binney & Smith
Canada, Lindsay Ontario Canada, extruded through rollers to a uniform 2.5 mm thickness and covered with a single
layer of plastic film) on the limb of the subject. An experienced technician applied the limb protection or padding (if
used) and cuff ensuring that the overlap of the cuff was positioned over the modelling clay sheet. The cuff was inflated
to 200 mmHg for one minute, deflated, and removed. The
modelling clay sheet (now imprinted with the texture of
the cuff or padding on the top surface and the skin texture
on the underside) was removed, allowed to dry, and bonded skin side down to a flat plastic card using double-sided
tape. The top surface (cuff/padding imprint) of the mounted mold was then digitized in a 5 mm proximal-distal (PD)
Tourniquet Safety: Preventing Skin Injuries
Table 1 Cuff and limb protection configurations
Configuration
Description
Cuff A, Bare
Disposable Cuff A (no limb protection supplied). No limb protection used.
Cuff A, Two layers cast pad
Disposable Cuff A (no limb protection supplied). Two layers of cast padding used.
Cuff B (Gel)
Disposable Cuff B with built-in ‘gel’ padding. No limb protection used.
Cuff C, Four layer
stockinette
Disposable Cuff C. Four-layer stockinette sleeve (as supplied in the sterile
package with the cuff) used.
Cuff A, matching Two layer
elastic sleeve
Disposable Cuff A (no limb protection supplied). Two layer tubular elastic
bandage sleeve (matched to specific tourniquet cuff) used.
Table 2 Wrinkle and pinch maximum height and sum of heights results (mm)
Trial
Cuff A, bare
Cuff A, two
layers cast
pad
Cuff C,
four-layer
stockinette
Cuff B (gel)
Cuff A,
matching
two-layer
elastic sleeve
Max
Sum
Max
Sum
Max
Sum
Max
Sum
Max
Sum
Subject A, L thigh
3.08
122.80
6.23
194.3
3.20
154.3
1.70
18.0
1.45
4.88
Subject A, R thigh
4.68
151.2
3.08
63.5
3.53
85.0
2.50
37.0
0.00
0.00
Subject A, L arm
2.70
173.1
1.78
8.7
6.23
123.0
0.00
0.0
0.00
0.00
Subject B, R thigh
5.18
138.1
2.43
75.7
2.38
44.6
0.00
0.0
0.00
0.00
Subject B, L arm
2.03
24.4
1.63
32.3
2.95
68.6
1.40
3.6
0.00
0.00
Subject C, R thigh
1.63
82.5
2.48
83.6
4.65
69.7
1.65
12.8
0.00
0.00
Subject C, L arm
2.55
134.9
2.10
69.6
3.65
114.5
1.38
3.6
0.00
0.00
Subject D, R thigh
2.20
58.0
1.48
25.4
4.13
80.8
2.15
9.8
0.00
0.00
Subject D, L arm
2.15
67.75
2.15
64.9
3.00
62.4
1.58
13.1
0.00
0.00
Subject E, R thigh
3.93
117.9
3.13
64.7
3.23
43.6
2.58
16.2
0.00
0.00
Subject E, L arm
3.20
76.7
2.90
53.0
4.50
92.3
1.70
13.7
0.00
0.00
by 0.20 mm circumferential grid on a coordinate measuring
machine (Picza Pix-3, Roland Digital Group). The resulting section profiles approximate the circumferential profile
of the skin surface at 5 mm PD intervals under the cuff. An
area of 95 mm (circumference) by 45 mm (PD, 10 sections
spaced at 5 mm intervals) at mid-cuff, including the cuff
overlap, was analyzed in all trials.
11
Wrinkles in the skin surface are defined as a change in
height of at least 1 mm with a slope of 0.25 (1 mm height
change for every 4 mm of distance along the skin surface)
or steeper, lying within a 10 mm circumferential length
of skin surface. Wrinkles less than 1 mm high are ignored.
Pinching of the skin, where the skin is gathered by the cuff
from a deep level up to a superficial peak and back down
again within 20 mm, is counted as two wrinkles. The maxTourniquet Safety: Preventing Skin Injuries
imum wrinkle height and the sum of all wrinkles greater than 1 mm high found on each mold are compared. Five
healthy adult volunteers with normal skin and muscle tone
(medical research center staff members, age 19-46 years,
four male, one female) were recruited. Five different cuff/
padding configurations (see Table 1) were chosen for comparison. Each configuration was tested on one arm and
both thighs of one subject, and one arm and one thigh of
the remaining four subjects for a total of 55 trials. A repeated measures study design is used with five treatments and
11 subjects, where each different limb is considered to be
a separate subject. To compare maximum wrinkle heights,
rank sums are compared using Friedman’s statistic, and all
possible pairs of configurations are compared using a Student-Newman Keuls’ test.9 Wrinkle height sums are compared using the same methods.
Results
Maximum wrinkle height represents the single most severe
wrinkle or pinch found on a sample regardless of the number or height of the remaining wrinkles. The wrinkle height
sums provide comparisons of both the severity and quantity of wrinkles and pinches greater than 1 mm high. All test
results are listed in Table 2.
The two-layer elastic sleeves matched to the specific
tourniquet cuffs used produced significantly lower maximum wrinkle heights and lower wrinkle height sums than
each of the other configurations (P < 0.01 for all paired
comparisons). On 10 of the 11 limbs tested, the two-layer
elastic sleeve had no wrinkles or pinches higher than 1 mm
(the minimum detectable height). The four-layer stockinette sleeve eliminated wrinkles and pinches higher than
1 mm on two of the 11 limbs tested and was significantly
more effective (P < 0.01) than all configurations except the
two-layer elastic sleeve. Two layers of cotton-cast padding
gave a slight reduction in maximum wrinkle height compared to applying the same cuff on bare skin and applying
the ‘gel’ cuff to bare skin (P < 0.05), but did not significantly
reduce the sum wrinkle and pinch heights in either case (P
> 0.05). The ‘gel’ cuff applied on bare skin produced slightly higher maximum wrinkle and pinch heights (P = 0.05)
with no significant reduction in the sum of wrinkle and
pinch heights (P > 0.05) compared to a typical cuff (Cuff
A) applied on bare skin.
Discussion
Rudolph et al surveyed 44 clinics in Europe concerning
over 75,000 procedures involving tourniquet use (adult and
pediatric).4 Tissue damage was reported in 1.4% of lower
limb and 0.4% of upper limb cases (usually reddening with
blisters). Many cases involve fluids such as antiseptic flowing under the cuff, but the survey indicates that fluid leak-
12
age, excess pressure, excess duration of cuff or a combination of these factors can cause skin damage. Sixty-five percent of the clinics reported using cotton padding material, 20% other types of padding, and 15% no material under
the cuff. Choudhary reported a case of friction burns on an
adult patient’s leg due to the tourniquet cuff sliding distally off the padding material during the procedure (no fluids
were found under the cuff in this case).6
Present recommended practices for operating room personnel, intended as guidelines adaptable to various practice settings, refer clinicians to cuff manufacturers’ recommendations for limb protection.1 However some manufacturers do not make specific recommendations and refer the
clinician to the established protocol at their practice setting. There is little discussion in the literature of pinching
of the skin or local high pressure areas and shearing stresses caused by wrinkles in the inflated cuff. Pedowitz qualitatively observed a difference in the limb shape and skin ‘ridges’ (pinched areas) on cross-sectional CT views of a rabbit
hindlimb under two different cuffs. He noted similar ridges in MRI images of a human thigh under tourniquet pressure, but did not analyze these differences in detail.10 In a
brief note on technique, Harland observes that unprotected
skin under a cuff can be damaged due to shearing stresses
and that stockinette folded back over the cuff is effective as
a padding material and in keeping the cuff in position.5
In the current study, we use a quantitative method to
compare the severity of wrinkling and pinching of the
skin in adults under the inflated cuff. The two-layer elastic sleeves were significantly more effective in eliminating
wrinkles and pinches than all other types of limb protection. In this study, a specific size of two-layer elastic sleeve
was selected for each cuff size, so the sleeves stretched to
about 1.1 to 1.6 times their relaxed circumference when
applied to limbs within the recommended size range of
the cuff. This applies compression of between 5 and 15
mm Hg to the limb, ‘artificially’ improving the tone of the
skin under the cuff and making the skin resistant to being
gathered up into a pinch (particularly at the cuff overlap).
Although a standard tensor bandage material could be
wrapped around the limb to the same effect, the pressure
applied to the limb is highly variable depending on operator technique. Such pressures could easily be above typical
venous pressure of 20 mmHg, leading to venous congestion
if the sleeve remains on the patient after the cuff is deflated.
For example, Biehl measured pressures under Esmarch bandages used as ankle tourniquets and found standard deviations of 35 to 53 mmHg in multi-operator tests.11
The four-layer stockinette sleeves, used in this study
(supplied with the cuffs), were loose or only slightly
stretched and applied negligible compression when used
on a limb within the size range of the corresponding cuff.
These sleeves provide a ‘padding’ effect due to their thick
buildup of material (rather than the ‘toning’ effect provided
by the two-layer elastic sleeves). Wrinkling and pinching of
the skin is clearly more severe when applying a typical, disposable cuff directly on the patient’s skin, using a two-layer wrap of typical cotton-cast padding under a typical disposable cuff, and using a ‘gel’ cuff directly on the skin. Cast
padding may offer some reduction of the maximum pinch
or wrinkle height compared to no limb protection or the gel
cuff, but the sum of wrinkle and pinch heights is the same
among all three methods.
The mold material itself may affect pinching of the skin,
and at this stage, no attempt has been made to measure differences in the absolute dimensions of irregularities in the
skin surface between actual tourniquet use and the molds.
Therefore, this method can be used as a comparison measure only (as used in the current study) and serves the purpose of identifying clear differences between limb protection methods. Due to the wide variety of skin properties
found among surgical patients, validation of the mold material’s ‘skin-like’ properties would only apply to a certain percentage of patients and would therefore be of limited value.
However, to draw conclusions for clinical practice from the
current study, it must be assumed that the relative performance of the various methods is similar on actual skin and
over the variety of skin types not fully represented by the
healthy volunteers. Although the patient population is not
fully represented by testing healthy adult volunteers in a
controlled laboratory setting, this approach allows a repeated measures study design (in which each subject receives
all of the treatments being compared, in this case different cuff/limb protection combinations) which is the most
powerful way of comparing treatments. Such repeated cuff
applications may not be practical in a clinical setting or with
patients having certain health conditions. The detection of
irregularities is sensitive to the height, slope, and maximum
distance parameters chosen, and results will change with
these parameters. The parameters were adjusted by reviewing each section of a variety of molds and confirming that
all irregularities that would be subjectively identified on the
mold as a wrinkle or pinch were recorded by the data processing routine. The chosen parameters were then used on
all molds and each section was reviewed during processing.
For future study, an absolute measure of the cuff/skin
interface could be made by taking cross sectional images (MRI) of inflated cuffs on limbs and analyzing the wrinkles and pinches using similar criteria to the current study.
Clinical observation of the skin condition (pattern of redness and indentation, reports of irritation or rash) of a series
of typical patients after tourniquet cuff removal could also
be done to make a more representative but less quantitative
comparison of limb protection techniques.
13
Survey Results
Prior to researching information for this article, the
author conducted a qualitative survey of 10 covered entities. Ten survey questions were asked of
the individual or group of individuals responsible
for setting up the HIPAA compliance program at
their facility (Please refer to Appendix 1).
Of the 10 facilities surveyed, a single person
was responsible for the program at half of the facilities. There were also teams of two at three facilities, one team of three, and one team of four.
Of the 10 facilities surveyed, five facilities put the
HIPAA compliance program together from scratch,
two facilities hired consultants, and three facilities
purchased planning kits. Of the two facilities that
hired consultants, both were very satisfied with the
consultant’s work. Of the three facilities that purchased planning kits, only one was satisfied with
the contents of the kit. The most challenging part
of program implementation was reported as time
constraints by six of the respondents, one reported
that choosing a consultant was the most challenging, one reported problems with the print shop, and
two reported no challenges.
Eight out of 10 facilities reported compliance
problems with the physical layout of the facility and
nine out of 10 facilities reported problems with personnel not following the regulations. None of the
facilities reported performing regular comprehensive evaluations of the HIPAA program and three
are not doing any type of evaluation at all. Of the
10 facilities surveyed, only one reported a relevant
patient question about HIPAA. Ninety percent of
the facilities reported that they had no HIPAA violations that resulted in citations.
Conclusions
There has been a lack of clear guidelines and published
studies in the clinical literature referring to proper limb protection technique under tourniquet cuffs. Our hypothesis
that some types of cuff/padding combinations will cause
substantially less severe wrinkling and pinching of the skin
than others is supported by the current comparative measurements of skin surface deformation. Based on a total of
55 trials of five different limb protection types on the upper
arms and thighs of five adults, stretched sleeves made of
two-layer tubular elastic material and matched to specific
tourniquet cuffs produced significantly fewer, less severe
pinches and wrinkles in the skin surface than all other padTourniquet Safety: Preventing Skin Injuries
ding types tested (maximum P < 0.01). When using typical disposable cuffs, wrinkling and pinching were clearly
more severe with no padding and with two layers of typical
cotton-cast padding compared to both the two-layer tubular elastic and the four-layer loose stockinette sleeves (maximum P < 0.01). Cast padding gave only a slight reduction
in maximum wrinkle or pinch height (P < 0.05) and did not
reduce the overall amount of wrinkling significantly (P >
0.05) compared to applying the same cuff on bare skin. A
new disposable cuff with built-in gel padding applied on the
bare skin was worse or not significantly different than the
typical disposable cuff applied over either bare skin or cast
padding.
Acknowledgements
The authors would like to thank Kathy Bailey RN, Michael
Jameson, Ken Glinz, and the volunteer subjects for their
assistance with this study.
References
1. AORN (Association of periOperative Registered Nurses).
“Recommended practices for use of the pneumatic tourniquet.”
In: Standards, Recommended Practices, and Guidelines. Denver:
Association of Operating Room Nurses, Inc, 2000: 305-309.
2. McEwen JA, Kelly DL, Jardanowski T, Inkpen K. “Tourniquet
safety in lower leg applications: Limb occlusion pressure measurement and a wide contoured cuff allow lower cuff pressure.”
Orthopaedic Nursing. 21(5); Sept/ Oct 2002 (in press).
3. Pedowitz RA, Gershuni DH, Botte MJ, Kuiper S, Rydevik BL,
Hargens AR. “The use of lower tourniquet inflation pressures in
extremity surgery facilitated by curved and wide tourniquets and
an integrated cuff inflation system.” Clin Orthop. 287 (Feb. 1993)
237-44.
4. Rudolph H, Gartner J, Studtmann V. “Skin lesions after utilization of a tourniquet.” Unfallchirurgie. 1990; 16(5): 244-51
(Abstract in English & German, article in German).
5. Harland P, Lovell ME. “An alternative method of tourniquet padding.” Annals Royal College of Surgery. England 1994; 76(2):107.
6. Choudhary S, Koshy C, Ahmed J, Evans J. “Friction burns to
thigh caused by tourniquet.” British Journal of Plastic Surgery.
1998; 51:142-3.
7. Tourniquet Safety Home Study Guide. Warsaw, IN: Zimmer Inc.
Denver: Education Design, Inc; 1997.
8. Tredwell SJ, Wilmink M, Inkpen K, McEwen J. “Pediatric Tourniquets: Analysis of cuff/limb interface, current practice, and
guideline for use.” J Ped Orthop. 21(5); Sept/Oct 2001: 671-676.
9. Glantz, SA. Primer of Biostatistics. 4th ed. New York: McGrawHill; 1997.
10.Pedowitz RA, Rydevik BL, Gershuni DH, Hargens AR. “An animal model for the study of neuromuscular injury induced beneath
and distal to a pneumatic tourniquet.” Journal of Orthopaedic
Research. 1990;8(6):899-908.
11.Biehl WC 3rd, Morgan JM, Wagner FW Jr, Gabriel RA. “The
safety of the Esmarch tourniquet.” Foot & Ankle. 1993; 14(5):
278-83.
Webril is a registered trademark of of Reemay, Inc.
14
CE Exam: Tourniquet Safety: Preventing Skin Injuries
1. Tourniquets are used:
A To establish a dry
surgical field
B To decrease blood loss
6. Which showed no significant reduction in the
sum of wrinkle and pinch heights compared to
a cuff applied to bare skin?
C In conjunction with limb
anesthesia
D All of the above
A Four-layer stockinette
sleeve
B Gel padding
C Two-layer elastic sleeves
D Two-layers of cast
padding
2. Limb occlusion pressure is defined as:
A The minimum cuff
pressure required to
maintain
a bloodless surgical field.
B The maximum cuff
pressure required to
maintain a bloodless
surgical field.
C High pressure on the limb D The normal blood
under a tourniquet
pressure of the radial
cuff.
artery.
3. A wide cuff, plus which setting minimizes cuff
pressure?
7. Wrinkle and pinch heights can be affected by:
A Mold material
B Patient’s skin properties
C both
D neither
8. If arterial blood flow is observed past the
tourniquet cuff:
A Increase tourniquet
pressure in 25 mmHg
increments until flow
stops
B Decrease tourniquet
pressure in 25 mmHg
increments until flow
stops
4. Researchers in this study used molding clay to:
C Change padding
configuration
D Amputate the limb
A Approximate the skin
profile under the cuff
B Measure patient’s LOP
9. Prior to tourniquet inflation,which method is
used to exsanguinate the limb?
C Decrease wrinkling and
pinching
D All of the above
A elevation
B elastic bandage
C both A and B
D exsanguination is not
necessary
A Patient’s LOP
B LOP minus 40-80 mmHg
C LOP plus 40-80 mmHg
D 40-80 mmHg
5. Which configuration produced the lowest
maximum wrinkle heights and lower wrinkle
height sums?
A No limb protection
B Four-layer stockinette
sleeve
C Gel padding
D Two-layer elastic sleeves
15
10. If a limb protection sleeve is unavailable, which
should be used?
A Two layers of tubular
stocking
B Two layers of cotton-cast
padding
C Two layers of tubular
elastic bandage
D Either A or C
Understanding anaphylaxis
by Jessica Gentry
1. Examine the symptoms that
characterize the onset of analphylaxis.
2. Identify some of the causes of
anaphylaxis.
3.Understand the characteristics of an
anaphylaxic reaction to anesthesia.
4.Evaluate the problems of insect stings
and allergic reactions.
5.Explore idiopathic anaphylaxis.
In 1972, Jackie Kwan was quietly working on her research,
munching on some pistachios a coworker had brought back
from the Middle East. After she had gorged herself with pistachios, she decided to take a break and proceeded upstairs
to collect her paycheck. By the time she had reached the
fourth floor, she began to feel very warm and extremely itchy. At that point, the reaction triggered a memory of
when she was a child and the same thing had happened
after she had eaten pistachio ice cream. Within 10 minutes,
hives had covered her body, making her skin flush and swollen. Along with those reactions, she started to vomit and
have diarrhea. She could feel her throat swell and start to
close shut. Kwan was indeed having an anaphylactic reaction—an acute, life threatening medical emergency. Her
symptoms were classic.3,4
Anaphylaxis
Anaphylaxis is a very serious manifestation of the allergic
response. It is an Immunoglobulin E (IgE) mediated reaction that results when mast cells suddenly release chemical
mediators that overwhelm the body. “IgE antibodies attach
themselves to mast cells and basophiles [type of white
blood cell], priming the body for the allergic reaction…
The released mediators cause blood vessels to dilate and
leak fluid into the surrounding tissues and cause smooth
muscle in the airways to [constrict].”3,4 Since the skin, respiratory, and digestive tracts are rich in mast cells, the organs
of these systems are the ones primarily affected in the reaction.
The onset of anaphylaxis is usually sudden. Symptoms usually begin to develop within minutes of exposure to some triggering allergic response that may result in
16
death. “The first symptom is usually a sensation of warmth
followed by intense itching. The skin flushes, hives may
appear, and the face may swell. Breathing becomes difficult,
and the patient may feel faint and anxious. The blood pressure may drop precipitously. Convulsions, shock, unconsciousness, even death may follow. Roughly 60% to 80%
of anaphylactic deaths are caused by an inability to breath
because of swollen airway passages obstructing airflow to
the lungs. The second most cause of anaphylactic deaths,
about 24% by one estimate is shock, caused by insufficient
blood circulating through the body.”3,4
In the 1900s, Charles Richet and Paul Portier initiated
research that ultimately clarified the cause of many mysterious deaths. Richet and Portier studied the toxic qualities of
the tentacles of the Portuguese man-of-war. They injected
dogs with the different toxins to determine fatal levels and
to test whether the animals could build an immunity or tolerance to the toxin. To their surprise, some dogs receiving a
second injection at very low, presumably harmless, dosage
levels suddenly died. Richet and Portier called this result
anaphylactic, meaning “contrary to protection.”3
In the same period, other researchers discovered that
anaphylaxis could be caused by nontoxic proteins, including animal blood serum. Richet went on to theorize that
some special substances in the blood of sensitized animals
must react with the toxin to produce anaphylactic disorder.
He was on the right track and, in 1913, his work was recognized with a Nobel Prize.
Until the post-World War II era, horse serum, the source
of an antitoxin used for diphtheria, scarlet fever, tetanus,
and tuberculosis, was found to induce the reaction. Scientists have since discovered that the explosive reaction (anaphylaxis) is the culmination of a complicated sequence of
events.
Today, human serum is the preferred tetanus treatment.
In the meantime, penicillin has become one of the most
widely administered drugs in the world and one of the most
common causes of anaphylaxis.
Causes of anaphylactic reactions
The following substances are among those reported to have
caused anaphylactic reactions:
∎∎ Antibiotics: penicillin, cephalosporin, tetracycline,
nitrofurantoin, streptomycin
∎∎ Local anesthetics: more than 100 kinds
∎∎ Anti-inflammatory: aspirin, ibuprofen, indomethacin,
fenoprofen, naproxen, tolmetin
∎∎ Enzymes: chymopapain, chymotrypsin, streptok inase
∎∎ Psyllium: present in laxatives and added to cereals
∎∎ Hormones and serum: insulin, ACTH, parathyroid
hormone, cortisone, horse antibody
∎∎ Diagnostic agents: iodinated contrast media dyes such
as bromsulphalein (BSP)
∎∎ Food: most commonly, peanuts, eggs, fish, shellfish,
milk, and tree nuts; less common: grains, seeds and
fruits.
Anaphylactic reaction to anesthesia
Occasionally, a patient will have a severe allergic reaction to
a muscle relaxant or other drug used during general anesthesia. This presents a concern, because the patient is anesthetized and the reaction is somewhat difficult to spot
unless it shows up clearly in the skin with hives, for example. But an alert anesthesia provider will note a change in
the patient’s blood pressure or breathing status, indications
that the patient is in trouble, and quick action can be taken.
Anaphylaxis occurs in one out of 15,000 instances, but only
3% of anaphylactic reactions during surgery result in death.
Most deaths occur among adults, and it seems that the risk
of anaphylaxis increases somewhat with age. Heightened
sensitivity because of repeated exposure to allergens, plus
generally weaker health, account for the greater risk as time
goes on. The possibility of an allergic reaction is one of the
many reasons to be very conservative in using general anesthesia.3
Anaphylactic reactions to insect stings
Insect stings are another (among many) major cause of anaphylactic death. About 40 deaths a year are attributed to
insect stings, but many others probably go unrecognized.2
Several studies show that some people have no warning that
they may be susceptible to a life-threatening reaction to an
insect sting until it occurs.
A pharmacist from Los Angeles, who was traveling to a
convention in the South several years ago, was driving alone
in his car when suddenly a yellow jacket made a direct hit
on his face. He flinched, but there was no pain and he kept
driving. Five to 10 minutes later, he became hot, his faced
puffed up and his chest became tight. He considered pulling over, but realized he needed to get to the nearest hospital, which was about five minutes away. The pharmacist
recognized that he must have been having a reaction to the
yellow jacket, but never knew that he was allergic at all to
any kind of insect. He was treated in time and sustained no
major repercussions. Unfortunately, delayed reactions to
stings can lead to such serious problems, such as kidney dis-
17
ease, vascular disorders, fever and serum sickness, neuritis,
and arthritis-like symptoms. People allergic to insect stings
can be desensitized, which usually provides good protection.3
Miscellaneous reactions
Surprisingly, everyday foods are a relatively common cause
of anaphylaxis. Certain foods, such as nuts, eggs, fish, and
seeds, are highly allergenic in some people. Anaphylaxis can
occur during the transfusion of blood or blood products,
as a result of antigens in the donor’s blood, such as egg protein, to which the patient is sensitive.
A drug called protamine sulfate, which is derived from
fish sperm, is used to counteract overdoses of the blood
thinner heparin. This can cause anaphylaxis in people allergic to fish. Men who are infertile or who have had a vasectomy are commonly allergic to protamine.2,3
Seminal fluid evidently can cause anaphylactic reaction
in women. A few cases have been reported and the only protection seems to be the use of a condom. Desensitization is
now available experimentally for couples that want and are
trying to conceive a child.
Latex allergy presents a common problem, particularly
among health care workers.
Idiopathic anaphylaxis
Idiopathic anaphylaxis by definition is a form of anaphylaxis where no identifiable stimulus can be found. The incidence in the United States has been estimated recently at
close to 33,000 cases.1,3
A typical case of idiopathic anaphylaxis is that of a
healthy 35-year-old woman, in New York City, who on a
normal afternoon was speaking on the phone with her stepson, who lived about 20 blocks away. He began to realize that she seemed to be ill and fading, and then she hung
up abruptly. He quickly called 911 and arrived to find her
unconscious with the paramedics working on her. (Her
embarrassed husband, who’d been working in the home
office, hadn’t heard a thing until the paramedics knocked on
the door).
The diagnosis at the hospital was anaphylaxis, but no
cause was found. In three years, the incident never recurred,
but following the advice of her doctor, the woman carries
epinephrine and a card in her wallet identifying her problem. In repeated cases, ongoing doses of antihistamines and
even ongoing, alternate-day doses of cortisone are used to
try to stop the recurrences.3
Because of the life threatening nature of the reaction, a
diagnosis and appropriate treatment including emergency
protocols, are critical. To aid in the diagnosis and treatment
of idiopathic anaphylaxis, an algorithm, classification system and treatment protocol were developed. Recent analyUnderstanding anaphylaxis
sis of this protocol have shown to be both effective in placing a majority of patients into remission and decreasing the
number of emergency room visits, hospitalizations, intensive care unit admissions, and high health care cost of undiagnosed and untreated cases.
Treatment
For almost all varieties of anaphylaxis, there are just two
treatments: avoidance and emergency measures. The main
exception is insect stings, for which venom immunotherapy
can be used. Occasionally, an effort is made to desensitize
a drug-allergic person so that the drug can be used in treatment. This must be done under constant medical supervision in an appropriate medical facility.3,4
The key in emergency treatment is injection of epinephrine (adrenalin) as soon as possible after reaction begins.
This acts to stop the release of chemical mediators of the
allergic reaction, and it buys time to get to the hospital or
to call medical personnel to the scene. The patient should
be in the ER or under the care of trained medical personnel
within five to 15 minutes of the onset of the attack, if possible. A tourniquet can be used in the case of an insect sting
on the arm or leg. First, the stinger should be removed. The
tourniquet should be applied above the site of the sting and
loosened every 10 minutes to allow sufficient blood circulation to the extremity. If possible, a cold pack should
also be applied. The cold causes the blood vessels to constrict, which slows the venom from getting into the bloodstream.3,4
Epinephrine injections can be repeated every 15 minutes. Antihistamines may be added. Intravenous medications and fluid replacement are often indicated. Oxygen
therapy and the insertion of a tube into the trachea to keep
it open are frequently necessary. Corticosteroids are used to
prevent a second-phase reaction later.
Immunotherapy may be attempted for patients who
need treatment with a life saving drug to which they are
allergic. Desensitization is managed in a medical facility
over a short period of time, beginning with extremely diluted solutions of the allergen. The patient will be monitored
closely as the dose is gradually increased, so they may be
treated immediately if symptoms occur.3,4
Anyone who has had an anaphylactic attack, perhaps
anyone in an isolated household, should have emergency
epinephrine in injectable form available. This also applies to
patients who are on immunotherapy. An EpiPen is a device
patients can easily use in an emergency and is available as
an EpiPen Jr for children who have attacks. However, some
doctors prefer and recommend the Ana-kit, which contains
a syringe and needle and two doses of epinephrine. Antihistamines can be kept on hand, but do not help in life-threat-
18
ening situations. It is more important to use epinephrine
and to get to an emergency facility quickly.
People should also wear a medic alert bracelet or carry a
card stating their allergies, that they have had anaphylaxis,
and the cause.
“Experts disagree about whether certain individuals are
predisposed to anaphylaxis. Many feel that people with a
history of allergies are more likely to have an anaphylactic episode. Others are unconvinced that this or other factors (such as age, gender, ethnicity, or geographic location)
predispose a patient to it. One thing is clear, previous exposure to allergens usually precedes the anaphylactic reaction.
Sometimes people will notice that an allergen makes them
feel bad in some way, perhaps mild itching or upset stomach. This may indicate that future exposure will produce a
more severe reaction.”3,4
Whatever the reason may be for anaphylaxis, it is a condition that must be taken seriously.
About the author
Jessica Gentry is a second term surgical technology student
at San Joaquin Valley College in Fresno, California.
References
1. Cook AR. Allergies Sourcebook. Health Reference Series. Vol 19.
Detroit: Omnigraphics Inc; 1997.
2. Young SH, Dobozin BS, Miner M. Allergies The Complete Guide
to Diagnosis, Treatment, and Daily Management. New York, New
York: Plume; 1999.
3. Young H Stuart, MD. Allergies The Complete Guide to Diagnosis,
Treatment, and Daily Management. Consumer Reports Books.
Yonkers, New York: Consumer Union of United States, Inc; 1991.
4. Segal M. Anaphylaxis: An Allergic Reaction That Can Kill.
US Food and Drug Administration. www.fda.gov/bbs/topics/
CONSUMER/ CON00086.html Accessed 10/14/03
CE Exam: Understanding anaphylaxis
1. Which is primarily responsible for an
anaphylactic reaction?
6. Delayed reactions to insect stings can lead to
.
A basophiles
B mast cells
A kidney disease
B vascular disorders
C IgE antibodies
D none of the above
C serum sickness
D all of the above
2. The leading cause of death by anaphylaxis is:
A convulsions
B shock
C obstructed airflow
D insufficient blood
circulating through the
body
3. Symptoms of anaphylaxis include
A itching and hives
B vomiting and diarrhea
C swelling and difficulty
breathing
D all of the above
7. Anaphylaxis from undetermined sources is
called
.
A spontaneous anaphylaxis
B necrosis
C idiopathic anaphylaxis
D immuno anaphylaxis
8. After an anaphylactic reaction,the patient
should
.
A wear a med alert bracelet
B carry epinephrine
D all of the above
4. A common cause of anaphylactic reactions is:
C carry a card with allergy
and emergency contact
information
A penicillin
B ibuprofen
9. Which is a false statement about anaphylaxis?
C peanuts
D all are common causes
A After a reaction,the
patient will be immune to
further anaphylactic
episodes.
B More than one
epinephrine injection may
be required to stop the
reaction.
C Corticosteroids are
used to prevent a
secondphase
reaction.
D Immunotherapy may help
avoid anaphylaxis in the
future.
5. Which is most likely to indicate allergic
reaction during surgery?
A skin rash
B temperature change
C change in blood pressure
or breathing
D none of the above
10. Which is the most helpful in an anaphylactic
emergency?
19
A antihistamines
B cold packs
C epinephrine
D a tourniquet
Electrosurgery
by Bob Caruthers, CST, PhD, FAST
1. Understand the basic terminology
related to electrosurgery.
2. Compare electrocautery and
electrosurgery.
3.Contrast bilpolar and monopolar
techniques.
4.Examine the factors affecting
coagulation.
5.Review the four classes of lasers.
Common language usage in the operating room uses the
term electrocautery as an umbrella term for all-electrical
instruments and procedures. This is incorrect and will be
clarified in this article. A proper understanding will assist
with safe, effective, and efficient usage.
Basic terminology
The following definitions are necessary to a basic understanding of electrosurgery:
∎∎ Blend: a term that indicates that the electrical current
is interrupted between 20-50% of the time.
∎∎ Current: the passage of a given amount of electrons
through a conductor over a specified period of time
(measured in amperes).
∎∎ Electrical power: watts = volts x current.
∎∎ Electricity: the movement of electrons between two
poles that are charged, one positive and one negative.
∎∎ Electron: a particle of positive or negative energy that
creates heat as it passes through human tissue.
∎∎ Impedance: the resistance to the flow of electrons to a
given conductor.
∎∎ Joules: the total energy consumed or given off over a
specified period of time.
∎∎ Resistance: difficulty passing a current through a given
conductor (measured in ohms).
∎∎ Sparking: the result of an electrical current flowing
through a gas.
∎∎ Voltage: the force required to push electrons through a
given the substance (eg human tissue).
20
A conceptual distinction
A distinction needs to be made between two terms that are
typically used interchangeably in the operating room. Electrocautery refers to the use of a direct electrical current to
heat metal. The hot metal is then applied to a tissue, which
is cauterized. This is a technique that is no longer employed
in the operating room. Electrosurgery refers to the manipulation of the electrons through living tissue, using an alternating current that can cause heat build up in the cell and
thereby destroy the cell. A generator is the machine that creates an alternating current at a frequency that does not stimulate muscle activity (500,00-3 million cycles per second).
An alternating current is one that flows in one direction and
then the other. The current flow increases to a maximum
in one direction, which produces a positive peak and then
flows backward to the alternate maximum or negative peak.
This current produces what is called a “sinusoid” wave. This
type of current can be manipulated in such a way that it
has different effects upon tissue. The wave type has a positive and negative peak. A measurement to from the positive
peak to the negative peak is called peak-to-peak voltage.
In order to perform electrosurgery, the alternating current must be manipulated. A wave form that is simple, sinusoidal, undamped (unmodulated), is produced by a continuous energy supply. This current is the cutting current used
in electrosurgery. The cutting current does not require a
peak voltage as high as the coagulating waveform.
One advantage of the coagulation current is that the
electrons are pushed through in short bursts. A cooling
effect between the electrical bursts allows coagulation to
take place. Most of the generators today provide a blended
current, which is a result of combining the cutting and coagulation currents. The blended waveform interrupts the current at variable intervals. The effect is to have periods of cutting current and periods of coagulating current.
Monopolar/bipolar
Modern electrosurgery uses monopolar and bipolar techniques. When using the monopolar technique, current travels through an active electrode and is received at another neutral plate (ground plate) after it passes through the
body. In this case, the body serves as the conductor.
Since the current is disbursed over both plates, it is of
relative low intensity. Heat is generated, because the plates
Electrosurgery
are of dramatically different sizes. The active electrode is
small and capable of creating a current of a sufficient density to cause a burn at the point where the electrons enter the
body. Even though the ground plate is larger, burns may be
produced at the exit point also.
Because the potential for unwanted burns is high, the
surgeon should use the lowest setting to accomplish any
given task. The surgical team must guarantee that the dispersive electrode is making good contact with the patient
and is large enough to prohibit a build up in the current
density.
Generators
Generators are required to produce the current. Those used
for surgical purposes can produce about 8,000 volts when
they are in the coagulation mode; however, normal usage
occurs in the 1,000–3,000 volt range. The generators in current usage are relatively safe. They offer what is called an isolated ground circuitry system, which reduces the chances that
the current will seek an alternate path to the ground. The
most common system used in the operating room employs
disposable return electrodes known as “ground pads.”
There is a built-in monitor at the generator that will sound
an alarm if an imbalance registers between the two pads or
points of contact. The operating room team should remember that the returning electrode must be oriented so that
each of the two pads is an equal distance from the operating site.
Bipolar electrosurgery
A bipolar system incorporates an afferent and efferent electrode into an instrument that has two poles. This eliminates
the need for a grounding pad. Bipolar current is pure cutting current. The instrument can produce a high power density at each pole of the forceps. This permits a small amount
of tissue desiccation, confined to the shape and size of the
forceps at the point it is in direct contact with the tissue.
This system eliminates the chance of alternate pathways for
the current to flow through. This is a clear advantage over
the monopolar system.
That said, there are some drawbacks and restrictions on
the use of the bipolar system. With bipolar use, the impedance load is several times that of monopolar use. This means
that there is much less output for any given setting when
using the bipolar technique. Bipolar technique, therefore, is
generally restricted to situations in which small portions of
tissue are being desiccated.
In gynecologic surgery, one must be aware that instruments used in laparoscopy and for the purposes of sterilization can differ in both design and the ability to desiccate tissue. The manufacturer’s guidelines should be followed pre-
21
cisely. These guidelines should be known by both the CST
in the scrub role and the surgical assistant.
Safety
Safety principles during electrosurgery should be followed
without exception, since the surgeon is often focused elsewhere, the surgical technologist and surgical first assistant should monitor the safe usage of electrosurgical instruments. Surgical technologists should already know basic
principles of safety, but select reminders are:
∎∎ All the electrode pencils should be in a safety holster
when not in use.
∎∎ A monitored return electrode system should be used.
∎∎ Use the lowest voltage that will create the desired effect.
∎∎ Place the return electrodes as close to the operative
site as possible.
∎∎ Inspect the instrument and cord insulation prior to
each use.
∎∎ Be aware of the extra length of laparoscopic instruments and make appropriate adjustments.
Uses
Electrosurgery may be used to vaporize tissue (cut), desiccate tissue (coagulate), and fulgurate tissue (coagulate
superficially). When the coagulation waveform is in use,
the current sparks to tissue without a cutting effect, because
the heat is widely dispersed and the heating effect is intermittent. The water inside of the cells is heated and the cells
dehydrate slowly. The term coagulation is generally used to
include both desiccation and fulguration. Technically, this
is incorrect usage and the two can be compared and contrasted in several different ways:
∎∎ Fulguration always produces necrosis anywhere the
sparks land.
∎∎ Desiccation may or may not produce necrosis.
∎∎ Fulguration is more efficient at producing surface-level
necrosis.
∎∎ Desiccation is more efficient at producing a deep tissue
reaction.
∎∎ Fulguration requires about 20% of the current flow
required for desiccation.
Factors affecting coagulation
Some factors that affect the amount of coagulation verses
cutting current include:
∎∎ The faster an electrode is moved over or through tissue, the greater the cutting effect.
∎∎ The broader the electrode, the greater the coagulation
defect.
∎∎ If the tissue is touched with the electrode prior to keying the generator, more lateral charring will result.
Electrosurgery
When a cutting effect is desired, a high electrical current
is delivered via a fine electrode. This generates intense intracellular heat and causes the intracellular water to boil and
vaporize the cell. Vaporization dissipates some of the heat.
This cooling effect prevents thermal spread to adjacent tissues. The reduction and spread is not limited to the lateral
direction but includes the depth of penetration and, therefore, may prohibit any deep coagulation effect. In order to
increase the vaporizing effect of the cutting waveform, the
electrode should be activated prior to touching the tissue to
be cut. Four technical points are worth mentioning at this
time:
∎∎ Unless the surgeon has extensive experience, skin incisions are best made with a normal surgical scalpel.
∎∎ When working in fatty tissue, one should change to a
flat blade and coagulation waveform in order to perform a cutting function.
∎∎ Any time that tissue is grasped with a forceps, either
the cutting or coagulation waveform produces desiccation of tissue.
∎∎ When attempting to coagulate surface vessels in a
bloody field, irrigation with non-electrolyte solutions
improves the efficiency and effectiveness.
Argon beam coagulator
The argon beam coagulator is a relatively recent method of
achieving coagulation. A monopolar electrode is used in
conjunction with a beam of argon gas that passes through
the cannula at rate of 12 L/min, when used during a laparotomy, and at 4 L/min, when used in conjunction with laparoscopy. Argon gas has certain ionization properties that
enhance the distance a spark can travel to complete an electrical circuit. The beam that is produced by the argon is
bright with a bluish tint that makes it easy to see and to aim
at a bleeding surface. The CST should be familiar with the
manufacturers’ guidelines for the specific machines used in
their institutions.
Lasers
Laser stands for Light Amplification by the Stimulated
Emission of Radiation. Light is produced when energy is
applied to an atom and changes an electron to a higher level
of instability. The electron will return to its stable state by
releasing a photon of light. This type of light is called incoherent light and has many different wave settings, directions,
and phases.
When energy is applied to a laser medium, the electrons are changed into an unstable energy level. These electrons spontaneously decay to a lower energy level but one
that is higher than its normal international level. This new
state is relatively long-lived and stable. Enough energy can
be pumped into the laser medium so that the population
22
of atoms is produced which are mostly of this higher energy state. Whenever an electron spontaneously returns to its
normal state, a photon is emitted. The photon is of the same
wavelength. The photon travels down the long axis of the
optical cavity and continues to stimulate at the same wavelength. The photons reach the mirrored ends of the optical
cavity and are reversed. They continue to be able to stimulate the further release of photons. Laser radiation is produced as energy is applied to the laser medium. There are
four classes of lasers:
1. Low powered or high-powered, embedded lasers
2. (A) Visible lasers (400-700 nm). Under normal circumstances, these do not present a hazard to vision,
but if viewed directly for extended periods, the light
could cause damage to the eye.
(B) Visible lasers that are not intended for viewing and, under normal operating conditions, do not
produce an injury to the eye (if viewed directly and for
less than 1,000 seconds).
3. (A) Lasers that would not cause injury to the eye if
momentarily viewed.
(B) Lasers that present a hazard if viewed directly.
This includes Intrabeam and specular reflections.
4. These lasers present a hazard from direct, specular,
and diffuse reflections. They may also produce skin
burns and be a fire hazard.
Lasers are commonly identified by their active medium.
Excimer gas lasers are either argon or xenon. Excimer lasers
include nitrogen, helium-cadmium, argon, krypton, xenon,
helium-neon, and hydrogen fluoride. Metal vapor lasers
include copper vapor, gold vapor, neodymium-YAG, erbium, holmium-YAG, holmium-YLF, and chromium sapphire
as the active medium. Dye lasers use rhodamine, and semiconductor lasers use gallium arsenide. Of course, most of
these are not used in the surgical setting.
For controlling and focusing the beam, there are two
delivery mechanisms available. The first is a micromanipulator. This is a joystick that is used to move a mirror that is
placed distal to the focusing lens. This type of manipulator
is commonly found on the colposcope and the operative
microscope. In the second system, the focusing lens is located in the handpiece.
Accidents
Because of the potential danger presented by the laser,
every hospital has a laser committee and a person appointed as laser safety officer. Everyone should be aware of the
guidelines established for the various lasers. Causes of laser
accidents are listed below in order of frequency:
∎∎ Incorrect alignment procedure (almost 30%)
∎∎ Incorrect eye wear
∎∎ Voltage too high
Electrosurgery
∎∎
∎∎
∎∎
∎∎
Eye protection not used
Equipment malfunction
Improper service
Accidental exposure
Indications and frequency
As with most new technology, the indications for laser
usage continue to expand. At this time, some indications for
the use of laser in gynecologic surgery are:
∎∎ Cervical cone
∎∎ Condylomata
∎∎ VIN
∎∎ VAIN
∎∎ Adhesiolysis
∎∎ Endometrial ablation
∎∎ Salpingostomy
∎∎ Myomectomy
The relative frequency of laser procedures is as follows:
∎∎ Excision of endometriosis
∎∎ Lysis of adhesions
∎∎ Ovarian cystectomy
∎∎ Uterosacral ligament procedures
∎∎ Presacral neurectomy
∎∎ Salpingo-oophorectomy
∎∎ Ectopic pregnancy
∎∎ Myomectomy
∎∎ Laparoscopic assisted vaginal hysterectomy
∎∎ Retropubic urethropexy
∎∎ Sacral colpopexy
CUSA
The Cavitron Ultrasonic Surgical Aspirator (CUSA) is a
surgical device that affects tissue in three ways: viscous
stress, heating, and cavitation. Viscous stress occurs secondary to an interaction between intracellular water and
the vibration of bubbles, which are at the micron size. This
causes vibration and, if a critical point of shear stress is
induced, a breakdown in the cell with attendant hemolysis
occurs.
The CUSA is an acoustic vibrator. It converts electrical
energy into mechanical motion. The handpiece contains an
electric coil that is wrapped around a nickel alloy magnetostrictive transducer. This transmits an alternating electrical
field to an alternating magnetic field, causing contractions
and expansion in the transducer. This fluctuation pulses the
hollow, cone-shaped, titanium tip. The standard size has an
inner diameter of 2 mm, however, a microtip is also available. Laparoscopic versions are also available today.
Both irrigation and aspiration features are built into the
handpiece. Cellular debris can be removed from the operative site with ease. The greatest advantage to using the
23
CUSA is that cancerous tissue can be broken down easier
than healthy tissue. This makes the CUSA an appropriate
device for debulking pelvic tumors.
Conclusion
Electrosurgery, laser surgery and the Cavitron Ultrasonic
Aspirator are just a few of the recently developed resources
that enable surgeons to function more efficiently and facilitate the patient’s recovery. More applications for these technologies are undergoing research and, undoubtedly, new
benefits will be available in the future.
About the author
Bob Caruthers, CST, PHD, FAST, served as former AST deputy director and director of professional development.
He received his BA from the University of Texas, Austin, in 1972 and his PhD in 1995. He started his medical
career as an emergency room orderly and was subsequently employed as a certified operating room technician. He
later specialized in neurosurgery and developed a consuming interest in the human brain and its study.
He joined the faculty at Austin Community College and
later moved to Colorado to work for AST. He was responsible for leading many significant efforts and was executive
editor of the first edition of Surgical Technology for the Surgical Technologist: A Positive Care Approach, launched a program of educational CD-ROMs, was instrumental in the
success of the AST National Conference and initiated the
development of advance practice forums.
In January 2000, Bob was diagnosed with glioblastoma
multiforme and faced his illness with strength and determination. In 2002, he lost the battle—and is still missed. This
article was excerpted from his manuscript that was related
to an OB/GYN advanced practice manual.
Electrosurgery
CE Exam: Electrosurgery
1.
refers the use of a direct electrical
current to heat metal which is then applied to
tissue.
A Electrosurgery
B Electrocautery
C Coagulation
D Fulguration
2. What is the passage of a given amount of
electrons through a conductor of a specified
period of time?
A Electricity
B Joules
C Current
D Voltage
3. One consequence of coagulation is a cooling
effect produced by:
A Vapor spray tip
B Reducing current
C Interval between
electrical bursts
D Decreasing generator’s
output
4. During monopolar electrosurgery, current
travels through
and is received at
another
.
A Active electrode, neutral
plate
B Dispersive electrode,
active electrode
6. Electrosurgery may be used to:
A Cut
B Coagulate
C Fulgurate
D All of the above
7. When a electrode moves
through tissue, the
over or
the cutting effect:
A Faster, greater
B Slower, greater
C Faster, smaller
D Faster, shallower
8. Argon gas has certain
properties that
enhance the distance a spark can travel.
A Physical
B Ionization
C Biological
D Neutral
9. Lasers are commonly identified by:
A Color
B Active medium
C Delivery mechanism
D Frequency
10. The Cavitron Ultrasonic Surgical Aspirator
affects tissue in:
A Viscous stress
B Heating
C Cavitation
D All of the above
C Generator, grounding pad D Patient’s body, active
electrode
5. Bipolar surgery is generally restricted to
situations involving:
A Large area of tissues
being desiccated
B Small area of tissues
being desiccated
C An inexperienced
surgeon
D Younger patients
24
Electrosurgery
Blood Clotting Mechanism
by Teri Junge, CST, CSFA, FAST
1. Review the four basic steps of
hemostasis.
2. Understand the process of
vasoconstriction.
3 Examine blood vessel wall anatomy.
4. Identify various blood clotting factors.
5.Define common blood clotting tests.
Introduction
This article is intended as an introduction to the blood clotting mechanism for the student surgical technologist and as
a review for those in practice. Effective control of bleeding
occurs through a complex process called hemostasis, which
will be explained in four basic steps. The basic steps of the
blood clotting process are vasoconstriction, platelet activation, thrombus formation, and dissolution of the clot. Basic
laboratory tests used to identify blood clotting problems
will also be presented.
Blood clotting is initiated in one of two ways. The first,
referred to as the intrinsic or internal pathway, occurs when
a clot forms inside of a blood vessel due to an internal
abnormality or an injury to the blood vessel itself.8 The second, referred to as the extrinsic or external pathway, occurs
following an injury, such as a cut, when blood is exposed
to the outside environment. No matter how the clotting
process is initiated, the clot forms in the same way. This is
referred to as the common pathway. Another term used to
describe blood clotting is coagulation.
Blood cells called platelets, along with numerous factors—proteins, enzymes, vitamin K, and calcium—found
in blood plasma, are involved in the clotting process. Blood
clotting factors are referred to by Roman numerals and also
have names associated with them.
Injuries leading to extrinsic blood clotting and the related chain of events will be the focus of this article, as this is
the type of injury most commonly seen in the surgical environment. An example is provided in the case study below.
Case Study
George, an eighteen-month-old male, has fallen while playing on the patio at his home. As he fell, he hit his chin on a
terra cotta flower pot and cut himself. His mother rushed to
25
his aid. First, she cleaned the wound with a soft moist cloth;
she then applied pressure and ice to help control the bleeding and held George in a sitting position on her lap to calm
him. It was determined that George needed stitches in his
chin, and he was taken to the urgent care center for further
treatment. By the time of his arrival at the urgent care center, the bleeding from his cut had stopped.
Anatomy Review
To facilitate understanding of the process of vasoconstriction, blood vessel wall anatomy will be reviewed. Please
refer to Table 1 for a brief glossary of terms related to blood
vessel wall anatomy.
Walls of blood vessels, specifically veins and arteries,
consist of three main layers called tunics. The outer tunic is
called the tunica externa or tunica adventitia and consists of
the connective tissue that maintains the cylindrical shape
of the blood vessel. The middle tunic is called the tunica
media or tunica muscularis and consists of smooth muscle
tissue. The inner tunic is called the tunica interna or tunic
intima and consists of smooth epithelial tissue that allows
the blood to flow freely within the vessel. Additionally, a
layer of elastic tissue is present to allow for expansion (vasodilation) and contraction (vasoconstriction) of the vessel.
The muscular layer is thicker in arteries than it is in veins,
and veins have additional structures called valves, which
keep the blood from flowing backward. The exception to
the three-layer structure of blood vessel walls are the capillaries that consist of only a single layer of cells. This layer
allows the passage of fluids, cells, and molecules to and
from the tissue cells.7
Vasoconstriction
Vasoconstriction is the term used to describe tightening of
the muscle in the blood vessel wall. When an injury occurs,
nerves in the tissue surrounding the blood vessel stimulate the muscle of the blood vessel wall to constrict, narrowing the lumen of the vessel, thereby temporarily restricting
the flow of blood from the wound. This initial vasoconstriction lasts only about a minute, but then a secondary mechanism takes over that sustains vasoconstriction at the site of
the wound. The secondary mechanism involves release of
chemicals, such as serotonin and epinephrine, from blood
cells called platelets that have started to gather at the site of
Table 1 Glossary4,7,8
Artery
Large blood vessel that carries blood away from the heart
Arteriole
Small artery that delivers blood rich in oxygen and nutrients to a capillary
Capillary
Tiny blood vessel that allows oxygen and nutrients to be delivered to the
tissues and carries waste products away
Endothelium
Smooth flat cells that line the heart, as well as blood and lymphatic vessels
Lumen
The inside of a tubular structure (eg, the inside of a blood vessel or
intestinal tract)
Tunic
Coat or layer of a structure
Tunica Adventitia (Externa)
Outer layer of a blood vessel consisting of connective tissue
Tunica Intima (Interna)
Smooth inner layer of a blood vessel consisting of endothelium
Tunica Muscularis (Media)
Middle layer of a blood vessel consisting of muscle tissue
Vein
Large blood vessel that carries blood toward the heart
Venule
Small vein that carries blood and waste products away from the capillary
to a vein
the injury. Platelets continue to stimulate the nerves, which
causes contraction of the muscle of the vessel for several
more minutes.4
First aid measures such as those described in the case
study—application of ice and pressure to the wounded
area, as well as elevating the wounded area—all assist in the
vasoconstriction process.
Platelet Activation/Aggregation
Following damage, such as an accidental cut or a surgical incision, blood is exposed to collagen from the nearby tissues. At the time of injury, two things happen almost
instantly and simultaneously. First, two substances—fibrinogen, found in collagen, and prothrombin, found on the
surface of the platelets—are activated. (See Table 2) The
platelets, or thrombocytes, begin to adhere to the exposed
collagen. This initial step in blood clotting, or coagulation,
is called platelet activation or platelet aggregation.
As the platelets begin to assemble at the site of the injury,
several factors are released from the platelets. One of them,
the von Willebrand factor (vWF), binds the platelets to the
collagen fibers. Several substances are also released from
the platelets, including adenosine diphosphate (ADP),
which attracts more platelets until a seal is formed over the
opening in the blood vessel wall.
The clump of platelets is known as the platelet plug. The
platelet plug may be sufficient to seal a small vessel. However, in larger vessels, the platelet plug is temporary and will
be replaced by a thrombus.6 The platelet plug does not con-
26
tain red blood cells; therefore, it is sometimes referred to as
the white thrombus.1
Thrombus Formation
A more stable clot, called a thrombus, must form to make
a longer lasting seal on larger injured blood vessels. The
thrombus must be able to maintain a seal on the damaged
blood vessel wall, especially that of an artery where the
blood pressure is higher than in a vein, even after the blood
vessel walls are no longer constricted. Fortunately, the clotting process is self-limiting. Substances called antithrombins prevent the clot from continuing to enlarge; otherwise
the established clot would block the flow of blood within
the vessel.6
Activation of prothrombin in the platelet aggregation
phase sets off a series of additional events, starting with activation of factor X, that leads to formation of the thrombus. Activated factor X (Stuart-Prower) leads to activation
of factor II (prothrombin). Prothrombin in its active form
is referred to as factor IIa (thrombin). Several substances,
including thromboplastin (factor III), calcium, and vitamin
K, play a role in activation of prothrombin to thrombin.1
Thrombin, in turn, helps to convert fibrinogen (factor
I) to fibrin (factor Ia). Fibrin is an insoluble protein that,
when it reacts with other substances, polymerizes to form
strands that web together to form the basis of the thrombus.
The web of fibrin is referred to as fibrin mesh. Factor XIII
(fibrinase) is activated to serve as additional stabilization
of the fibrin mesh. When viewing the fibrin mesh that has
been stabilized with fibrinase under a microscope, it is said
Table 2 Blood Clotting Factors
5,6
Roman
Numeral
Name
I
Fibrinogen
Ia
Fibrin
(a = activated)
II
Prothrombin
IIa
Thrombin
III
Thromboplastin (also called tissue
factor)
IV
Calcium
V
Proaccelerin (also called labile factor
and accelerator globulin (AcG))
VI
Accelerin
VII
Proconvertin (also called serum
prothrombin conversion accelerator
(SPCA), cothromboplastin,
autoprothrombin I,
prothrombokinase and stable factor)
VIII
Antihemophilic factor A (also called
antihemophilic globulin (AHG))
IX
Antihemophilic factor B (also
called Christmas factor, plasma
thromboplastin component (PTC),
and autoprothrombin II)
X
Stuart-Prower factor (also called
autoprothrombin C, Prower factor
and thrombokinase)
XI
Antihemophilic factor C (also called
plasma thromboplastin antecedent
(PTA))
XII
Hageman factor (also called glass,
contact or activation factor)
XIII
Fibrinase (also called fibrin stabilizing
factor (FSF) and Laki-Lorand factor
(LLF). The inactive form is also called
protransglutaminase, and the active
form as transglutaminase.)
27
to have the appearance of cross stitching on loosely woven
fabric.3
Within a few hours of the injury, as part of the inflammatory process that normally occurs following damage to tissue, leukocytes (white blood cells) gather at the site of the
injury to help reduce the risk of infection. Local inflammation is identified by the presence of pain (dolor), redness
(rubor), heat (calor), swelling (tumor), and loss of function
(functio laesa). Systemic inflammation is identified by the
presence of fever.7
The thrombus may contain red blood cells; therefore it is
sometimes referred to as the red thrombus .1
Dissolution of the Clot
Dissolution of the clot, also called fibrinolysis, occurs when
a negative feedback system signals that sufficient healing of
the blood vessel wall has occurred, and a substance called
plasminogen is activated. Plasminogen in its active form is
called plasmin. Plasmin signals the clotting mechanism to
inactivate the procoagulant (clotting) process and begins
the anticoagulant process, with the use of naturally occurring heparin. This is achieved by digesting the fibrin, which
is the main component of the thrombus.6 The body then
returns to its state of balance, called homeostasis.
Identification of Blood Clotting Problems
Due to the complexity of the blood clotting mechanism,
numerous problems can occur that will impact the clotting ability of the injured patient or the patient scheduled
for surgery. Blood clotting disorders will not be discussed
in this article; however, knowledge of the status of the
patient’s blood clotting mechanism prior to and during surgical intervention is valuable to the surgical team members
in planning the care of the patient.
Several laboratory tests are available that will help determine if the patient has normal or abnormal clotting ability. If an abnormality is detected, intervention—such as providing blood products, procoagulants, or anticoagulants—
may be indicated.
Blood Clotting Tests
The following is a list of some of the more common blood
clotting tests, as well as brief descriptions of each.
∎∎ Bleeding time—Measures the time elapsed from
infliction of a small cut until active bleeding has
stopped. Normal bleeding time is three to eight minutes.
∎∎ Coagulation factor assay—Measures specific proteins
(clotting factors, as well as anticlotting factors) in a
volume of blood for normalcy, deficiency or absence.
∎∎ Complete blood count—A group of several tests performed on a volume of blood to detect the number and
∎∎
∎∎
∎∎
∎∎
∎∎
∎∎
size of certain cells or cell fragments, including red
blood cells, white blood cells (including the various
types of white cells), and platelets present in the blood.
Fibrinogen test—Measures the levels of fibrinogen
(Factor I) in the blood.
Miscellaneous—Various tests may be performed as
needed to detect vitamin deficiencies, liver malfunction, or leukemia that may affect the blood clotting
mechanism.
Partial thromboplastin time (PTT)—Measures the
amount of time needed (in seconds) that it takes for
clotting to occur when reagents are added to plasma
in vitro. Normal partial thromboplastin time is 30-45
seconds.
Platelet aggregation test—Measures the amount of
time needed for platelets to aggregate (adhere to) and
seal off the lumen of a vacuum tube that had been
coated with collagen and either epinephrine (EPI)
or adenosine diphosphate (ADP). As being drawn
through the tube, the coating activates the platelets
promoting platelet aggregation. The term closure time
(CT) is used to refer to the amount of time it takes for
a clot to form inside the glass tube and prevent further
blood flow.
Platelet count—Detects the number of platelets
present in the blood. It is typically included in the
CBC, but may be ordered independently. The normal
platelet count is between 150,000 to 450,000 platelets
per ML.
Prothrombin time (PT)—Measures the amount of
time needed for blood to clot in vitro. Normal prothrombin time is 10–15 seconds.7
Conclusion
Many factors influence hemostasis, and the clotting process
is a very complex series of chemical interactions that are not
all listed in this brief overview. Keep in mind the four basic
steps of the blood clotting process (vasoconstriction, platelet activation, thrombus formation, and dissolution of the
clot) as you think back to the case study, and try to answer
the following questions:
1. Why did George’s mother apply ice and pressure to the
wound?
George’s mother applied ice and pressure to the
wound to assist his body in achieving and maintaining
vasoconstriction.
28
2. Why was George kept in a sitting position following his
injury?
George was kept in a sitting position while his mother
was comforting him to elevate the injured area allowing gravity to direct blood away from the wound.
3. Why do you think that the bleeding had stopped by the
time George arrived at the urgent care center for stitches?
George’s bleeding had stopped by the time he arrived at the urgent care center for stitches, because all
the steps involved in his blood clotting mechanism
worked correctly.
About the author
Teri Junge, CST, CSFA, FAST, is surgical technology program
director at San Joaquin Valley College in Fresno, California.
She is also the editorial reviewer for this journal.
Editor’s note: To review the main constituents of the blood,
please refer to “Blood Components” by this author in the July,
2003 issue of this journal. For more information about fibrin’s
extraordinary elasticity and strength, please visit http://www.
wfu.edu/wfunews/2006/2006.08.03.f.html and http://www.
madgadget.com/archives/2006/08/fibrin_superher_1.html.
References
1. Atkinson L, Fortunato N. Berry & Kohn’s Operating Room Technique, 10th ed. USA: Mosby; 2003.
2 Bhonoah Y. Blood Coagulation. Imperial College of Science,
Technology and Medicine: Department of Chemistry. Available
at: http://www.chemsoc.org/exemplarchem/entries/2003/imperial_Bhono/bloodcoagulation.html. Accessed June 19, 2006.
3. Carlson C. How Blood Clots. Available at: http://www.med.uiuc.
edu/hematology/PtClotInfo.htm. Accessed June 1, 2006.
4. Cohen B. Memmler’s The Human Body in Health and Disease, 10th
ed. USA: Lippincott Williams & Wilkins; 2005.
5. Corrigan D. The Blood. Englewood, CO: Association of Surgical
Technologists; 1994.
6. King M. Blood Coagulation. Available at: http://web.indstate.edu/
thcme/mwking/blood-coagulation.html. Accessed June 3, 2006.
7. Price P, Frey K, Junge T, eds. Surgical Technology for the Surgical
Technologist: A Positive Care Approach, 2nd ed. USA: Thomson
Delmar Learning; 2004.
8. Stedman J. Stedman’s Medical Dictionary for the Health Professions and Nursing Illustrated, 5th ed. USA: Lippincott Williams &
Wilkins; 2005.
9. Tiscali Encyclopedia. Available at: http://www.tiscali.co.uk. Accessed June 3, 2006.
CE Exam:
1. The control system in which feedback
concerning changes in the body’s internal
environment causes a response that reverses
these changes is called
A Homeostatic mechanism
B Negative feedback
C Countercurrent
mechanism
D Feed-forward
2. Which of the following is NOT a basic step of
the clotting process?
6. Plasmin begins the anticoagulant process by…
A Using heparin to signal
the clotting mechanism
B Digesting the fibrin
C Activating plasminogen
D Accelerating the negative
feedback system
7. Which platelet-released substance attracts
more platelets until a seal is formed over the
opening in a blood vessel?
A Adenosine diphosphate
B Thrombin
A Vasoconstriction
B Platelet aggregation
C Proconvertin
D Fibrinase
C Thrombin formation
D Fibrinolysis
8. Which of the following is NOT a layer of a blood
vessel?
3. As platelets gather at an injury site, which
released factor binds the platelets to the
collagen fibers?
A von Willebrand
B Hageman
C Stuart-Prower
D Laki-Lorand
4. Which of the following does NOT play a role in
the activation of prothrombin?
A Vitamin K
B Calcium
C Fibrin
D Thromboplastin
5. The platelet plug…
A Contains red blood cells
B Sufficiently seals large
blood vessels
C Binds the platelets to the
precollagenous fibers
D Is also known as a white
thrombus
29
A Tunica muscularis
B Tunica adventitia
C Tunica interna
D Tunica serosa
9.
polymerizes to form strands, which
form the basis of a thrombus.
A Proconvertin
B Fibrin
C Accelerator globulin
D Fibrinase
10. During coagulation…
A Platelet aggregation
begins
B Antithrombins prevent
an overreaction of the
clotting process
C Fibrinogen and
D Factor X is activated and
prothrombin are activated
converts fibrinogen to
fibrin
Bioethics in Solid Organ Transplantation
Alternative methodologies being utilized in the prevention of solid organ shortage
by Shawn P Huelsman, CST, FAST; Bijan Eghtesad, MD; Charles Modlin, MD
1. Examine the types of organ donors
2. Analyze the issues related to organ
recovery from living donors
3.Understand the concerns of organ
recovery from deceased donors
4.Explore the role of education in organ
donation
5.Understand the bioethics concepts in
organ allocation
Introduction
Currently in the United States, 95,062 individuals wait for
their chance of receiving a lifesaving organ for transplantation.11 Though there were 26,689 transplants performed
in 2006, there is still not a sufficient supply of donors and
organs to meet the demand of those individuals needing
transplantation. Unfortunately six percent of possible recipients die while on the waiting list.11
These staggering figures have opened the bioethical
debate of how the United States can compensate for the
shortage of solid organs for transplantation. With this in
mind, the transplant community is utilizing new methodologies in order to increase the number of organ donors and
the amount of solid organs used in transplantation.
These methodologies of utilizing marginal donors, living
donation, alternative organ allocation systems, xenotransplantation and stem cell research are currently approached
in bioethical debate from the local to the national levels.
This article will give insight into these methodologies and
how they can assist in the increased amount of solid organs
for use in transplantation.
Organ recovery from marginal donors
In today’s organ donation system, organs are recovered
from deceased donors (DD) and living donors (LD). In the
past, most surgeons would use only those organs that came
from healthy, young donors. With the number of waiting
candidates surpassing the number of donors 7:1, there has
been a need to seek organs from donors who are considered
marginal.
Marginal donors include those individuals over 55 years
of age (extended criteria donors), pediatric donors under
30
5 years of age, non-heart beating donors (or donation after
cardiac death, DCD), and donors who have certain disease
processes and serologies (ie diabetes and HIV).1
Non-heart beating donors
There has been increasing debate in the field of non-heart
beating donation. Until recently, few communities would
allow recovery of organs from non-heart beating donors.
In this type of donation, the patient does not meet all of
the criteria to be pronounced “brain dead.” Although, if the
patient is removed from life-sustaining medications or ventilation, the patient will ultimately pass on.
Donation after cardiac death
Donation after cardiac death allows the family to donate
their loved one’s organs immediately after the patient’s
heart stops beating. The controversy behind this donation is that when the patient enters the operating room, he
or she is technically still alive. These patients are removed
from their medication and from their ventilator in a controlled method by the intensive care unit staff, as the recovery team waits outside for pronouncement of death.
An ethical question surrounding DCD is this: Are physicians being presumptuous in stating that there is no hope
for these patients, in order to fight against the problem of
organ shortage? Or does this open up another avenue to
obtain organs from those individuals for whom, if medications and ventilation are removed, there is no hope of survival?
HIV-positive donors
Another controversial issue concerns donors who are
HIV-positive. With the creation of life-sustaining drugs
(ie AZT), HIV patients are able to survive longer than first
expected. With their life expectancy increasing, do HIVpositive patients have the right to obtain solid organs for
transplantation if they are in need?
In order to facilitate this, organs are being recovered
from HIV-positive donors and are being transplanted into
HIV-positive recipients. This allows the recipient to receive
an organ, which they might not otherwise have the opportunity to receive. Does their placement on the Organ Procurement and Transplantation Network (OPTN) list jeopBioethics in Solid Organ Transplantation
ardize HIV-negative candidates’ chances of receiving an
organ?
Organ recovery from living donors
(related, unrelated and altruistic)
In the shadows of deceased donation, there has been an
increase in living donation. Living donation is the process
in which a live person is willing to give an organ or a part of
an organ to another individual. Though these procedures
were created for individuals who were related to one another, there has been a growth of unrelated living donation and
donation by altruistic strangers.
In 2006, there were 6,194 living donors, compared to
7,383 deceased donors.11 In these cases, an individual who
is not related genetically—or is a complete stranger—to
the possible recipient, is willing to donate an organ or a part
of an organ to someone in need.
With the invention of the Internet, it has become easier
for altruistic strangers to find a “worthy” candidate for their
organs. Websites such as www.MatchingDonors.com and
personal websites like www.babymarkjr.com allow prospective living donors to read stories from thousands of individuals that are in need of lifesaving organs. Currently the solid
organs that can be given by a living donor include kidney,
split liver, lung, split pancreas, and small bowel depending
on the situation.
The ethical concerns surrounding the use of living donation has sparked the interest of discussion within the US
Department of Health and Human Services (HHS), the
United Network of Organ Sharing (UNOS), and has most
recently been the subject of the President’s Council on Bioethics.
The key issue of current discussions has been the question of whether or not performing surgery on a living donor
violates the Hippocratic Oath—“To do no harm and to act
always in the best interests of every patient in his care.”5
Among the bioethical questions regarding living donation, focus has been placed on donor safety. Currently, neither UNOS nor the HHS has policies regarding a standardized informed consent for living donation.9 This informed
consent needs to be created in order to inform possible
donors properly of surgical risk, their right to change their
minds, and that there may be a possibility of future health
problems resulting from the donation, and that those problems may not be covered by insurance.9 In order for living
donation to continue being an avenue for preventing organ
shortage, the benefits to both donor and recipient must
outweigh the surgical and psychological risks.
In addition, there is the question of whether living
donors should be rewarded for their gift. This reward would
come in the form of treatment of future complications
resulting from the donor procedure. It would also include
31
allowing the living donor extra points on the OPTN waiting list, in case they are ever in need of an organ. There are
also those who feel that living donors should be given financial compensation, but it is still being debated.
One effort that has assisted in the living donation of
paired exchange (where two or more sets of living donors
and candidates are matched with each other to provide
compatible donors to each recipient) has been the recent
introduction of US House of Representatives Bill 710
and US Senate Bill 487. These proposed bills would create federal legislation that would allow more individuals to
become donors, thus creating more opportunities for transplant candidates to receive needed organs.13
Increasing organ recovery from deceased
donors
Despite efforts to increase the use of extended criteria
donors, donation after cardiac death, and living donations,
the best source of donors for solid organ transplantation
remains deceased donors. Unfortunately the number of
deceased donors has increased only 45% since 1988, while
the number of living donors has increased 71%.11 How can
we increase the number of deceased donors, and therefore
reduce the organ shortage?
Proposal 1: Greater education
According to Cantarovich, society must increase the role
of education—both for medical providers and the general public.4 He feels that society must be informed that organ
transplantation is a common and successful practice and
that the act of donation “offers a unique source of health
and provides a chance of life and well-being for everybody.”4
Some of his ideas on education include a youth commitment to organ donation as an obligation to society, the
assurance of integrity and respect for the cadaver during
and after organ recovery, and an overall improvement in the
general public’s unawareness and belief in myths and superstitions regarding organ donation.3 He concludes that education of society could change behaviors toward the use of
organs after death, eventually leading to a reduction of the
organ shortage.4
Proposal 2: Auction market
Dr Jack Kevorkian, the man made famous over the concept
of physician-assisted suicide, proposed a second concept
of increasing the number of deceased donors. He suggested the implementation of a free, nonprofit and potentially
global online auction market.10
His system resembles a modern-day “organ stock market.” When a donor is pronounced “brain dead,” the organs
are listed on the auction site. Individuals who want to purBioethics in Solid Organ Transplantation
chase the organs make their bid through an “organ broker”
at a regional transplant center.
Upon confirmation of a bid, the recipient must make
payment within 48 hours, or the organs will be given to the
next highest bidder. According to Kevorkian’s formula, 33%
of the funds would go to the donor’s family, 11% would go
to each of the recipient transplant centers (for future bidding and for those patients who are poor or uninsured).
Finally a 1%-fee would be applied to cover the administrative costs of running and operating the auction. The idea
behind this proposal is that it would give families an incentive to donate their loved one’s organs, and it would provide
financial stability to the family.
The negative side of this proposal is that some patients
may not be able to compete in the bidding process as well
as wealthier patients could, regardless of which patient is in
greater need of the organ.
In addition, how would the money for the donor’s family be distributed? Will it be deposited as part of the donor’s
estate, or will it be given to the family member who decides
to donate the deceased person’s organs?
Similar programs that have been created have included tax breaks, paying for funeral expenses and even paying
the family a flat rate for donation. The question for debate
is, “Should family members receive financial compensation
for donation, since our society views organ donation as an
altruistic and unselfish giving of one’s self?”
In Kevorkian’s article, “a procured human organ is the
most valuable and essential item in any transplantation procedure.”10 It is a fact that without the presence of the human
organ the recipient would not be able to receive a transplant, the physicians would not have patients, and the organ
procurement organizations (OPO) would not receive any
funding.
What is wrong with putting a financial number on the
recovered human organ? OPOs currently place fees on
every organ that is recovered. For instance, many OPOs
charge insurance companies and Medicare upwards
of $25,000 per kidney recovered. That equals $50,000
received for just the donor’s kidneys, and that doesn’t
include other organs that may be recovered, such as heart,
lungs, liver, pancreas and small bowel. Regardless, there are
still physicians and organizations that feel that payment for
organs is “unethical.”
Proposal 3: Increased awareness
The third proposed way of increasing deceased donation
relies on the use of mass media and the Internet to focus
attention on the issue. Websites such as www.lifesharers.com
as well as personal websites have added the same dynamic
as previously stated with living donation.
32
With Lifesharers, individuals volunteer to donate their
organs to other Lifesharers members primarily and to nonmembers if there is no suitable member candidate. This
allows possible donors to choose who will receive their
organs when they die.
On the flip side of this method, there has been discussion over presumed consent. Currently in the US, individuals choose if they want to become organ donors by stating
this information in the form of a living will, a donor organ
card or an indication of consent on one’s driver’s license.
Unfortunately, even if a deceased donor has indicated his or
her consent to donate, final authorization is still requested
from the donor’s family.
With presumed consent, it will be presumed that the
individual wanted to become an organ donor, unless there
is documentation stating that he or she did not. This will
eliminate the need to ask the family’s permission and will
allow the donor’s organs to be recovered sooner.
The downside to the policy of presumed consent is that
the altruistic characteristics of organ donation would be
abandoned. Organ donation would no longer be “a gift of
life”—it would be “an obligation to society.”
Changes in organ allocation policy
Another area of concern regarding the bioethical concepts
to increase the number of organs for transplant is the status of the organ allocation policy. Currently, every individual who is in need of an organ is placed on the OPTN waiting list.
This list is based on the individual need of the candidate.
It is not influenced by the disease that caused the organ failure, the age of the candidate, nor the socioeconomic status
of the candidate. If a deceased donor organ becomes available, the organ is allocated to the person highest on the list
based on need, length of time spent on the waiting list and
geographical proximity of the candidate to the donor.7
Should an individual with an emergent need but a shorter life expectancy receive an organ before someone with a
longer life expectancy? Should individuals who have donated organs in the past be given preference on the list?
Should organs be given to individuals who are responsible for their disease processes, for example organ damage
caused by smoking or alcohol abuse? Should organs be allocated based on age, geography or racial disparity? Should
organs be given to patients who are incarcerated? These are
many of the questions being asked in the field of organ allocation.
UNOS is currently debating a new system of kidney
allocation that would provide kidneys to those individuals
who are expected to live the greatest number of years posttransplant.8 One problem with this proposed system is that
younger candidates will be given preference over those who
are elderly.
The second problem is that with the emphasis on
extended criteria donors, how many more years of survival
will a 25-year-old recipient have with a kidney from a donor
who is 60 years old? A possible solution is delegating organs
from young donors to young recipients and organs from
elderly donors to elderly recipients.
A third problem involves geography. The Los Angeles
Times reported the story of two candidates.15 A patient in
New York was on the waiting list for a new liver for more
than 10 years. Unfortunately he died on his 53rd birthday
before receiving the organ. Another individual waited for
four years for a liver and kidney in New York. Frustrated
with waiting, he moved to Florida, where he received a new
liver and kidney 14 days later.
With reports like this, one can see why an individual would move to a place where the waiting list is shorter,
but what about people who are not able to relocate? What
is the justification for a shortage of organs in one geographical area and a surplus in another? Should these organs be
distributed equally among everyone on the waiting list,
regardless of geographical distance between donor and
recipient?
Alternative methodologies
Due to the current shortage of organs, there has been a new
focus on utilizing alternative methodologies to increase the
supply. Some of the methodologies, including xenotransplantation, cloning and the use of stem cell research, challenge some of our society’s traditional concepts and practices and therefore become the subject of media attention
and political debate.
With xenotransplantation, an organ is removed from
a primate or porcine model and is transplanted into a
human. Xenotransplantation first entered the bioethical
area in 1963, when James D Hardy transplanted the heart
of a chimpanzee into the chest of a cardiac-compromised
patient.14
This was later followed by Leonard Bailey, MD, who
transplanted a baboon heart into an infant with hypoplastic left heart syndrome in 1984. Left untreated, this congenital malformation causes mortality in the first month of
life.2 Though both of these grafts failed, research continued
in the field of xenotransplantation and prevention of organ
rejection.
Xenotransplantation lead the way to experimentation
with other therapies, including cloning, stem cell research,
islet cell research and the development of artificial organs.
Unfortunately the bioethical debates concerning these
modalities continue to hinder their progress.
33
Some of the ethical issues being debated include the
experimental status of these procedures and any potential side effects that may occur, the psychological stress
of receiving a cell or organ from an animal and the spread
of retroviruses.6 As for artificial organs, they still are used
primarily as a temporary measure to preserve life until a
human donor organ becomes available.
Consider the case of the infant who received the baboon
heart. If this therapy had not been used, the chances were
very slim of receiving a heart from a donor who was the
same age and weight; her only chance of survival was by
xenotransplantation. As with human organs, a xenograft has
the same potential for rejection. Is it not worth the risk, in
order to provide a young infant a chance to live to his or her
full potential?
Conclusion
The 21st century has become the age of discovery in the
field of organ transplantation. There are increasing debates
on how the US will be able to meet the need for the evergrowing number of candidates in need of lifesaving organs.
How can the country face this challenge? It can utilize marginal organs, living donors and new allocation
methods. It can also utilize such controversial techniques
as xenotransplantation or organs created via stem cell
research. It can even give a financial reward to those who
donate their organs.
Regardless of which technique is used, there is still a
need to increase the number of deceased donors by educating the general public about the myths and facts involved in
organ donation and transplantation. In addition, the country must also educate the growing number of individuals
who are entering the various health professions. If health
professionals do not understand this topic, then how will
prospective donor families be convinced to donate?
About the authors
Shawn Huelsman, CST, BSHM, FAST, is an organ preservation specialist at Cleveland Clinic in Cleveland, Ohio.
Bijan Eghtesad, MD, is a liver transplant surgeon in the
Division of Liver Transplant Surgery at the Transplant Center at Cleveland Clinic.
Charles Modlin, MD, is a renal transplant surgeon and
department head for the Men’s Minority Health Clinic in
the Glickman Urological Institute at Cleveland Clinic.
References
1. Abounda GM. The use of marginal-suboptimal donor organs: A
practical solution for organ shortage. Annals of Transplantation,
9:2004;62-66.
2. Bailey LL, Nehlsen-Cannarella SL, Concepcion W, Jolley WB.
Baboon-to-human cardiac xenotransplantation in a neonate.
JAMA, 254 (23):1985;3321-3329.
3. Cantarovich F. The role of education in increasing organ donation. Annals of Transplantation, 9:2004a;39-42.
4. Cantarovich F. Organ shortage, Are we doing our best? Annals of
Transplantation, 9:2004b;43-45.
5. Cohen E. (2006). Organ transplantation: Defining the ethical
and policy issues. The President’s Council on Bioethics. 2006.
Available at: http://www.bioethics.gov/background/staff_cohen.
html. Accessed January 18, 2007.
6. Cortesini, R. Ethical aspects in xenotransplantation. Transplantation Proceedings, 30:1998;2463-2464.
7. Davis D, Wolitz R. The ethics of organ allocation. The President’s
Council on Bioethics. 2006. Available at: http://www.bioethics.
gov/background/davispaper.html. Accessed January 18, 2007.
8. Graham J. Transplant change would sideline old for young,
healthy. The Plain Dealer. January 9, 2007.
9. Gruters GA. Living donors: Process, outcomes, and ethical
questions. The President’s Council on Bioethics. 2006. Available
at: http://www.bioethics.gov/background/ginger_ gruters.html. Accessed January 18, 2007.
10.Kevorkian J. Solve the organ shortage: Let the bidding begin!
American Journal of Forensic Psychiatry, 22:2001;7-15.
11.Organ Procurement and Transplantation Network (OPTN).
2007. Available at: http://www.optn.org/data. Accessed February
9, 2007.
12.Steinberg D. The allocation of organs donated by altruistic strangers. Annals of Internal Medicine, 145:2006;197-203.
13.United Network for Organ Sharing (UNOS). UNOS statement
regarding bills to clarify paired donation within the national organ transplant act. 2007. Available at: http://www.unos.org/news/
newsDetail.asp?id=802. Accessed February 12, 2007.
14.University of Mississippi Medical Center. The James D Hardy Archives. 2007. Available at: http://www.umc.edu/hardy/. Accessed
March 2, 2007.
15.Zarembo A. Death by geography. Los Angeles Times. June 11,
2006. Available at: http://www.latimes.com/news/local/la-natransplant11jun11,0,2800948.story?coll=la-home-headlines. Accessed February 14, 2007.
34
CE Exam: Bioethics in Solid Organ Transplantation
1. The number of living donors has increased
since 1988.
6.
A 45%
B 56%
A Seven
B Eight
C 71%
D 84%
C Six
D Nine
2. Which of the following is not a subject of
current bioethical debate?
A Organ donation should
require authorization from
a family member.
B Split pancreas
transplants should be
performed only if the
donor and recipient are
related.
C Performing surgery on a
living donor violates the
Hippocratic Oath.
D The potential for
psychological side
effects makes
xenotransplantation a
risky option.
3. A living donor may donate all of the following
except:
A Kidney
B Lung
C Split liver
D Cornea
4. US House Bill 710 and US Senate Bill 487
would…
A Facilitate more paired
B Guarantee life-time
exchange living donations
insurance coverage for
donors
C Eliminate the need for
family authorization prior
to donation
D Create a standardized
informed consent for
living donors
percent of transplant candidates die
prior to receiving an organ.
7. Organ allocation is influenced by…
A Distance between donor
and candidate
B Age of candidate
C Availability of an
alternative, such as an
artificial organ
D Cause of candidate’s
organ failure
8. The number of waiting candidates compared
to the number of donors is:
A 5:1
B 7:1
C 4:1
D 9:1
9. Which of the following are not considered
marginal donors?
A Children younger than 5
years
B HIV-positive adults
C Non-heart beating
donors
D Adults younger than 55
years
10. Cantarovich recommends all of these except:
A Dispelling myths and
superstitions
B Educating the general
public
C Convincing young people
that organ donation is an
obligation to society
D Improving insurance
coverage
5. Xenotransplantation first became the subject
of ethical debate in…
A 1958
B 1963
C 1972
D 1984
35
Maintaining Patient Confidentiality:
HIPAA Compliance
by Teri Junge, CSFA, BS, FAST
1. Evaluate your workplace for potential
HIPAA trouble spots.
2. Assess your own personal practices
as they relate to HIPAA requirements.
3.Examine the potential consequences
for noncompliance.
4.Compare and contrast the different
methods for notifying patients of the
HIPAA policy.
5.Examine the intricacies of business
associate agreements.
A HIPAA compliance program is necessary in a medical
setting to protect the patient’s personal, medical and financial information. It will be necessary to share patient information with other entities, and that must be done legally.
This article addresses planning, implementation and evaluation of a HIPAA compliance program.
The acronym HIPAA represents the term Health Insurance Portability and Accountability Act, which became
federal law in 1996. Implementation and enforcement of
HIPAA is the responsibility of the Office for Civil Rights,
which is part of the US Department of Health and Human
Services.1 A HIPAA compliance program is necessary to
ensure delivery of quality health care to the general public
and to protect the patient’s personal, medical and financial
information. The two main goals of the HIPAA program are
portability and accountability.2
The portability portion of HIPAA was set up to broaden
the health care options available to an individual by increasing his or her ability to obtain and maintain health coverage,
even when changing jobs, or by allowing individuals to purchase health insurance if group coverage is not an option.
HIPAA also limits exclusions from health insurance coverage due to preexisting and current conditions.3 The portability portion of HIPAA pertains primarily to health plans,
and the focus of this article is on the accountability portion
of HIPAA as it pertains to health care providers and health
care clearinghouses. Therefore, additional information concerning portability will not be provided.
The accountability portion of HIPAA was set up to protect patient privacy in relation to health care. This type
36
of information is called protected health information,
and there are three types of health organizations that are
required to follow the HIPAA privacy rules. These organizations are called covered entities and include health plans,
health care providers, and health care clearing houses.4
Protected Health Information
Protected health information (PHI) is defined as any health
information that is created or maintained by a covered entity in any form. Forms of information include handwritten
or printed documents, electronic documents, and the spoken word. Protected health information consists of anything that is individually identifiable including the patient’s
physical or mental status (past, present or future), care that
he or she has received, is receiving, or will receive, and the
method of payment for that care.2
Protected health information may be released in limited situations. The HIPAA Privacy Rule allows protected
health information to be released as permitted by the rule
or at the written request of the patient or the patient’s legal
representative. Additionally, information must be released
to the US Department of Health and Human Services if
requested during an investigation of an alleged HIPAA violation or as required by state or federal law.5
Permitted Uses of Protected Health
Information
Under the HIPAA privacy rule, the two main reasons for
release of protected health information without written
authorization or notification are to the individual and to
business associates who are directly or indirectly involved
with treatment, maintenance of treatment records or payment for treatment. Additionally, protected health information may be released in facility directories and to family and
friends involved with the patient’s care. Incidental release
of information is also allowed, as is release of information
for the sake of public interest. Limited information may be
released for research purposes.6
Policies and Procedures
Each covered entity must appoint an individual as the privacy officer. This person is responsible for creation and
maintenance of a HIPAA policy manual that describes all
policies and procedures relating to a patient’s protected
Maintaining Patient Confidentiality: HIPAA Compliance
health information. The policy manual must contain information concerning the covered entity’s business associates and the working agreements that are in place to protect
patient information handled by those associates. The manual also includes information notifying the patient about
how his or her confidential information is used by the covered entity. This is done via a document called a notice of
privacy practices. The patient signs an acknowledgment
that he or she has received the notice, and that acknowledgment is kept on file. Should the patient choose to have his
or her protected health information released, an authorization form must be available for the patient, or his or her representative, to sign prior to that information being released.
The privacy officer is also responsible for updating the policy manual as needed, ensuring that all staff receives HIPAA
training and that the training is documented in the employee’s file. Additionally, the privacy officer is to handle all
patient questions or complaints concerning the covered
entity’s privacy practices.2
Business Associates
A business associate is typically not a covered entity, but is
an individual or a business that provides services to a covered entity and has access to a patient’s protected health
information. Examples of business associates include (but
are not limited to) transcription services, billing services,
insurance claims processing services, answering service personnel, accountants, consultants (such as quality assurance
or utilization review teams), members of a legal team, etc.7
Table 17,8
Component
Rationale
Name, address and
telephone number of
covered entity
Identifiable information.
Name, address and
telephone number of
business associate
Identifiable information.
Brief explanation of
HIPAA
Raise awareness of the
business associate.
Definition of related
terms
To eliminate misunderstanding of contractual contents
(examples include covered
entity, business associate,
individual, protected health
information, etc.).
List of responsibilities
of the business
associate
List the exact terms of the
contract including specifics
concerning how the privacy
rule is to be followed, timelines for completion of work.
List of permitted
activities of the
business associate
Description of exactly how the
protected health information
is to be used. Also contains a
provision to extend the agreement to any subcontractors
hired by the business associate. Lists reporting requirements and limitations.
Procedures to follow
should a breach of
security occur
Covered entity must be
notified.
List of consequences
for noncompliance
Includes civil monetary
penalties and federal criminal
(monetary and incarceration)
penalties.
Disclosure
Covers any possible errors
or omissions in the contract
and states that HIPAA
regulations will prevail.
Liability insurance
requirement
May be optional (according
to state law).
Signatures and date of
signing
Validation of the contract.
Notarization
If desired or required by state
law.
Business Associate Agreement
All business associates of a covered entity who have access
to a patient’s protected health information must have a
signed business associate agreement in place.7 According to
Hinkley, et al, the required contractual provisions include:
∎∎ Ensuring that PHI will not be used or disclosed except
in accordance with the business associate contract;
∎∎ Ensuring that appropriate safeguards are in place to
protect the confidentiality of PHI;
∎∎ Requiring business associates to report breaches to
the covered entity;
∎∎ Requiring agents and subcontractors to comply with
the same requirements that apply to business associates;
∎∎ Making PHI available to satisfy patients’ rights;
∎∎ Making PHI available to satisfy HHS’s right to investigate and enforce HIPAA; and
∎∎ Returning or destroying all PHI upon termination of
the agreement, if feasible.7
An overview listing the main components of a business
associate agreement and the rationale for each entry is provided in Table 1.
37
Notice of Privacy Practices
Patient Authorization
The notice of privacy practices must be given to the patient
and a signed acknowledgment of receipt must be obtained
prior to the first interaction unless an emergency situation
exists. In the case of treatment necessitated by an emergency, the notice must be provided as soon as is feasible following the emergency and a signed receipt is not necessary. As
the notice of privacy practices is updated, the information
need only be available to the patient. This may take place by
making written brochures available, by posting the information in the reception area, or by posting the updated information on the covered entity’s Web site. As the notice of
privacy practices is updated, it is not necessary to obtain
an updated, signed acknowledgment of receipt from each
patient as long as the necessary updates are available upon
request. The document must not use legal or medical terminology, but must be written in terms that most patients can
easily understand.9
An overview listing the main components of a notice of
privacy practices and the rationale for each entry is provided in Table 2.
A covered entity must secure that patient’s permission in
writing prior to releasing any protected health information
that does not fall under permitted usage or is not covered by
a business associate agreement. The patient (or the patient’s
legal proxy) must sign and date an authorization form that
states exactly what information is to be released, to whom
and for what purpose. The date or date range for which the
authorization is effective is noted, and the method for revocation of the authorization is also included.9 A log should
be kept in each patient’s chart documenting any release of
information.11
Table 2 9,10
Component
Rationale
Name, address, and telephone
number of covered entity.
Identifiable
information.
Brief explanation of HIPAA and
definitions for any terms that the
patient may not understand.
Patient education.
Disclose how private health
information is used, stored, and
protected.
Raise awareness
of the patient.
Explain how changes in the
notice of privacy practices are
handled.
General patient
information.
Patient’s rights and
responsibilities are explained.
Inform patient
of his or her
rights and
responsibilities.
Describe the mechanism by
which a patient may make a
complaint regarding HIPAA.
General patient
information.
Explain the legal duties of the
covered entity.
General patient
information.
List the name and contact
information of the privacy officer.
Raise level of
patient confidence.
38
Operating Procedures
When developing the policies and procedures for protecting the patient’s health information, the two main concerns for consideration are privacy and security of information that is to be exchanged between the covered entity and
other covered entities, the patient, and business associates,
as it applies to written or printed information, electronic
information, and spoken information.12
Written or printed information is anything that is on
paper, including faxes.13 Some methods of protecting written or printed information include using patient sign-in
sheets that contain minimal protected information, placing treatment sheets and staff assignments away from areas
where they may be viewed by non-employees, ensuring that
patient charts are secure, such as in a locked cabinet or storage room, or by restricting access to the storage location,
and placing fax machines where they are not visible to nonemployees.14
Electronic information is anything that is stored in a
computer or that is transmitted electronically (excluding
faxes). Some methods of protecting electronic information
include restricting physical access to computers, including
placing computer monitors in locations where they cannot
be viewed by non-employees, restricting access to computer files and e-mail accounts, use of firewalls to protect computer files, use of passwords to access computer files and
e-mail accounts, and remembering to log off when the computer is not in use. Also, maintenance of computer software
and routine backup of computer files is necessary. Laptop
computers and personal digital assistant (PDA) devices
must be stored in a secure location. Any type of file sharing
between covered entities and their business associates, as
well as file sharing with patients (for example, access to laboratory results), must be secure.14
Spoken or verbal information is anything that is said
about the patient. Some methods of protecting spoken
information include conducting telephone and face-to-face
conversations with patients or about patients in private areas
so that the conversation is not overheard by non-employMaintaining Patient Confidentiality: HIPAA Compliance
ees. Employees must also use caution when communicating with the patient by telephone that information is not
inadvertently given to someone other than the patient. For
example, messages concerning appointments and lab results
should not be left on an answering machine without the
consent of the patient because someone else could intercept
the message or overhear the message being played back.14
Staff Training
One of the responsibilities of the privacy officer is to ensure
that the staff has been trained according to the HIPAA policy and procedure manual of the covered entity as part of his
or her initial orientation and annually thereafter. Documentation of the training must be maintained in the employee’s
file. Training should include an overview of the policies and
procedures and a review of the patient’s rights. The consequences for violation of the policies and procedures as set
forth in the manual are also made known to the employee,
who may be legally held personally responsible for any violation that may occur.11
Consequences of Noncompliance
Employees of covered entities who do not comply with
the HIPAA Privacy Rule by disclosing or improperly using
a patient’s protected health information could face civil
and federal charges. “Improper use or disclosure of PHI
could result in civil monetary penalties of $100 per incident, or as much as $25,000 per person, per year, per standard. Because certain criminal violations qualify as a felony,
criminal penalties can range from $50,000 to $250,000 and
up to 10 years in prison.”2 All employees of a covered entity
should be aware of the severity of the criminal penalties and
take compliance with all HIPAA regulations in all aspects of
the organization seriously.
Evaluation of the HIPAA Compliance
Program
Most instances of failure to comply with the HIPAA compliance program are inadvertent and, unfortunately, some
are purposeful. In order to maintain compliance and reduce
the risk of suffering the penalties of noncompliance with
the HIPAA regulations, ongoing audits or self-evaluations
should occur on a regular basis. Typically, the responsibility for evaluation of the HIPAA compliance program falls to
the privacy officer. The evaluations may also be conducted
by the risk manager or by an outside consultant. First, the
contents of all documents that relate to HIPAA should be
compared to the actual regulation to ensure accuracy and
thoroughness. Then, actual compliance with the prescribed
policies and procedures should be assessed and any corrective action taken. Physical inspections of the facility may
also turn up unexpected policy violations. A task as sim-
39
ple as sitting in a reception area while watching the activities and listening to any verbal interactions that involve protected patient information may prove useful in identifying
any problem areas. If a violation is suspected, immediate
corrective action (that may actually be very easy to implement) must be taken to avoid a possible patient complaint.
A potential government-initiated investigation will be time
consuming and will take personnel away from his or her
normal duties and may result in punitive action.15
Numerous tool kits for self-evaluation of HIPAA compliance programs are available online or for purchase.
Conclusion
Each facility must maintain a HIPAA policy manual that
describes all policies and procedures relating to a patient’s
protected health information. Business associate agreements are needed between the covered entity and any organizations that are contracted to provide service to the covered entity that involve protected health information. Additionally, a notice of privacy practices informing the patient
of his or her rights concerning protected health information
and how his or her protected health information will be
used by the covered entity must be developed and provided
to each patient. The notice must be provided to the patient
and a signed acknowledgment of receipt must be obtained
and retained by the covered entity. The patient must authorize in writing any release of protected health information that does not fall under permitted usage or is not covered by a business associate agreement. All staff members
must receive and have documentation of HIPAA compliance training upon hire and annually thereafter. The consequences for violation of HIPAA regulations are harsh and
may involve fines of up to $250,000 and 10 years in prison
for the most severe offenses.
About the Author
Teri Junge, CSFA, BS, FAST, is the surgical technology program director at San Joaquin Valley College in Fresno, California. She also serves as AST’s editorial review consultant.
Ms. Junge recently finished her bachelor’s degree in health
services administration.
References
1. Frimpong J., Rivers P. (2006). Health insurance portability and
accountability act: blessing or curse? Journal of Health Care Finance. New York: Fall 2006. Vol. 33, Iss. 1; pg. 31,9pgs. Retrieved
on December 6, 2008, from http://proquest.umi.com/pqdweb?did=
1152143131&Fmt=3&clientId=4684&RQT=309&VName=PQD
2. Ziel, S. (2002). Get on board with HIPAA privacy regulations.
Nursing Management. Chicago: Oct 2002. Vol. 33, Iss. 10; pg. 28,
3 pgs. Retrieved on December 7, 2008, from http://proquest.umi.
com/pqdweb?did=223140251&Fmt=3&clientId=4684&RQT=309
&VName=PQD
3. Gruber, J., Madrian, B. (1994). Health insurance and job mobility: the effects of public policy on job-lock. Industrial & Labor
Relations Review, Vol. 48, 1994. Retrieved on December 6, 2008,
from http://www.questia.com/googleScholar.qst;jsessionid=J7yTpm
RQnGpGcYlhjm7nlnNPJ5tsY1Q y3fvdKW1bJK0l8Dk63yCv!51528
6004?docId=98939193
4. Davino, M. (2004). Covered entities. Medical Economics. Nov
3, 2004 v81 i21 p25 (1). Retrieved on December 6, 2008, from
http://wf2dnvr6.webfeat.org/
5. United States Department of Health and Human Services.
(2008). HIPAA medical privacy—national standards to protect
the privacy of personal health information. Retrieved on November 23, 2008, from http://www.hhs.gov/ocr/hipaa
6. Guthrie, J. (2003). Time is running out—the burdens and challenges of HIPAA compliance: a look at preemption analysis,
the “minimum necessary” standard, and the notice of privacy
practices. Annals of Health Law Pub.: 2003, Volume: 12, Issue:
1, Pages: 143-77, V retrieved on December 7, 2008, from http://
www.ncbi.nlm.nih.gov/pubmed/12705207?ordinalpos=1&itool=En
trezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
7. Hinkley, G., Glitz, R., & Hirsch, W. (2003). Do you know your
business associates? Healthcare Financial Management. Westchester: Jan 2003. Vol. 57, Iss. 1; pg. 54, 6 pgs. Retrieved on December
7, 2008, from http://proquest.umi.com/pqdweb?did=276608411&F
mt=4&clientId=4684&RQT=309&VName=PQD
8. United States Department of Health and Human Services Department of Human Rights. (2006). Medical privacy—national
standards to protect the privacy of personal health information
sample business associate contract provisions. Retrieved on December 8, 2008, from http://www.hhs.gov/ocr/hipaa/contractprov.
html
9. Sarraille, W., Spencer, A. (2003). Assembling the HIPAA privacy
puzzle. Healthcare Financial Management 57 no1 46-52 Ja 2003.
Retrieved on December 9, 2008.
10.United States Department of Health and Human Services Office
of the Assistant Secretary for Planning and Evaluation. (2008).
Section 164.512 notice of privacy practices; rights and procedures. Retrieved on December 9, 2008 from http://aspe.os.dhhs.
gov/admnsimp/nprm/pvcnprm3.txt
11. Caplin, R. (2003). HIPAA: Health insurance portability and
accountability act of 1996. Dental Assistant. Chicago: Mar/Apr
2003. Vol. 72, Iss. 2; pg. 6, 2 pgs. Retrieved on December 9, 2008,
from http://proquest.umi.com/pqdweb?did=324849131&Fmt=4&c
lientId=4684&RQT=309&VName=PQD
12. McNealy, T. (2008). HIPAA compliance training. POWERPoint
accessible to San Joaquin Valley College faculty.
13. Dodek, D., Dodek, A. (1997). From Hippocrates to facsimile.
Protecting patient confidentiality is more difficult and more
important than ever before. Canadian Medical Association Journal.
Ottawa: Mar 15, 1997. Vol. 156, Iss. 6; pg. 847. Retrieved on December 10, 2008, from http://proquest.umi.com/pqdweb?did=4183
42341&Fmt=3&clientId=4684&RQT=309&VName=PQD
14. Pabrai, U., (2003). Getting started with HIPAA (1st ed). United
States: Course Technology PTR.
15. Ross, L., Friedman, M. (2006). HIPAA privacy audit tool.
Healthcare Financial Management. Westchester: Feb 2006. Vol.
60, Iss. 2; pg. 133, 4 pgs. Retrieved on December 9, 2008, from
http://proquest.umi.com/pqdweb?did=989047281&Fmt=4&clientI
d=4684&RQT=309&VName=PQD
40
Survey Results
Prior to researching information for this article, the
author conducted a qualitative survey of 10 covered entities. Ten survey questions were asked of
the individual or group of individuals responsible
for setting up the HIPAA compliance program at
their facility (Please refer to Appendix 1).
Of the 10 facilities surveyed, a single person
was responsible for the program at half of the facilities. There were also teams of two at three facilities, one team of three, and one team of four.
Of the 10 facilities surveyed, five facilities put the
HIPAA compliance program together from scratch,
two facilities hired consultants, and three facilities
purchased planning kits. Of the two facilities that
hired consultants, both were very satisfied with the
consultant’s work. Of the three facilities that purchased planning kits, only one was satisfied with
the contents of the kit. The most challenging part
of program implementation was reported as time
constraints by six of the respondents, one reported
that choosing a consultant was the most challenging, one reported problems with the print shop, and
two reported no challenges.
Eight out of 10 facilities reported compliance
problems with the physical layout of the facility and
nine out of 10 facilities reported problems with personnel not following the regulations. None of the
facilities reported performing regular comprehensive evaluations of the HIPAA program and three
are not doing any type of evaluation at all. Of the
10 facilities surveyed, only one reported a relevant
patient question about HIPAA. Ninety percent of
the facilities reported that they had no HIPAA violations that resulted in citations.
Appendix 1 — Survey Questions and Responses (continued)
Please explain who was
responsible for setting up
the HIPAA compliance program at your facility.
1. I did it myself.
2. I was the only one responsible for setting up the HIPAA compliance program.
3. Two of us were assigned to the task.
4. The owner and I worked together on the program.
5. Just me.
6. It started out as a committee of four, but I ended up doing all of the work
without any input from the other three.
7. I was.
8. Me, by myself.
9. Me and one other person.
10. Three of us worked on the assignment together.
Would you please describe
the planning and implementation process for the
HIPAA compliance program
at your facility?
1. I did the research online and set up the program.
2. I hired a consultant.
3. We did quite a bit of research and then decided to purchase a prepackaged
program.
4. Neither one of us had much time, so we decided to buy a program from the
internet.
5. I did everything.
6. When the committee fell apart, I got permission from the boss to hire a consultant.
7. I started out thinking that I would do everything myself, but it was too much
so I bought a kit and worked from there.
8. I researched the options and because of cost constraints I put the program
together on my own.
9. We did it all.
10. We divided up the work at the start of the project and then put the finishing
touches on together.
If a proprietary service
(such as a consultant or
document center) was used
to provide assistance with
planning and implementing the program, please
describe the amount of
the work that was accomplished by the service?
1. N/A.
2. The consultant did about 95% of the work.
3. About half. Even with the purchase of a program, we still did quite a bit of
work on the project.
4. The program was good, but we had to tailor it to our facility, so I would say
about 75%.
5. Does not apply.
6. The consultant did most of the work, I’d say about 90%. I just had to
approve the final documents and train the staff.
7. The kit provided about half of what I actually needed. It was a bare bones
kit. I should have done more research before deciding.
8. Did not use.
9. We did not use a service.
10. N/A.
41
If you relied solely on a proprietary service to provide
everything necessary for
implementation of the program, what did you like or
dislike about their work?
1. N/A.
2. I was very pleased with the consultant’s work - she took care of everything.
3. We were not pleased. The program was basically an outline and we had to
fill in all of the information.
4. The program that we bought met our expectations and was satisfactory.
5. Does not apply.
6. Yes, I really liked the consultant. He did absolutely everything!
7. I really disliked the fact that after spending all that money I still had to do a lot
of the work myself.
8. Does not apply.
9. We did not use a service.
10. N/A.
Please describe what was
the most challenging part
of planning and implementing the program.
1. Finding the time to do it.
2. Interviewing the three consultants and deciding who would be the best fit.
3. Realizing how much work that the owner and I still had to do after purchasing a prepackaged program.
4. Working with the people at the print shop to make sure that all of the documents were ready by the time we needed them.
5. I wasn’t able to train the staff all at the same time, so I had to repeat the
class four times.
6. The consultant pretty much took care of everything. If there were challenges, I was not aware of them.
7. Thinking that I could do everything myself and then caving in a buying a kit.
8. I wish there had been money to hire a consultant because it took me almost
a month of working full time (+) to get the HIPAA program together.
9. We didn’t really have any problems.
10. Finding time for the three of us to meet to review and finalize the program.
What concerns do you
have about maintenance of
the program that relate to
the physical layout of your
facility?
1. The FAX machine had to be moved because it was too visible.
2. We should have planned for a private consultation room.
3. Now that we have redirected traffic to the restroom, we can put the patient’s
charts outside of the exam rooms again.
4. I am concerned about security of the patient’s charts because they are not
locked up.
5. The walls between the exam rooms are not soundproof.
6. So far, no concerns have arisen.
7. The scale is in a busy hallway.
8. People in the waiting room may be able to overhear telephone conversations.
9. The sign in sheet at the front desk was visible to all and asked for lots of private information, so we simply stopped using it.
10. None yet.
42
What concerns do you have
about maintenance of the
program that relate to the
personnel at your facility?
1. One employee shared her computer password to another employee.
2. There is no place to hold a private conversation, so we have to really concentrate on keeping our voices low and watching to make sure that nobody
hears who shouldn’t.
3. No personnel problems so far (that I know of).
4. The patients are a bigger problem than the personnel because this is a
small community and they all know each other.
5. We have a large staff and ensuring that the training is up to date is huge. I try
to do all of the training annually, but every time we get a new employee they
are off the schedule. Then to get them on track with everyone else, sometimes they take the training twice on one year, so that they are in sync with
everyone else.
6. The hardest thing is getting the employees to tell me when we start running
low on the printed material so that I can order more before we run out.
7. One employee is constantly leaving charts, lab reports, etc. scattered
around the office where they could be seen by other patients and their family members.
8. We had an employee tell her mother that another family member came in
for treatment and provided details of the visit. This was reported to HIPAA
as a violation and is currently under investigation. This is the only personnel
problem that we have had.
9. One employee was using the phone in the reception area to call in prescriptions to the pharmacy. People in the waiting room could hear the conversation. This actually came to our attention because someone in the waiting
room reported it to the office manager.
10. We need to set up a formal training program for the employees. So far, we
have been doing it from the top of our heads without a checklist. Three of us
share the responsibility for training and I think that we each focus on different aspects
What types of evaluations
are carried out to ensure
effectiveness of the program?
1. Requests for information are tracked to be sure that written releases are
obtained before the requested information is sent out.
2. All employees are trained and the training is documented in his or her personnel file.
3. We conducted one patient satisfaction survey, but very few patients
responded and I don’t think that many of the ones that did actually understood what we were asking.
4. None yet. We just opened about a month ago.
5. I guess the fact that the patients are complaining about having to sign a
release to get information released to a family member is a good indicator
that we are doing something right!
6. We have a HIPAA binder with all of the regulations and documents in it, but I
don’t think that anyone is making sure that we follow the instructions.
7. Are we supposed to be doing evaluations? Like what?
8. We don’t have time to do evaluations.
9. When I have time, I randomly audit patient charts to see if the front office
staff is getting them to sign the receipt for the Notice of Privacy Practices.
10. About twice a year I make sure that the Business Associate Agreements are
up to date.
43
What types of questions,
if any, do the patients ask
about the program?
1. None, most are familiar with the privacy policies from dealing with other
facilities.
2. None.
3. I can’t recall anyone asking, but I could check with the receptionist if you
need more information.
4. They just sign the receipt without asking.
5. Some people ask why they have to sign the HIPAA document at every facility, but that’s it.
6. None.
7. They don’t ask.
8. We had one patient ask if the privacy policies would prevent her ex-husband from getting information about her health because she was still on his
insurance.
9. We stopped using a sign-in sheet at the front desk and the patients quite
often ask about that.
10. I can’t remember anyone asking questions about HIPPA. They are more
concerned about how long they might have to wait.
Please list any citations that your facility has
received for HIPAA violations and the describe consequences.
1. None.
2. No citations.
3. One patient threatened to report us for a violation, but once we explained to
her that we were allowed to release information to her insurance company
in order to receive payment, she understood and did not file a complaint.
4. N/A.
5. None, so far.
6. None.
7. N/A.
8. One complaint has been filed, but it doesn’t look like the facility will be cited.
The (former) employee who violated the policy will be held responsible and
will most likely pay a significant fine however the investigation is ongoing.
9. N/A.
10. None.
44
CE Exam: Maintaining Patient Confidentiality: HIPAA Compliance
1. The two main goals of the HIPAA program are
and
.
6. Written or printed information does not include
.
A Privacy/accessibility
B Portability/confidentiality
A Medical charts
B Faxes
C Portability/accountability
D Privacy/accountability
C Emails
D None of the above
2. Which is an example of a health organization
that is required to follow HIPAA privacy rules?
A Health plans
B Health care providers
7. Messages concerning appointments and lab
results should only be left on an answering
machine if
.
C Health care clearing
houses
D All of the above
A The patient is not home
B The patient has given
consent
C The information is time
sensitive
D Information should never
be left on an answering
machine
3. Information that is created or maintained by a
HIPAA-covered entity in any form is
.
A Medical records
B Protected health
information
C Public domain
D Available only to
immediate family
8. The most severe consequences for a HIPAA
violation include
.
A A fine of $100 per
incident
B $25,000
C 10 years in prison
D All of the above
4. Prior to interaction with a patient, the
must be given to the patient and a signed
receipt must be verified.
9. A notice of privacy should
A Notice of privacy
practices
B Liability waiver
A Explain the legal duties of
the covered entity
B Explain patient’s rights
and responsibilities
C A&B
D None of the above
C Disclose how information
is used, stored and
protected
D All of the above
5. The notice of privacy practices can be supplied
via
.
A Written brochures
B Posted information in the
reception area
C The entity’s Web site
D All of the above
45
.
10. A business associate agreement includes
.
A A list of consequences
for noncompliance
B An advance directive
C An appointed trustee
D All of the above
Radiation Risk
by Mark Otto Baerlocher, MD
∎∎ Examine the effects of radiation on the
human body.
∎∎ Compare and contrast the difference
between necessary procedures and
procedures that are perceived to be
necessary.
∎∎ Evaluate the rate of radiation-associated
cancer risk.
∎∎ Analyze methods of reducing radiation
exposure.
∎∎ Explore methods of tracking your
personal radiation exposure level.
Question: What is the estimated risk of both nonfatal and
fatal malignancy associated with a CT of the abdomen at 10
milliSieverts effective dose (mSv) in a 25-year old woman?
The use of medical imaging and related exams and procedures includes everything from X-rays, intra-operative fluoroscopy, CT scans, coronary angiography/angioplasty, embolizations, and endoscopic retrograde cholangiopancreatography (ERCP), among others. The use
of these exams and procedures has rapidly increased over
the last two decades, and has led to enormous improvements in both the diagnosis and the treatment of diseases
and pathologies. With this increase comes a concomitant
increase in the cumulative exposure to ionizing radiation to
patients, and by extension, an increase in estimated associated cancer risk.
As patients are largely unaware of the associated risks,
it is therefore imperative that health care workers become
educated on the topic. The following article briefly discusses the background of radiation risk, the model used to estimate radiation-related cancer risk, and potential education
strategies.
This article is written with a primary focus on patients.
However, the issues apply equally to health care workers, and certainly, to surgical technologists, for their own
protection. While patients are undergoing medical imaging and related exams and procedures for their own health,
health care workers are being exposed occupationally. A
lack of awareness or appreciation could therefore lead to a
lack of safety and appropriate protection in an occupation-
46
al setting. And because there is potential for occupational exposure on a daily basis, a lack of appropriate protection could result in very high, systematic exposure rates. It
is therefore crucial that all health care workers attain a basic
understanding and awareness of the related issues, not only
for the sake of patients, but for personal protection as well.
Radiation
The simplest definition of the term, “radiation,” is the transport of energy through space, which will eventually be
absorbed by a material (the Earth, the human body, air particles, etc). Radiation comes in different forms—for example, a person is able to listen to his or her radio due to radiowave radiation, and people can see their surroundings due
to light-wave radiation.
The type of radiation used for medical imaging purposes is generally “ionizing,” which means that the radiation
carries sufficient energy to eject electrons from particles,
resulting in the creation of ions.1 Ionizing radiation is used
in X-rays, CT scans, fluoroscopy, coronary angiography/
angioplasty, and many other exams and procedures.
These positively-charged ions, once created, can then go
on to cause damage in human tissue, by creating damage to
DNA for example. Due to different protective mechanisms
and growth characteristics, some cell types in the human
body are more prone to radiation than others; ie they are
more “radiosensitive.” In general, it has been found that cell
radiosensitivity is directly proportional to the rate of cell
division and inversely proportional to the degree of cell
differentiation. In short, this means that actively-dividing
cells, or those not fully mature, are most at risk from radiation.2 For example, hematopoietic cells, reproductive cells,
and cells within the digestive tract are particularly radiosensitive.
Effects of Radiation
There are two categories of harm that may be caused by
radiation: deterministic (nonstochastic), and stochastic.
Deterministic effects are those that occur once a given
exposure is reached. Infertility and cataracts are two examples of deterministic effects. Skin erythema/redness occurs
at a dose of at least five sieverts. The sievert is a unit used
to derive a quantity called equivalent dose. This relates the
absorbed dose in human tissue to the effective biological
Radiation Risk
damage of the radiation. Not all radiation has the same biological effect, even for the same amount of absorbed dose.
Equivalent dose is often expressed in terms of millionths of
a sievert, or micro-sievert. To determine equivalent dose
(Sv), you multiply absorbed dose (Gy) by a quality factor
(Q) that is unique to the type of incident radiation.1
Stochastic effects are those effects that are probabilistic.
In other words, there is no threshold above which the effect
always occurs, however, the greater the exposure, the greater the probability of occurrence. The primary stochastic
effect is the development of cancer.
Estimation of Radiation-Associated
(Cancer) Risk
Estimation of radiation-associated cancer risks is very difficult due to numerous complexities involved. Many of the
estimates are based on extrapolation from atomic bomb
data. Arguably, the most expert risk-estimate model estimation comes from the National Academy of Sciences (NAS)
Committee on the Biological Effects of Ionizing Radiation
(BEIR) VII, which is available to read online at http://www.
nap.edu/catalog.php?record_id=11340.
The BEIR VII committee uses the linear-no-threshold (LNT) model, which assumes that radiation risk is linear, and non-threshold (ie, there is no minimum radiation
exposure which must be surpassed in order to increase the
associated risk of developing cancer). As with any model,
there are inherent deficiencies and inaccuracies. However,
as additional data become available, the risk estimates are
re-evaluated and modified.
Radiation in Medicine
As mentioned above, ionizing radiation is utilized quite
extensively in medicine, both in diagnosis (X-rays, CT
scans, nuclear medicine scans, fluoroscopy, coronary
angiography, ERCP, etc) and in treatment (embolizations, angiogplasty/stenting, ERCP, etc). One of the largest sources of cumulative radiation exposure in medicine
is from CT scans, which has increased rapidly over the last
two to three decades.3 There have been estimates, for example, that if current CT usage rates continue, up to one and
a half to two percent of all cancers in the United States may
be caused by CT radiation in the future.3
While patients assume that any test or procedure
requested is clinically indicated or necessary, this may not
always be the case. There has been evidence, for example,
that not all exams ordered may be clinically indicated, and a
substantial minority may be ordered for other reasons, such
as miscommunication or medico-legal reasons.3 Perhaps
one contributing factor is an underestimation of the risks of
radiation-associated cancer by many clinicians.4
47
Periodically, there are very high-profile papers published
in high-impact medical journals such as the New England
Journal of Medicine,3,5 which then lead to articles published
in the mainstream media (eg U.S. News & World Report,
CBS, The Wall Street Journal, USA Today, CNN, etc). Following such stories, there may be a tendency for misinformation to propagate and misunderstanding to ensue.
Decreasing Radiation Exposure
There are a number of approaches that are necessary in
order to decrease radiation exposure, or more specifically,
to ensure that unnecessary radiation is avoided.
Education
The primary and the crux of any approach must be education, both of health care workers, and of patients. Without
at least a general awareness of radiation risk issues, there is
little likelihood either group would include radiation risk
into decisions regarding their own, or their patients’ care.
This author is currently a final-year radiology resident in
Toronto, Ontario, Canada. All radiology residents undergo mandatory, extensive radiology and radiation physics training, which includes radiation-risk education. The
topic is formally tested on the final medical boards exam (in
fact, in the United States, one part of the board exams for
the American Board of Radiology is specifically focused on
radiology-related physics). As medical imaging and related exams and procedures are so pervasive that they are relevant for most all health care workers, this author suggests
that all health care workers be given at least some basic education on radiation-risk awareness. This could be in the
form of formal lectures during training, during continuing
medical education-style courses and conferences, and in
formal publications such as The Surgical Technologist.
The best example of an international, large-scale radiation risk awareness initiative is the Image GentlySM campaign by The Alliance for Radiation Safety in Pediatric
Imaging, a consortium of professional societies concerned
about the amount radiation exposure children receive when
undergoing medical imaging procedures (www.pedrad.org).
The campaign has achieved much success in increasing
awareness among both health care workers and patients,
and continues to increase its reach, influence, and its partners. Although this author may hold an obvious bias as a
resident in radiology, it is his opinion that the leadership on
radiation risk education and awareness should come from
within the field where it is most relevant—radiology. This
is certainly the case, as the Image GentlySM campaign demonstrates.
Radiation Risk
Increased Communication
Communication, or lack thereof, is one potential cause of
unnecessary radiation, such as redundant exams.3 Communication includes exchanges between patients and health
care workers, as well as among health care workers themselves. For example, if there is a concern that an exam may
be redundant due to miscommunication, contact the relevant person and clarify prior to exposing the patient to
potentially unnecessary radiation.
Protocol Optimization
Depending on the modality and type of exam or procedure, consideration should always be given to decreasing
radiation exposure to the patient by optimizing the technique and protocol. This may include the use of shielding
and protective garments, and adjustment of specific imaging parameters.
The proper use of protective garments for the personal safety of health care workers is crucial. Whereas patients
tend to undergo solitary exams sporadically, occupationally-exposed health care workers may have the potential for exposure on a daily or near-daily basis, and therefore, improper protection may lead to very high, systematic,
cumulative exposure.
Tracking/Logging Exposure, Radiation
Passport for the iPhone/iPod Touch
There are several excellent electronic and online resources available that have the potential to both educate patients
(such as the Image GentlySM campaign and Web site), and
now to track radiation exposure and estimate associated
risks.
One such resource is an application for the iPhone and
iPod Touch that this author co-developed with Tidal Pool
Software and his brother, Adrian Baerlocher, called Radiation Passport. Radiation Passport is an application that is
meant to be useful for both health care workers and patients
alike. The application serves two primary functions. It
can be used to estimate the associated (nonfatal and fatal)
cancer risk from a given medical imaging exposure, related exam or procedure for a patient of a given age and gender; and it can also track or log all of the radiation exposures
from medical imaging over a patient’s lifetime, and estimate
the associated cancer risks from that radiation.
The average effective radiation doses associated with the
relevant exams and procedures (modality and body part)
were obtained by performing an OVID/Medline search of
published medical literature (though if known, users can
enter custom radiation doses instead for any given exam or
procedure). The risk estimates are based on the LNT model
used by the BEIR VII committee (linear, non-threshold,
cumulative). The risks are customized to the exam or pro-
48
cedure modality, body part, age, and gender of the patient.
The application also includes a series of questions to estimate background (nonmedical) exposure, as well as an
extensive background/information section.
The application is available on Apple’s iTunes electronic
store. Additional information can be found at http://www.
tidalpool.ca/radiationpassport/. *
While many countries require mandatory radiation logs
for those deemed “radiation workers,” most do not require
a similar log for patients and other health care workers. This
author suggests that it is time that this is considered.
Should Patients Be Informed of the Risks?
There has been some implied criticism questioning whether or not it is fair to give patients information about the radiation risks, with the worry that they may refuse an exam or
procedure based on this information.6
This author argues that not only is it fair, but it is necessary for patients to be provided with full disclosure on
potential radiation risks. When any given treatment or procedure is prescribed to a patient, it is implied that the riskbenefit equation tips favorably toward the potential benefit side, meaning that the perceived and potential benefits of the treatment or procedure outweigh the perceived
and potential risks. Both sides of the equation should be
explained to the patient, as well as all feasible options. The
patient should be allowed to make the final treatment decision.
In the case of imaging and imaging-related procedures
that utilize ionizing radiation, one of the potential risks
is developing associated radiation-induced malignancy,
and therefore, patients should be made aware of this information. This author co-authored a study that is currently under review, which demonstrates that 92 percent of
patients about to undergo an imaging-related exam or procedure are unaware of any radiation risks. The more information patients are empowered with, the better (though
it may be to the chagrin of many health care workers who
then have to spend additional time discussing the risks). As
a patient, if you are about to undergo a cholecystectomy,
you would probably want to be informed of the associated
major and relevant risks. This is analogous in this author’s
opinion, except that the primary risks are of radiation, and
potentially contrast reaction, contrast-induced nephropathy (CIN), and extravasation (if relevant).
Prepare Yourself with Knowledge
There is no question that both the diagnostic and treatment abilities of health care workers has been significantly improved with the greater use of more sophisticated
imaging and related exams and procedures. However, it
also comes with a price—the increasing risk of radiationRadiation Risk
induced cancer. The precise balance between use and misuse, as well as more accurate estimates of radiation risks,
will surely come under increasing examination in the coming years.
In the meantime, it is the responsibility of those involved
with its use to become educated on the topic, both for their
own sake, and for the sake of patients. As surgical technologists, you are often the face patients will see coming into
and out of their surgery.
About the Author
Answer to question
at the start of the article
∎∎ Approximately risk of nonfatal malignancy to
single CT abdomen at 10 mSv for a 25-year
old woman: 1 in 1500.
∎∎ Approximately risk of fatal malignancy to single
CT abdomen at 10 mSv for a 25-year old
woman: 1 in 750.
Mark Otto Baerlocher, MD, is a final-year resident in radiology at the University of Toronto, in Toronto, Ontario, Canada. Following his residency, he will attend the University of California, San Diego for a fellowship in interventional radiology. Dr Baerlocher eventually plans on entering the
academic field. If you have questions or feedback, please
contact him at [email protected].
References
1. Idaho State University. Radiation Information Network’s Radiation
Related Terms. 2009. Accessed: 12/8/09. Available at: http://
www.physics.isu.edu/radinf/terms.htm.
2. Rubin P; Casarett G W. Clinical Radiation Pathology. WB Saunders. Philadelphia. 1968.
3. Brenner DJ, Hall EJ. “Computed Tomography—An Increasing
Source of Radiation Exposure.” New England Journal of Medicine.
2007; 357:2277-84.
4. Lee CI; Haims AH; Monico EP; Brink JA; Forman HP. “Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks.” Radiology.
2004;231:393-8.
5. Fazel R; Krumholz HM; Wang Y; Ross JS; Chen J; Ting HH;
Shah ND; Nasir K; Einstein AJ; Nallamothu BK. “Exposure to
low-dose ionizing radiation from medical imaging procedures.” N
Engl J Med. 2009; 361(9):849-57.
6. Mason C. “Tracking radiology’s risks.” CMAJ. 2009; 181(3-4):E5.
49
Radiation Risk
CE Exam: Radiation Risk
1. The use of medical imaging
.
A Has rapidly increased in
the last 20 years
B Has improved diagnosis
and treatment
C Increases estimated
cancer risks
D All of the above
2. Radiation that carries enough energy to
eject electrons from particles is described as
.
A Ionizing
B X-Ray
C Radiosensitive
D All of the above
6. If current rates continue, 1.5-2 percent of
future US cancers will be caused by
A CT scans
B Nuclear medicine scans
C Embolizations
D Coronary angiography
7. Radiographic procedures can be ordered due
to
.
A Diagnostic reasons
B Miscommunications
C Medico-legal reasons
D All of the above
8. Deterministic effects do not include
3. Radiation effects that are measured by
probabilities are considered
.
A Infertility
B Cancer development
C Skin erythema
D Cataracts
A Deterministic
B Radiosensitive
C Stochastic
D Sieverts
9. By optimizing technique and protocol,
radiation exposure may be
.
4. Many estimates of radiation-associated cancer
.
risks are based on
A Stochastic data
B Radiation absorption rate
C Atomic bomb data
D Size of absorbed dose
5. Cell radiosensitivity is directly proportional to
.
A The degree of cell
differentiation
B The rate of cell division
C The cell maturity level
D None of the above
50
.
A Eliminated
B Decreased
C Accurately measured
D Improved
.
10. Unnecessary radiation and redundant exams
can be eliminated through
.
A Technological advances
B Patient cooperation
C Communication
D Proper safety attire
Radiation Risk
Birmingham Hip Resurfacing
by Jill Wehling
∎∎ Review the relevant anatomy for this
procedure.
∎∎ Examine the set-up and surgical
positioning for this procedure.
∎∎ Compare and contrast the differences
between hip resurfacing and hip
replacement.
∎∎ Assess the indications for hip
resurfacing, including selecting strong
candidates.
∎∎ Evaluate the step-by-step process of the
Birmingham Hip Resurfacing System.
People who are very physically active—whether in a physical work environment or simply playing sports—are often
uneasy when told by a physician that they need hip surgery to fix the severe, arthritic groin pain that can become a
chronic problem. This article discusses options to return to
pre-surgery activity levels without going through a total hip
replacement.
Rather than replacing entire hip, as in a total hip replacement with traditional metal-on-plastic implants, (high
impact activities are restricted because of increased (plastic) wear and loosening of the prosthesis), hip resurfacing
simply reshapes the bone by shaving a few millimeters off
the femoral head and socket and caps it with a metal component made of cobalt chrome, which allows the patient to
get back to his or her active lifestyle in a matter of months.
History of Hip Resurfacing
Originally developed in the 1970s, many early hip resurfacings resulted in poor outcomes and caused many surgeons
to abandon the procedure. These early attempts at the procedure failed largely because the large, metal femoral head
rubbed on the then-polyethylene socket, wearing it out.
This degenerative wear-and-tear caused the components
to loosen, ultimately leading to femoral neck fractures. Surgeons preferred the total hip replacement.
In 1997, Derek McMinn, MD, and Ronan Treacy, MD
released the original concept of the Birmingham Hip
Resurfacing System. Unlike the total hip replacement, in
the resurfacing procedure, the femoral head and neck is
51
not resected. McMinn’s and Treacy’s model eliminated the
polyethylene component of the resurfacing hardware, and
with it, prior concerns about it wearing out. This adaptation
allows for a much greater level of activity postoperatively.
Because of the larger metal-head size, the risk of dislocation
is reduced by a factor of 10. Because the femoral shaft is not
broached, future revision, if necessary, is much easier and
longer lasting.
There are currently three FDA-approved hip-resurfacing systems: the CONSERVE® Plus Total Hip Resurfacing
System, Corin Cormet™ Hip Resurfacing System, and the
Birmingham Hip™ Resurfacing System, which will be discussed in this article.
Ideal Candidate for a Birmingham Hip
Resurfacing (BHR)
The most common indication for hip resurfacing is osteoarthritis (ie, cartilage loss and bone-on-bone articulation).
Other indications include hip dysplasia, avascular necrosis (impaired or disrupted blood supply) and rheumatoid
arthritis. Younger, formally active patients with good bone
density are the best candidates for this procedure.
Surgical Preparation
After a patient time out, the patient is anesthetized under
general anesthesia on the operating table and the surgeon
positions the patient in a lateral position. There are many
varieties of positioning equipment, but this article addresses the Maquet positioning equipment. The patient is wellsupported using a pubic padded post and lumbar post along
with an axillary roll under the armpit with the upper arm
in a “gutter” support. The operative leg is placed in a candy
cane stirrup for prepping purposes. A compression stocking is applied to the nonoperative leg, which is slightly
bent. The surgical staff is then hooded, gowned and gloved
and the patient is draped. A sterile compression stocking is
placed on the operative leg.
Procedure
The surgeon marks his or her incision lines, and 20 cc of
local mixture of one percent lidocaine with 1:1,000 epinephrine (30 ml), mixed with 0.25 percent sensorcaine
plain (30 ml) for a 50/50 mixture totaling 60 ml. This mixture, used to help maintain hemostasis, is injected at the
incision site. An initial incision is made and deepened
through the fat while an ESU is used to cauterize bleeding vessels. The fibers of gluteus maximus and fascia lata are
divided. A self-retaining retractor is placed to open the gluteus maximus incision. The surgeon must be careful not to
injure the inferior gluteal nerve, as this can cause weakness
and leave a divot in the buttock from muscle atrophy.
Dissection between the undersurface of gluteus maximus and the greater trochanteric bursa should be carried
out so that the sciatic nerve can easily be palpated. A Charnley retractor is then substituted for the self-retaining retractor. At this point the surgeon injects an additional 20 cc of
the local mixture to help maintain hemostasis. The greater
trochanteric bursa is divided with the ESU. The next step is
to identify the piriformis tendon and divide the connection
between the piriformis and the gluteus medius fibers. A dull
Hohmann retractor is used to retract the edge of the gluteus
medius muscle. A tag suture using 1 polyglactin 910 CT-1,
is placed on the piriformis, and it is released. The capsular incision is made over the femoral head to the edge of the
acetabulum. A tag suture is also placed on the posterior capsule. The femoral head and posterosuperior edge of the acetabulum is exposed. The superior hip capsule is divided at
the edge of the acetabulum and a third tag suture is placed.
The hip is now ready to dislocate.
Capsular scissors are used in cutting the capsule further
around the femoral neck. A sharp Hohmann retractor is
used to retract back the minimus medius. A rongeur is used
to remove any osteophytes surrounding the femoral head.
The surgeon needs to find the true femoral neck in order
to be able to size the head and neck for resurfacing. Once
the measurement is checked the femoral head is prolapsed
under the abductor muscle with a sharp Hohmann. A second sharp Hohmann retractor is placed on the outer edge
of the acetabular wall and the Omni-Tract® system is used
to secure the Hohmann retractors. A headed pin is placed
below the transverse ligament and below the tear-drop and
hooked to the Omni-Tract® holder. A full view of the acetabulum is achieved and the surgical technologist is ready
for preparation and cup insertion.
The acetabular labrum is fully excised, and the ligamentum teres remnant also removed. If an osteophyte is present on the posterior acetabular wall, it is divided with an
osteotome and removed with a rongeur. Sometimes there
is soft tissue that needs to be removed. Osteophyte in the
acetabular floor is excised with an osteotome and rongeur.
The surgeon can now begin reaming the acetabulum. Starting with a size 44 or 46 mm reamer, the surgeon reams until
he or she is confident that the acetabular floor has been
reached—reaming up in 2mm increments until he or she
comes close to the final acetabular reaming. At this point,
the surgeon will proceed in 1mm increments. It is general-
52
Total hip resurfacing
This surgery replaces the diseased and damaged
bone in the hip joint with specially-designed and
manufactured “ball and socket” all-metal implants.
Step 1 After the thigh bone is separated from the
hip socket, the damaged area is removed. The hip
ball is reshaped to fit the femur and just 10 millimeters of bone is removed from the tip.
Step 2 Damaged cartilage and bone are removed
from the hip socket (acetabulum).
Step 3 A specially-machined, metal shell implant
is firmly pressed into the socket of the pelvis in the
anatomic position.
Step 4 Now the surgeon focuses on the thigh
bone implant. The end of the thigh is drilled to
accept the stem of the implant and dried.
Step 5 Bone cement is placed inside the metal
ball component and around the dried bone of the
thigh
Step 6 The metal ball implant is securely inserted
on top of the thigh bone.
ly advised to ream one size under the estimated cup size and
then verify the measurement by trial. When the surgeon is
confident about the fit of the trial acetabular component,
the true implant is opened and inserted with an impactor
and heavy mallet. The surgeon can often tell by the sound
that the acetabular cup is fully seated as it contacts the floor
of the acetabulum. The surgeon is aiming for 40 degrees of
inclination and 20 degrees of anteversion. When the surgeon is satisfied with cup positioning, the acetabular cables
are cut and the impactor cap and the cables are removed.
Any protruding osteophyte is removed with a rongeur to
prevent impingement. An X-ray-detectable 4x4 is placed in
the acetabular cup to protect the cup during the next phase
of resurfacing. All retractors are now removed and the headed pin is taken out.
Accuracy is extremely critical in the following steps.
The femoral head must be fully exposed to carry out the reshaping of the head. In order to obtain the correct varusvalgus alignment of the femoral component, the template
distance from the tip of the lesser trochanter to the desired
point on the intertrochanteric crest must now be transferred from the X-ray measurement, into the operative field.
A ruler and an 18g spinal needle are used to obtain this
measurement, and it is marked with the ESU at its point for
pin insertion. The pin is then drilled into the lesser trochanteric space, and a McMinn guide jig is placed to gain proper varus/valgus alignment. A stylus on the guide jig is used
to check perimeters circumferentially on the femoral neck.
Once the surgeon is satisfied with the ideal entry point, he
or she will then drill a long-guide pin, via a cannulated rod,
into the superior femoral head. It is important to check the
guide-wire position by using the stylus tip around the femoral neck. The stylus should not touch the femoral neck in
any position and should touch the periphery of the femoral
head 360 degrees. These are the minimum requirements for
guide-wire position.
If the surgeon is not happy with the guide-wire position, a guide-wire repositioning instrument can be used.
The cannulated rod and stylus are removed, and the surgeon will drill through the lesser trochanter into the canal
of the femur to place a drain cannula for suction. A urology drape is then placed around the femoral head to protect the soft tissues from being contaminated by bony reaming during the femoral preparation. The guide wire is now
over-drilled with two different-sized drilling instruments
then replaced with a guide rod. A continuous flow of irrigation is recommended during the next three stages. A headneck template is used as a protector while reaming the femoral head with the cylindrical reamer. An osteotome is used
to remove the peripheral ring of femoral head bone. A rongeur is used to remove any osteophyte left behind on the
femoral head-neck junction. The cylindrical reamer is then
used by hand to remove any fragments left behind. A marking pen will mark the head and neck joint and summit of the
head. A plain cutter is used to carefully resect down to the
marked point. This is checked with the head-neck template.
The chamfer cutter is used until the instrument is fully seated. There is an internal stop in this instrument. This is the
final stage of re-shaping the femoral head. Keyholes are
drilled with a Wroblewski drill for cement. The guide rod
is removed with a slap hammer and the central hole in the
femoral head and neck is enlarged with a taper drill. Any
cysts seen are removed with a curette. The femoral head is
now prepped by pulse lavage and patted dry with lap sponges and suctioned dry. The surgeon checks the correct size of
the femoral head, and the box is opened to surgical staff.
Preparation of cement consists of a mixing bowl, spatula, 60 cc catheter tip syringe, cement powder, liquid and
stop watch with head impactor with heavy mallet available. The femoral head is draped with three clean lap sponges in alternating directions. At the surgeon’s request, he or
she will tell the surgical technologist when to start mixing as he or she has only one minute from the time the liquid contacts the powder to implantation. As a surgical technologist, the mixing has to be done quickly, but thoroughly. Ideally, at about 25 seconds, the surgeon should be able
53
to draw up the liquid in the syringe and start filling the femoral head to one-third full. At the one minute mark, the surgeon places the femoral head with the impactor. Any excess
cement is wiped away, and a rongeur is used to remove
any small osteophyte at the head—neck junction. A pulse
lavage is used to irrigate and clean the femoral head and surrounding tissue. The drain cannula is removed, and a clotting agent is injected into canal. Forceps are used to retrieve
the raytec from the acetabular cup, saline is used to fill the
acetabular cup and a bone hook is used to lift femoral head
component along with traction on the leg to reduce into the
acetabulum. The surgeon now double checks the leg length
and range of motion for any impingement.
Closure
For closure, the surgeon chooses to use a 3/32 drill to
place an anchor into the greater trochanter. Then a 1-Vicryl® CT-1 is used to close the external rotators and capsule
along with the tagged piriformis and posterior capsule. 2-0
Vicryl CT-1 is used to close the subcutaneous layer, followed by staples for skin. The incision area is cleaned with
a wet and dry. Skin glue is applied along with two, sterile
4x4s and an island dressing. An anti-embolism stocking is
placed on patient’s leg with one pillow between the legs for
the first few hours of recovery. An X-ray is taken in recovery
when the patient is awake to ensure that dislocation has not
occurred in moving from the operating table.
Recovery
Rehabilitation usually starts on the first day after surgery.
Patients are on crutches the next day and weight bearing is
allowed as tolerated. Physical therapy will start one or two
days after surgery, beginning with simple bed exercises that
will strengthen the muscles in the hip and lower extremity. It is the physical therapist’s job to teach the patient proper technique to perform such simple tasks as moving from
lying to sitting, sitting to standing and standing to sitting.
The patient must learn to perform these movements safely, so that he or she doesn’t dislocate the hip or suffer other
injury. Patients will start the use of the pool three days after
the operation. The patient should have hip flexion of about
90 degrees four to five weeks postoperatively.
Most patients can return to whatever level of physical
activity they previously enjoyed approximately one year
postoperatively. In the first three months, patients will be
able to golf, and at six months, high-impact activities should
be possible. However, during the first year, more conservative, low-impact activities, such as walking, swimming and
bicycling are recommended for strengthening the femoral
neck and muscles around the resurfaced joint. The bone is
strengthened as new bone grows. According to Wolff ’s Law,
bone in a healthy person will adapt to the loads it is placed
under. If loading on a particular bone increases, the bone
will remodel itself over time to become stronger and resist
that sort of loading.
Because the femoral neck is maintained in a resurfacing procedure, the weight-bearing forces through the calcar
and proximal femur remain normal and calcium deposition
is normalized gradually.
Conclusion
Hip resurfacing is a technically demanding procedure, but
it can be successful, and the results can be satisfying for the
patient. Hip resurfacing requires good bone quality. Some
acetabular deformities cannot be addressed. However, it is
an attractive option for a young patient fearing a potentially
difficult future revision.
About the Author
Jill D Wehling, lives in Verona, Wisconsin, and graduated
from Mt Hood Community College Surgical Technology
Program in Portland, Oregon, in 2003. She currently works
at Meriter Hospital in Madison, Wisconsin, where she is the
lead orthopedic surgical technologist.
References
∎∎ McMinn D, ed. Modern Hip Resurfacing. Birmingham,
UK: Springer-Verleg; 2009.
∎∎ Rogerson JS. Birmingham hip resurfacing. Available at:
http://orthorogerson.com. Accessed August 9, 2010.
∎∎ Wolff’s law. Encyclopædia Britannica. 2010. Encyclopædia Britannica Online. Available at: http://www.
britannica.com/EBchecked/topic/646611/Wolffslaw. Accessed July 19, 2010.
CONSERVE is a registered trademark of Wright Medical
Technology. Corin Cormet is a trademark of the Corin Group
PLC. Birmingham HIP Resurfacing System is a trademark of
Smith and Nephew. Omni-Tract is a registered trademark of
Omni‑Tract Surgical. Vicryl is a registered trademark of Ethicon, a division of Johnson & Johnson.
54
CE Exam: Birmingham Hip Resurfacing
1. A polyethylene component is used in the
system.
6. There are currently
resurfacing systems.
A Total hip replacement
B Birmingham Hip
Resurfacing
A 1
B 2
C Corin Cormet Hip
Resurfacing
D CONSERVE® Plus Total
Hip Resurfacing
C 3
D 4
7. A/an
is used to remove the peripheral
ring of femoral head bone.
2. The acetabular cup should be seated at
degrees of inclination and
degrees of anteversion.
A 40/20
B 20/40
C 44/46
D 46/44
B Sterile 4x4 pad
C Urology drape
D Drain cannula
4. Indications for hip resurfacing include
A Impaired or disrupted
blood supply
B Rheumatoid arthritis
C Bone-on-bone
articulation
D All of the above
B Cannulated rod
C Rongeur
D Cylindrical reamer
A Elderly, inactive patients
B Younger, active patients
C Elderly, moderately-active D Young, relatively inactive
patients
patients
9. Rehabilitation can begin
.
5. Why is an X-ray-detectable 4x4 placed in the
acetabular cup after it is set?
A To prevent impingement
B To protect the cup during
the next process
C To take X-ray
measurements
D All of the above
55
A Osteotome
8. The best candidates for hip resurfacing are
.
3. A ___ is placed around the femoral head to
protect soft tissues from being contaminated
by bony reaming during the femoral
preparation.
A Continuous flow of
irrigation
FDA-approved hip
after surgery.
A One day
B Three to five days
C One week
D 10-15 days
10. “If loading on a particular bone increases, the
bone will remodel itself over time to become
stronger and resist that sort of loading,” is a
principle of
.
A Science
B Medical theory
C Wolff’s Law
D Birmingham Hip
Resurfacing
Interactive Answer Form Click or use a pen to circle the credit answer
ASA Credit Pkg A: 10 Continuing Education Credits
(Available to dues-paying ASA members only)
ASA Member No.:
CSFA Certification No:
Name:
Address:
City:
Phone:
CSFA State:
CSA SA-C ZIP:
Email:
ASA CREDIT PKG A: 10 CONTINUING EDUCATION CREDITS
The fee is $15 for ASA dues-paying members
Check enclosed
Visa MasterCard AmEx #
Expiration Date
Signature
Hernias of the Abdominal Wall
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
Circle or click one answer next to each number.
Only one correct or best answer can be selected
for each question.
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
for each question.
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
for each question.
Understanding Anaphylaxis
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
for each question.
Electrosurgery
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
for each question.
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
for each question.
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
for each question.
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
for each question.
Radiation Risk
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
for each question.
1.
A
B
C
D
5.
A
B
C
D
9.
A
B
C
D
2.
A
B
C
D
6.
A
B
C
D
10.
A
B
C
D
3.
A
B
C
D
7.
A
B
C
D
4.
A
B
C
D
8.
A
B
C
D
for each question.
Directions: Complete all 10 answer keys for the exams. If paying by credit card,
complete all information with the appropriate amount. Click submit to send
electronically. To submit by fax, send both answer keys to 303‑694-9169. To submit
by mail, send in your answer keys and payment (check or credit card) to ASA
Member Services, ASA, 6 West Dry Creek Circle, Suite 200, Littleton, CO 80120.
Submit

ASA Dues-paying Members only -

Transcription

Similar documents

UA-787EJ Datasheet Front

choicepay - Quantum Solutions

- Wellness PRO Incorporated

the williams organ company epworth pump organ # 3676

Whether your customers prefer traditional silk knots, swivel bar

Custom Trousers Options

Secondary Assessment, Reporting Documentation

specification sheet - Protective Industrial Products

Retractable 6in. Feather Duster

safety specialty hand protection