Out of the hospital...

Beautiful fall days call for beautiful fall activities. This weekend, SWIMBO and I headed to Williams Canyon outside of Manitou Springs. Day one --- HIKE IT!

Looks like some bozo doesn't know how to read.

And for the next day's activities --- BIKE IT!




Sweet!

Gambling with Matches

"Match Day" came and went this year on March 17th; I find it interesting to look at the raw data from the residency match, as it gives one an idea of what the next generation of physicians are thinking about the future, and my chosen specialty in particular. It is also instructive to see what is put out as PR for the match and compare it to the match results themselves:

For Second Year, More U.S. Medical School Seniors Match to Primary Care Residencies
For the second year in a row, more U.S. medical school seniors will train as family medicine residents, according to new data released today by the National Resident Matching Program (NRMP). The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010. In Match Day ceremonies across the country today, these individuals will be among more than 16,000 U.S. medical school seniors who will learn where they are going to spend the next three to seven years of residency training.

Well. Here is the raw data.

I'd like to focus on three residencies --- Family Medicine, Internal Medicine, and General Surgery. For Family Medicine, 48% of the 2,708 slots this year went to US medical school graduates, compared with 44.8%, 42.2%, 43.9%, and 42.1% in the previous four years. For Internal Medicine, the numbers were somewhat higher, with 57.4% of the 5,121 positions being filled by US graduates, in comparison to 54.5%, 53.5%, 54.8%, and 55.9%. Both are a bit of a bump up, but the 11% rise noted for Family Medicine in the press release is a bit misleading, as the number of slots increased by 100 over 2010 as well.

General surgery numbers were a bit mixed, as there were more slots available this year (1,108 versus 1,077 in 2010), 81% of which were filled by US graduates; in comparison, the percentages were 83.1%, 77.4%, 83.1%, and 78.1% going back to 2007. Pediatrics and OB-GYN numbers are hanging in the low-to-mid 70% range for the same time period.

What does all of this mean? I'm not really sure. Not being a statistician, I can't say for sure but none of these numbers suggest a statistically significant change in the percentage of US medical school graduates going into these residencies, all political and PR posturing aside. One thing that many tend to forget is that subspecialty care will draw off many of these primary care physicians with time --- into cardiology, GI, neonatology, high-risk OB, plastic surgery, cardiothoracic surgery, etc.

If I was a betting man, I would bet that the minor increase in FP and IM numbers this year will not be sustained; there are too many financial forces working against the physicians in those specialties. And general surgery is not terribly different in the long run.

The Aggravated DocSurg Field Guide to the American Surgeon

I’m in Las Vegas. Actually, I was in Las Vegas, but because my swanky hotel didn't provide the basic internet service that your average Travelodge does, I didn't get to post this until now. Not my favorite place, to be honest --- I don’t gamble, smoke, or hang out with hookers. The ads for “Kourtney Kardashian’s birthday party” at Planet Hollywood don’t interest me in the least. I’m quite sure that that mobile billboard advertising for “girls that want to meet” me are a bit less than honest. And I think it is frankly immoral to charge a guy $22 for a martini that isn’t served in a quart-sized glass.

This trip was about business, not pleasure. I was at the Trauma, Critical Care, and Acute Care Surgery meeting held at Caesar’s Palace every spring. Basically, it’s a meeting that talks about all of the things that you don’t want to have happen to you. I have a general rule about medical meetings --- never stay at the hotel hosting the event. The room rates are high, despite the advertisements for “discounted” prices in the meeting brochure, and I like to stretch my legs a bit on the way to and from the lectures. This provides me plenty of time to practice my people watching skills.

This year, the trauma surgeon meeting was held one floor above a meeting for academic internists. Oil and water, so to speak. Being the slacker that I am, I didn’t bring along the meeting brochure with me to tell me where to go. And since Caesar’s wants people to wander and get mired in the casino, there were no signs directing me to the meeting this morning. So with a couple of thousand doctors streaming up the escalators to meeting rooms, how was I to tell where to go?

It’s simple. I know my peeps! I had no more trouble distinguishing the surgeons from the internists than a mother does her twins. And now, thanks to the Aggravated DocSurg Field Guide to the American Surgeon™, you too can know how to spot a surgeon in any environment.

The first clue to differentiating surgeons from internists at a meeting is a careful observation of how they walk --- surgeons are an impatient lot, and don’t tend to stand on escalators, wander, or stroll slowly. We tend to be on time, but just barely, and mostly arrive solo. Clothing is generally a bit rumpled, and at meetings older surgeons tend to adopt the same “uniform” --- khakis, a blue sport coat, and no tie. A quick glance at the wrist generally confirms a cheap watch --- Timex or Casio “nerd watch,” as SWIMBO calls them --- because we are always taking them off to scrub. Lost of loafers --- once again, because they have to be taken off frequently.

The internists were easy for me to pick out. They traveled in packs, ambled peripatetically, and were constantly fiddling with their smartphones. They tended to be rushing, audibly complaining of being late. All of them carried a meeting satchel every day, which the surgeons almost universally leave in their hotel rooms after the first day of the meeting (or never pick up). The shoes ranged from pumps to wingtips (really -- in 2011) to tennis shoes to sandals.

What about in the hospital? I know who everyone is at my place, but if somehow I was dropped into an ICU in Kalamazoo at midnight, and every doc in the place was wearing scrubs, it’s not really that hard. The surgeon in scrubs will unfailingly have messy hair from wearing a scrub cap all day, will be wearing some sort of OR-friendly shoes (Crocs, Danskos, etc.), more often than not is wearing a white coat, will roll his eyes a lot, and will have a feral look about him/her --- this is a deep-seated response to spending years in training where the hours were long and access to the next meal was suspect. If there’s a surgeon nearby, no doubt there’s a bit of food and coffee in the vicinity.

The internist in scrubs looks a bit different --- wearing the same shoes he came to the hospital in, almost never in a white coat, carrying an armful of stuff that generally consists of patient lists, scribbled notes, and a laptop. But the single most distinguishing characteristic that marks the internist who is wearing scrubs is the presence of a stethoscope slung around his neck. This is as pathognomonic as the blue light special at K-mart.

I hope this serves as a good introduction for those intrepid explorers who brave the halls of a hospital or who come across flocks of docs at a meeting place. The next edition of Aggravated DocSurg Field Guide to the American Surgeon™ will explore the finer points of surgeon identification, such as distinguishing residents from attendings, neurosurgeons from cardiothoracic surgeons, and the finer points of separating joint replacement orthopedists from hand surgeons based upon golf club brands.

If you are wondering if this guide is worthwhile, I can say I have already had one successful student -- Jimmy Buffett:

We're stayin' in a Holiday Inn full of surgeons

I guess they meet there once a year

They exchange physician's stories

And get drunk on Tuborg beer

Then they're off to catch a stripper

With their eyes glued to her G

But I don't think that I would ever let 'em cut on me

Waiting & watching for Jon

We were invincible. Packed into Jon’s pale yellow Olds Cutlass, the car I’d always wanted, careening down the road between our high school and its “sister” all-girls school, we’d sing along with whatever was playing on the oversized speakers garishly mounted in the back. More exactly, we’d usually be screaming along with the music, which was loud enough to rouse more than a few nearby drivers from their afternoon daydreams.

We were on our way to......take a typing class. Twice a week, seniors who had asked for the class would get to spend a glorious hour pecking away at the Smith Corona keys. It was a treat, a privilege, something bestowed only on those who had grades that were up to par, and I’m sure some other selection process was at work as well. Even though there were no girls actually in the class at the time, we were surrounded by them.

And Jon was in his element.

I had never met anyone quite like Jon. He was smart, but didn’t take himself -- or anyone else -- seriously. We’d joke and laugh like other teenage boys, but I never laughed as hard or long as when I was with Jon. His humor was so much a part of his personality that he was able to disarm even the scowling older priests at our school who had quite literally “seen it all” before. A quick jest and a raised eyebrow was generally all it took for him to win someone over to his side. Even when he screwed up, it was hard to stay angry at him for long. Heck, he even started dating a girl I’d broken up with a week before, and I couldn’t hold it against him.

Jon had one other arrow in his quiver, a gift from God, really. His eyes were the color of a Colorado winter sky, and brighter than a neon night. I suppose I’ve only seen something similar in movies, watching Grace Kelly or Paul Newman. But to see them in real life, in “action” so to speak, was remarkable. Personality plus pulsating blue eyes left the girls at Ursuline red-faced and giggling, and left the rest of us laughing, shaking our heads at how easily he could charm the pants off a nun.

Some time, somewhere later, Jon fell off a cliff. Looking back, as it always is, it is easy to recognize the direction he was headed. But the speed with which his drug problem took him down, and the depths to which it drug him, remains breathtaking to me even today. College was never completed --- hell, probably in reality never attempted. Having not seen him in several years, he showed up at my wedding, and then disappeared again, only to arrive unceremoniously at my doorstep with a pregnant girlfriend in tow. It was 11 PM, and I was dog-tired from working as a resident. And there he was, bright eyed as usual, but dirty, disheveled, and totally unaware of how badly he smelled.

That was 1990. I haven’t laid eyes on Jon since.

I know about the successive stents in drug rehab. I have had the opportunity to spend time with his ex-wife and children, and to learn of the tremendous loving influence his parents have had on them. And I have seen the pain in all of their faces, the ache in their voices. They, like me, miss Jon. But they have had to live with the person he became, and certainly don’t miss that guy.

I have put at least twenty versions of this down in electronic ink (those typing classes came in handy), and deleted them all. I have tried to write it in my head about a hundred times more. I guess I can’t come up with a way to end it, because there is no ending that will make me feel any better. Perhaps that is why I catch myself watching for Jon in places that I hope I might find him --- ski resorts, airports, restaurants when I go back to Dallas --- and more often in a place I fear I will find him --- in my ED.

We weren’t invincible.

It doesn't get any better than this -- America's mountain, a sunny day, and a mountain bike.

Thanks go to the surglings for my new Texas Tech mountain biking jersey!

Henny Penny in the Hospital

As much as I am not a fan of many of the studies that clutter medical journals --- poorly designed studies or those that display extreme bias --- I am occasionally delighted to find an article that is a bit out of the ordinary. It helps when it confirms my own biases (I admit it, I like to say "toldya so"), and there's an extra bonus for teaching me a new word. Such is the case for an article from the January edition of the American Journal of Surgery --- Catastrophizing: a predictive factor for postoperative pain.

What the heck is catastrophizing? Well, it's listed in Dorland's medical dictionary (not in my prehistoric version, but in their online version), but I haven't been able to find it elsewhere. Put simply, catastrophizing is an irrational belief that something is far worse than it actually is. In the realm of pain research, pain catastrophizing is defined in the article as:

...an exaggerated negative mental set brought to bear during an actual or anticipated painful experience (defined in simple words as expectation or worry about major negative consequences, even one of minor importance).

OK, that means that some people worry excessively about pain associated with medical care, either during or before the actual care event. So? I worry about lots of things --- whether my kids will be alright when they are adults, whether or not I'll be able to bike to the top of the next hill without hacking up a lung, or whether SWIMBO will wake up one day and realize that she was duped into marrying me 23 years ago. I lay awake at night worrying about patients in the hospital, knowing that there is little I can do but wait. Well, in this situation, it's the degree of worry involved --- hence the provocative name for the problem. Once again from the article,

High levels of catastrophizing have been reported to be associated with a heightened pain experience and can result in the development of chronic pain.

The authors reviewed a large number of pain studies in surgical patients, and came up with a few general findings:

• Pain catastrophizing is becoming recognized as a key predictor of the severity of acute post-surgical pain and its progression to chronic post-surgical pain. That's a big deal, because the severity of a patient's pain perception significantly alters their recovery and postoperative mobility, which can lead to other problems (DVT, atalectasis, etc.).
• There are screening tools available (the Coping Strategies Questionnaire and the Pain Catastrophizing Scale) to identify patients with a tendency to catasrophize, which could potentially allow us to tailor postoperative pain management for them.

Hmm. I am a surgeon. Basically, that means that everything I do hurts. It's important for me to make sure patients know and fully understand that before we go to the OR, because otherwise I would be a lying SOB. But, it is also important for them to know that we try to mitigate their pain ---- but we are unable to take it completely away --- and that it will gradually improve with time and eventually pass. I am definitely not a fan of the current pain management fads such as identifying pain as a "5th vital sign," and really think this sort of pain scale is a poor substitute for patient assessment:

I suspect that those who have pain catastrophizing issues would routinely self-assess their pain levels as "above 10" on such a scale.

So what should we do? Should we try to identify patients who have a tendency to catastrophize their pain levels preoperatively? That would involve yet another set of screening questions that already take up way too much of the preop nurses' time, and would probably cast such a wide net that many patients would needlessly be labeled (as almost every patient entering the hospital is now labeled as having the potential sleep apnea; that's a rant for another day). Or should we add this as a diagnosis to those who exhibit these tendencies, which will hopefully allow a more aggressive approach at working with these patients during subsequent hospitalizations?

I'm not sure. I just know that we all see patients with this issue, and now at least I have a name with which to identify them.

Perhaps until some regulatory body passes a decree mandating some new pain management rule, passing out these bumper stickers might be of some benefit, especially in the ED:

I am not...

I

am not

old enough

to have a

21 year old daughter today!

The OR Rorschach Test #8

For today's quiz, you need to be old enough to have read classic children's books, and young enough (at heart) to recognize a character:

OK, after searching high and low, I now realize that Curious George was never drawn with a tail, but c'mon ---

--- if you are as old as I am, you gotta think Curious George when you see a monkey shape! Besides, Cheeta never played the piano, and though the Barenaked Ladies sing about chimpanzees, there's not actually one playing an instrument in their video.

Any other ideas?

Snow White, RN and the Seven Surgeons

Once upon a time, there was a princess who lived on the hospital surgical ward named Snow White, RN. She was beautiful, cheerful, helpful, efficient, and a damn good nurse. She took great care of her patients, and expected the same level of care from her compatriots. Naturally, that meant that she ran afoul the wicked witch, AKA the Queen Nurse, RN, BSN, PhD, QRS, ABC, etc. Fearing her independence and strengths, the Queen refused to promote Snow White, RN, to management. Every day, she would peer into her Blackberry to ask "who is the ablest one of all who has filled in the most EBN matrix forms, completed the most forms on the EMR system, answered every question on the staff survey correctly, and doesn't ask "Who is that" on my semi-annual trips to the ward." Never seeing Snow White's name on the Blackberry, she was pleased; she did not need Snow White's heart in a jeweled box, because she was boxed in. (image source)

Snow White, RN was not pleased, and sought another position. The HR department, despite being warned by the Queen Nurse, had a moment of weakness and directed her to flee to the woods Operating Room. Lost and frightened, Snow White, RN was befriended by creatures who rarely ventured beyond the OR -- scrub techs, CNAs, anesthesia techs, PACU nurses and operating room RNs. The friendly staff showed her around, and she soon discovered a room deep in the woods OR. Finding seven scruffy chairs, crumbs on the floor, spilled soda, half-eaten pizza, a table with coffee stains resembling an ancient mozaic, and a TV permanently tuned to ESPN, she assumed the room was an adjunct of the frat house at the local university.

But it soon became apparent to Snow White, RN that the room was the surgeons' lounge, occupied daily by seven surgeons --- Doc, Grumpy, Happy, Sleepy, Bashful, Sneezy, and Dopey? Er, not exactly:

Dick Doc is the, well, you know...

Grumpy old Bastard is the general surgeon in his late 50s who has never seen an OR run more inefficiently, has never seen a room turnover in less than an hour, and looks like the barnacle encrusted crab that he is.

Hippie is the laid back surgeon who listens to Tales From Topographic Oceans during surgery. Thought he'd look like The Dude when he got to be 50, but looks a bit more like this dude instead.

Sleepy is the trauma surgeon who lives by the motto "Don't walk when you can ride the elevator, don't stand when you can sit down, don't sit down when you can lay down, and don't lay down when you can sleep." He enjoys a cozy relationship with the recliner in the surgeon's lounge; the anesthesiologists can tell him from the OB sleeping next to him by counting snorts per minute.

Brashful is the young general surgeon just out of training, full of piss, vinegar, and opinions. Sometimes wrong, but never in doubt.

Sleazy is the surgeon who is working -- hard -- on his third divorce; also known to the staff as "Dr. Winky" or "Dr. Pinchmeister." Never got the memo about sexual harassment in the workplace; thinks gold chains aren't just a fashion accessory, they are a lifestyle.

Mopey is the general surgeon who (according to him) just can't seem to catch a break. His cases never start on time, always run late, are always harder than everybody else's cases, and never seem to be elective. He'd hire Eeyeore as a personal life coach if he just got enough time off call....(deep sigh).

As for Prince Charming, Snow White, RN never found him in the surgeons' lounge. She wised up and met a nice cardiologist who swept her off her feet and took her away to live happily ever after.....working in his office with no night call, no medication reconciliation forms, no admission and discharge matrix forms, and no weekends!

Billing Fraud or Documentation Errors?

I'm not really sure where it came from. Perhaps it started during medical school, where I funded dates with SWIMBO by typing lecture notes ($30 a pop for the shared lecture note service). Maybe it came later, trying to understand a patient's prior hospitalization reading someone else's notes that were so cryptic Mr. Turing would have had difficulty sorting through them. Regardless, I am sort of compulsive about documentation of my interactions with patients --- histories are always dictated as soon as I see a patient, operative notes are dictated as soon as I have spoken with the patient's family, etc. Even if I check on a (sick) patient half a dozen times during the day, I always leave a brief note in the chart.

There are two reasons to be compulsive about medical record keeping: [1] to provide a clear trail of a patient's course of care, as well as the thought process that led to it; and [2] to protect myself in the possibility of a lawsuit --- the adage in medical malpractice cases is that "if it isn't documented, it didn't happen."

A third, and more troublesome to deal with, reason to be anal-compulsive about documentation is to be compliant with Medicare's billing regulations. The billing process involves a tangled mess of diagnostic (ICD9-CM) and treatment (CPT) codes that must align accurately to get the government (or insurance company) to cut you a check. Sounds simple --- you arrive in the office with uncomplicated gallstones (ICD code 574.10) and episodic right upper abdominal pain 789.01), I see you and schedule you for a laparoscopic cholecystectomy (CPT 47562). Assuming you are fairly healthy, most of the visit is taken up by discussing gallstone disease, treatment options, and the risks associated with surgery or observation. If you are not so healthy --- have heart disease, diabetes, a history of blood clots, etc. --- I gotta

think a bit more about how to care for you. Common sense would dictate that the healthier person with gallstones would be charged a lower level office visit than the sicker patient with the same problem, but getting paid for that service is not really common sense. In order to ensure that I get paid, I have to document a large amount of information; unfortunately, much of the documentation required is as useless to the patient's care as a wristwatch is to a pig.

Here is the 51 page document laying out the requirements for each "level" of evaluation and management charge. If it looks a bit silly and even contradictory in areas.....it is IMNSHO. It also forms the focus for a big chunk of electronic medical record systems, which can automate the process of documenting the large number of "negative" systems reviews and physical findings that patients have (which have nothing to do with their care or presenting problem), all required to make sure that your office note aligns with the bill for the patient's visit.

Because it is easier to measure, regulate, fold, spindle, and mutilate the documentation and billing part of medicine than actually measuring quality of care, there is a significant effort expended to prevent physicians from overbilling for patient care. From the OIG web site:

Because the Government invests so much trust in physicians on the front end, Congress provided powerful criminal, civil, and administrative enforcement tools for instances when unscrupulous providers abuse that trust. The Government has broad capabilities to audit claims and investigate providers when it has a reason to suspect fraud. Suspicion of fraud and abuse may be raised by irregular billing patterns or reports from others, including your staff, competitors, and patients. When you submit a claim for services performed for a Medicare or Medicaid beneficiary, you are filing a bill with the Federal Government and certifying that you have earned the payment requested and complied with the billing requirements. If you knew or should have known that the submitted claim was false, then the attempt to collect unearned money constitutes a violation. A common type of false claim is “upcoding,” which refers to using billing codes that reflect a more severe illness than actually existed or a more expensive treatment than was provided.

So, American physicians daily go through the exercise of trying to document properly --- not completely for patient care, but to make sure we can get paid for the care we deliver and to make sure that CMS can't come after us for improper billing. It's kind of like playing Jenga, but instead of pulling out blocks, each patient bill can be something that brings your whole practice down.

Of course, I have read about several instances where unscrupulous physicians have bilked the government out of substantial amounts of money; I like the idea that they are caught and prosecuted. But like most law abiding physicians, I am nervous about the idea that the government has created a system more Byzantine than the IRS with the potential to make any physician that is audited a criminal, because it is pretty dang difficult to document well enough to satisfy a government auditor who has never taken care of a patient.

Oh. One more thing. This process just got worse:

It has created a new interagency task force called HEAT (Health Care Fraud Prevention and Enforcement Action Team) under which health-care officials will collaborate with the FBI to go after Medicare fraud. In addition, it has expanded to several cities the Medicaid Fraud Strike Force that authorizes FBI and Drug Enforcement Agency agents to jointly analyze Medicare claims data in real time to detect and investigate irregularities by area doctors. More chillingly, however, the administration is defining Medicare fraud down to include “unnecessary” and “ineffective” care. And to root this out, it plans to make expanded use of private mercenaries—officially called Recovery Audit Contracts—who will be authorized to go to doctors’ offices and rummage through patients’ records, matching them with billing claims to uncover illicit charges. What’s more, Obamacare increases the fine for billing errors from $11,000 per item to $50,000 without the government even having to prove intent to defraud.

That doesn't give me warm and fuzzies about "single payer" health care delivery in this country.

What a difference 1/6th of a day makes

A spectacular day in Colorado today ---- more accurately, a spectacular morning. When the sun is shining, 30 degrees feels like 50, letting Fat Boy get out for a little ride. This photo was taken at 10:00 this morning:


This afternoon --- not so spectacular. The view from my window right now, 4 hours after my ride:

And the forecast for tonight....

Thu

36° | -4°

If I can ride my bike, walk my dog, and ski in the same week, I'll take it!

The OR Rorschach Test #7

For your viewing pleasure, or puzzlement, today's OR Rorschach Test ---

I spy.....a rounded schnozz and a huge chin. This guy perhaps?

As for me, I think I'd go with Marv from Sin City:

Who's with me?

The OR Rorschach Test #6

Today's pop quiz --- what can you make of this OR Rorschach?

Not much there, unless you have an active imagination (or unless you take these home from the operating room for study with a nicely chilled martini). I can see eyes -- slits with shadowed eyes really. And a face shrouded by something....gauze perhaps? Got it - Darkman!

Bad (über-bad, IMHO) movie, but a good image match. Any questions?

The OR Rorschach Test #5

Quiz time! Here's the OR Rorschach Test for today --- what do you see?

Droopy nose? Check.

Big round eye(s)? Check

Indistinct features otherwise? Check.

Ladies and gentleman, looks like we've bagged a Snuffleupagus!

As always, your image interpretation mileage may vary.

Operating Better, With Electricity!

Sharp knives. Sutures. Hot lights and warm blood. Great music. That's what most folks picture when thinking about operating rooms. It's easy to overlook that we make use of plain old electrical energy in the OR --- electrosurgery. Sounds like something from a '50s SciFi novel. Perhaps a gift from the Red Lectroids from the 8th dimension?

Actually, the modern era of electrosurgery started in 1926, courtesy of Dr. William Bovie, a physicist, and Dr. Harvey Cushing, the father of neurosurgery in the US. The term "Bovie" is still standard jargon for the electrosurgical generator used in surgery, though most surgeons are only casually aware of its origins (there is a fair amount of history here and here, for those interested; image from Medscape). Me? Back in the dark ages, when (general, non-GYN) laparoscopic surgery was undergoing rapid growth and research opportunities abounded, I spent a year doing research, teaching laparoscopic surgery courses, and writing papers & book chapters. There had been considerable debate about the relative merits of using laser energy versus electrosurgery in laparoscopic gallbladder removal, and I landed the plum job of writing one of the papers that helped relegate laser laparoscopic cholecystectomy to the dustbin. Of course, as these things go, I also had many more writing assignments, including a book chapter entitled "Endoscopic Technology" for a book about laparoscopic and endoscopic surgery.

Let's just say, for someone who struggled to remember everything his father taught him about wiring a house, I learned quite a bit about electricity to write that chapter. And I learned even more about the potential for patient safety problems when using electrosurgery. For simplicity, though, the best way to think about electrosurgery is to picture a complete electrical circuit (image source):

Any interruption in the circuit results in cessation of the flow of electrical energy (electrons). In the operating room, the "battery" is the electrosurgical generator, and rather than lighting a lamp, the energy is focused in the tip of an instrument, resulting in heat and tissue destruction, also called diathermy, where it is focused.

OK, wait a minute. The generator is connected to the instrument, which is supposed to deliver electrical energy. But that doesn't make a complete circuit --- where is the rest of the circuit connecting back to the generator?

Well, a big chunk of the circuit is made, just like Soylent Green, of people! More accurately, of one person -- the patient --, to whom is attached a grounding pad (the passive electrode) that then connects back to the generator. Voila! A complete circuit is made, allowing high current density produced at the tip of the instrument (the active electrode) to cut and cauterize tissue.

So what's different about using electrosurgery in laparoscopy? Well, a couple of things. First, we must use long instruments to reach the operative field, with an active electrode only at the tip of some of them. Second, those instruments must pass through trocars that maintain a seal to prevent the escape of CO2 from the inflated abdomen. And finally, we use a non-insulated telescope attached to a video camera to view what is happening in the operative field. As a result, there are many places where electricity may end up flowing other than where it is intended to be focused. If the active electrode/cautery tip is activated against an uninsulated portion of another instrument, tissue that is in contact with that instrument can be injured. If the cautery tip is activated out of view of the camera, it can result in unrecognized tissue injury. And there is a more complex problem called capacitive coupling, unique to laparoscopic surgery, that can result in tissue injury.

Perhaps the most pernicious risk, however, is insulation failure. Because we want action only at the tip of the active electrode, the remainder of the length of the instrument is insulated to prevent "leakage" of electricity ---- which can cause a tissue burn when the shaft of the instrument is laying against, for example, a piece of bowel, well out of view of the operative field. That risk, I have always felt, can be eliminated by using disposable rather than reusable cautery instruments. Additionally, the other instruments not actively delivering electrical injury may have insulation defects, and can similarly cause injury if they are used in contact with the active electrode/cautery.

Looks like I may be right for a change --- Insulation failure in laparoscopic instruments is a study published in Surgical Endoscopy earlier this year (unfortunately no unregistered access to article or abstract). Basically, the authors looked at reusable and disposable laparoscopic instruments used to deliver electrical energy and tested them for insulation defects. From the abstract:

Two hundred twenty-six laparoscopic instruments were tested (165 reusable). Insulation failure occurred more often in reusable (19%; 31/165) than in disposable instruments (3%; 2/61; p less than 0.01). When reusable sets were evaluated, 71% (12/17) were found to have at least one instrument with insulation failure. Insulation failure incidence in reusable instruments was similar between hospitals that routinely checked for insulation failure (19%; 25/130) and hospitals that do not routinely check for insulation failures (33%; 7/21; p = 0.16). Insulation failure was most common in the distal third of the instruments (54%; 25/46) compared to the middle or proximal third of the instruments (p less than 0.05).

Hmmm. One in five reusable instruments was found to have an insulation failure. Cue The Doors:

Five to one, baby
One in five
No one here gets out alive, now
You get yours, baby
I'll get mine
Gonna make it, baby
If we try

Hold on. If this was a humongous problem, wouldn't general surgeons be seeing electrosurgical injuries from laparoscopic surgery on a weekly basis? Yep. And we don't. Perversely, I would say that is a bit of an issue ---- because this is seen very rarely, it is something about which one may be less than vigilant.

From my standpoint, I have a few things I insist upon when doing laparoscopic surgery; most importantly, I will only use disposable cautery instruments, as they are heavily used and most prone to insulation failure. Secondly, I don't use any other instruments to help deliver electrical energy/cautery; in open surgery, we frequently pick up a small bleeding vessel with a pair of forceps and then deliver the cautery against the forceps, delivering the electricity through them to the tissue that they hold --- for me, an absolute never in laparoscopic surgery. Finally, when appropriate I use alternate methods of delivering energy to tissues --- bipolar electrosurgery (that's another post) or high frequency ultrasonic energy most commonly.

In the end, the problem associated with insulation failure is really no different than many other potential pitfalls in medicine --- being well aware of the potential problem is the best method of its prevention.