- Email: [email protected]
The hazards of electrosurgery
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II
The hazards of electrosurgery
Electrosurgery plays a role in nearly every dermatologic practice. The traditional Birtcher Hyfrecator and other high-frequency electrosurgical devices are office staples for dermatologists and numerous other medical specialists. These instruments are often viewed as trusted old friends who have proved their merit and safety by the test of time. However, we occasionally need to scrutinize our methods because the fact that we have had no problems does not necessarily imply that we are practicing with satisfactory standards of safety. What are the risks of electrosurgery? Two aspects of this issue need to be addressed. First, we must consider electrical and other risks to the patient. Second, we must consider the potential risks to the treating physician. This latter concern is relatively new to most practitioners. There is an increasing concern about the potential patient risk of contamination from electrosurgical treatment electrodes. This is largely due to the acute awareness of the risks of hepatitis and acquired immunodeficiency syndrome (AIDS). ~ As a result, several solutions have been offered. ~_.3 Many dermatologists use only disposable or resterilizable electrosurgical electrodes and cords. Others use handles that will accept sterile hypodermic needles, which can be discarded after use on each patient. 4 However, the majority of dermatologists still use a standard Birtcher Hyfrecator or similar electrosurgical generator with a reusable electrode, which is not sterilized and, at best, is only wiped with alcohol between procedures. Alcohol is a very marginal antiseptic when used in this manner? Is this an acceptable standard of care? This is a difficult question to answer. Many practitioners believe that the portion of the treatment electrode in contact with the patient is sterilized by the elecReprint requests to: Dr, Jack E, Sebben, 3009 K St., Suite 202, Sacramento, CA 95618.
trical energy passing through it. This may be true, but no studies have confirmed this self-sterilization concept. Picture an anxious patient sitting on a dermatologist's examination table waiting to have a seborrheic keratosis removed. Perhaps this patient works in the hospital operating room and is very well acquainted with the principles of asepsis. After nervously glancing at the Hyfrecator electrode tip that is encrusted with black char, the patient may ask, "Is that going to be used on me?" Is this dermatologist given the same level of respect as the surgeon observed using strict sterile technic in the operating room? The recent article in this journal by Sherertz et al 6 addresses the risks of hepatitis transmission from superficial electrodesiccation. This study does show that the hepatitis B virus can be transferred by an electrosurgical electrode, but this is not the key question that the practitioner needs to have answered. High-frequency electrical current does not generate any heat in the electrode. The heat and destruction occur in the tissue in the immediate area of the tip. The real question is whether or not a sterile electrode can transfer microorganisms from a contamined treatment site to another noncontaminated treatment site. In other words, does electrodesiccation sterilize the tissue at the point of electrode contact? The results of the study by Sherertz et al do not answer this specific question, but the article does focus muchneeded attention on an important subject for all dermatologists. The latest development in the risk factors associated with electrosurgery has been consideration for the physician. Physicians have become increasingly aware of the risks of exposure to hepatitis B. This has resulted in increased glove and mask usage by dermatologists for surgical procedures. 7 However, the risk of hepatitis B exposure from electrosurgery has been relatively overlooked. As electrodesiccation is being performed
869
870
Journal of the American Academy of Dermatology
Sebben
on tissue, small areas of moisture are vaporized, and the resulting gas expansion gives rise to an aerosol of blood droplets. These may travel a distance o f many centimeters and could be inhaled by the treating physician, s Dermatologists who doubt this aerosol effect should examine their hands after doing a procedure involving extensive electrodesiccation. It is easy to find numerous pinpoint blood stains. These are the larger visible droplets. What about the airborne microdroplets that are too small to be seen but are of sufficient size to carry hepatitis or AIDS? A long-standing debate on the subject of patient risk is the effect of high-frequency electrosurgical devices on patients who have cardiac pacemakers. There have been reports o f dangerous interactions in the past, ')'~° but these reports were about patients with the older model pacemakers who were subjected to levels of current not usually used by dermatologists. Modern pacemakers are quite resistant to outside electrical influence. ~ Guidelines for treating pacemaker patients have already been reviewed and it appears that there are very few risks if the practitioner observes established precautions. ~2.~3 For years many practitioners have avoided using electrosurgery on superficial lesions because of the risk o f hypertrophic scarring. With the advent of laser therapy, we are told that lasers tend to produce much less scarring than conventional electrosurgery. ~4,~5Because o f the increasing popularity of lasers, many practitioners have rediscovered electrosurgery. Perhaps we may find that when used with the same skillful approach, the differences between the effects of electrosurgery and laser surgery may be small. Time and comparative studies may provide some answers, t6 Smoke production from electrosurgery has recently been identified as a potential hazard for the physician. The amount of smoke and odor produced by normal electrodesiccation and electrocoagulation is usually no more than a minor annoyance. When very large areas are treated by electrodesiccation or when cutting current is used for large lesions, there may be a considerable amount of smoke and disagreeable odor. Animal studies have been performed with the smoke produced by electrosurgery. ~7 It has been shown that the smoke produced has a mutagenic potential.
This mutagenicity was determined to be comparable to that of cigarette smoke. The amount of smoke produced by the electrosurgical destruction of 1 gm of tissue has been estimated to be the equivalent of that produced by six to twelve cigarettes in terms of mutagenicity. This risk can easily be avoided by using some form of smoke evacuation. As in many fields of endeavor, we are left with many questions but few answers. However, an awareness of potential risks may change our actions sufficiently to decrease the hazards for physicians and patients alike. Guidelines have been established for the safe use of electrosurgical equipment.~8-2° Many of the guidelines apply to the use of high-output generators that are often used in hospital operating rooms. However, most of the same safety principles apply to the use of low-output generators in the private office. SAFETY GUIDELINES
1. The electrosurgical equipment should be in perfect working order. If the power output has been intermittent or of varying intensity, the machine should be serviced by a qualified technician. If the equipment has lights or audible tones associated with power activation, they should function appropriately. 2. All electrosurgical equipment should be properly grounded at the power source. A "cheater" plug that eliminates the grounding prong should never be used. 3. The electrode wire should be intact and show no signs of wear or damage. These wires should not be coiled because even a few coils may create enough electric impedance to alter the power output. 4. The treatment electrode should be clean and free of any charred material. To eliminate the risk of patientto-patient transfer of infection, the physician should consider the use of sterilized or disposable sterile electrosurgical electrodes. Adapters are available that allow the use of disposable hypodermic needles as electrodes.4 5. If a dispersive electrode is used, it should be clean, smooth, and free of any ridges. It should be placed against an area of clean, dry skin with uniform contact to a large skin surface area. It is best if the dispersive plate is as close to the operative site as possible. 2~It should not be placed over bony prominences, hairy areas, or scar tissue. It should not be in contact with any conductive surfaces other than the patient's
Volume 16 Number 4 April 1987
skin. There should be no contact with an earthed ground. 6. It is desirable to have the treatment table isolated from an earthed ground. This is not the case with most of the power examination tables used in private offices. This may not pose much of a hazard, but at the very least, the patient should be carefully placed so that there is no skin contact with conductive surfaces of the table. In addition, the patient should not be in contact with any other grounded electrical equipment or fixtures. If the examination or treatment table is equipped with a power outlet, the electrosurgical unit should not be plugged into this outlet. Both pieces of equipment may have different degrees of isolation from an earthed ground. 7. The patient should never be connected to any monitored equipment using needle electrodes while electrosurgery is being performed. If other forms of conductive electrodes are used on the patient, such as gel-impregnated electrocardiogram monitors, it is preferable to have these electrodes at a greater distance from the surgery site than the dispersive electrode for the electrosurgical unit. 8. Electrosurgery should never be perfbrmed on a patient who is in contact with an electric blanket or other form of heating pad. This is not likely to occur in the private office but could be overlooked when performing an electrosurgical procedure on a hospitalized patient in a hospital room. 9. Some electrosurgical units require the use of a dispersive electrode plate for proper operation. Sometimes these are incorporated with an incomplete-circuit alarm system. This is an excellent feature but may give a false sense of security. These alarm systems usually only monitor the competency of the electrical circuit between the machine and the dispersive electrode plate. They do not monitor the degree of skin contact between the patient and the plate. 10. Alcohol or any other flammable material should never be in close proximity to the electrosurgery treatment site. if an alcohol-based prep has been used, all alcohol-soaked sponges must be removed from the field. !n addition, there should be no residual antiseptic on the skin surface. 11. Electrosurgery should not be used in the presence of high concentrations of oxygen or other flammable gases. Patients with portable oxygen generators should have the oxygen flow briefly interrupted while electrosurgery is performed? 2 Caution is also necessary when electrosurgery is used in the treatment of anal warts because of the flammability of bowel gases, z~ 12. A fire extinguisher should always be available in any office where electrosurgery is being performed.
Hazards of electrosurgery
871
Liquid fire extinguishers should never be used on electrical fires. Many of the commonly used fire extinguishers deliver a fire-retardant powder. This is not acceptable for use around an open surgical wound. A fire extinguisher should be selected that delivers a nontoxic fire-retardant gas. 13. Cardiac pacemaker patients who are stable may be safely treated with light e!ectrodesiccation. The current should be limited to short bursts of less than 5 seconds. The cardiac status should be monitored with peripheral pulse. Cutting current usually involves higher power settings in prolonged bursts and should be avoided in pacemaker patients outside the hospital setting. ~'~
Jack E. Sebben, M.D., Sacramento, CA REFERENCES 1. Smith JG Jr, Chalker DK Jr, Should dermatologists be immunized against hepatitis B? J AM ACADDERMATOL 1983;8:252-4. 2. Stoner JG, Swanson NA, "Cargo N. Penrose sleeve. J Dermatol Surg Oncol 1983;9:523-4. 3. Sebben JE. Electroeoagulation in a sterile surgical field. J Dermatol Surg OncoI 1984;10:603-4, 4. Stegman S J, Tromovitch TA, Glogau RG. The Bernsco adapter. J Dermatol Surg Oneol 1984;10:680-1. 5. Sebben JE. Surgical antiseptics. J AM ACADDERMATOL 1982;9:759-65. 6. Sherertz EF, Davis GL, Rice RW, Harris BA, Franzini DA. Transfer of hepatitis B virus by contaminated reusable needle electrodes after electrodesiccation in simulated use, J AM ACAO DERMATOL1986;15:1242-6. 7. Smith JR Jr, Chalker DK Jr, A glove upon that hand. South Med J 1982; 15:129-31, 8. Berberian BJ, Bumett JW. The potential role of common dermatologic practice technics in transmitting disease [letter]. J AM ACADDERMATOL1986;15:1057-8. 9. O'Donoghue JK. inhibition of a demand pacemaker by electrosurgery, Chest 1973;64:664-6. t0. Schwingsehackl H, Maurer R, Amor H. Interfering influence of low frequency alternating currents on asynchronous and controlled pacemaker systems during the use of electrosurgical devices. Schweiz Med Wochenschr 1971;101:46-52. 11. Schultz W. Transurethral electro-resection in patients with cardiac pacemakers. Urologe !979;18:247-9. 12. Krull EA, Pickard SD, Hall JC. Effects of electrosurgery on cardiac pacemakers. J Dermatol Surg Oncol 1975; 1:43-5. 13. Sebben JE. Electrosurgery and cardiac pacemakers. J A~ ACAD DERMA'roL1983;9:457-63. 14. Bailin PL. Lasers in dermatology--1985. J Derrnatol Surg Oncol 1985;11:328-34. 15. Castro DJ, Abergel RP, Johnson K J, et al. Wound healing: biological effects of Nd: YAG laser on collagen metabolism in pig skin in comparison to thermal burn. Ann Plast Surg 1982;11:131-40. 16. Fry TL, Gerbe RW, Botros SB, Fischer ND. Effects of laser, scalpel, and electrosurgical excision on wound con-
Journal of the American Academy of Dermatology
Sebben
tracture and graft "take." Plast Reconstr Surg 1980; 65:729-3 l. 17. Tomita Y, Mibashi S, Nagata K, et al. Mutagenicity of smoke condensates induced by CO2-1aser irradiation and electrocauterization. Mutat Res 1981;89:145-9. 18. Recommended practices: e[ectrosurgery. AORN J 1985; 41:633-41. 19. Watson AB, Loughman J. The surgical diathermy: principles of operation and safe use. Anaesth Intensive Care 1978;6:310-21.
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II
I
I
20. Lawson BN. A nurse's guide to electrosurgery. AORN J 1977;25:314-29. 21. Neufeld GR, Foster KR. Electrical impedence properties of the body and the problem of alternate site burns during electrosurgery. Med Instrum 1985;19:83-7. 22. Pearce J. Current electrosurgical practice: hazards. J Med Eng Technol 1985;9:107-11. 23. Miller JM. Explosion in sigmoid colon after cauterization. Va Med 1980;107:296-7.
• I
III
II
Ill Iltll
III II
Medical isolationism The potential exists for the United States to enter a period of medical isolationism whereby its substantial expertise in medical education and training cannot be shared with other nations. The reasons this unfortunate possibility has arisen are analyzed. The impending oversupply of physicians has been a matter of great concern to many in the medical profession and to a number of health policy experts. One important contributory factor to the physician oversupply has been the continuing influx of foreign medical graduates. At this time 112,005 (21.6%) of the 519,545 licensed physicians in the United States received their medical degrees in foreign countries, and, as of 1983, 13,221 (18.3%) of the 72,397 residents in training in the United States were foreign medical graduates. t This figure had decreased to 16.8% in 1985. Furthermore, the 12,509 foreign medical graduates in training in 1985 represents a 6% decrease from 1984 and an 11% decrease in first-year positions. 2 Of this group 6,149 (46.5%) were alien foreign medical graduates and 7,072 (53.5%) were United States citizens educated in foreign medical schools. To some extent, the heavy influx of foreign medical graduates represents a holdover from previous United States immigration policy. In 1965, the Congress bestowed preferential immigration status upon alien physicians because of Reprint requests to: Dr. Peyton E. Weary, Department of Dermatology, University of Virginia Medical Center, Box 134, Charlottesville, VA 22908.
872
a perceived shortage of physicians in this country. In 1970, the immigration laws were further amended to permit alien foreign medical graduates who were here on exchange visitor visas to receive permanent resident status without having to return to their countries of origin for the customary 2-year period prior to application for such status. In time it became increasingly apparent that this influx of alien foreign medical graduates was no longer needed and, in fact, might prove detrimental not only because of a potential oversupply of physicians practicing in the United States but also because it removed productive citizens from other countries. Therefore, in 1976, the Congress passed Public Law 94-484, rescinding the preferential status and reestablishing the 2-year exclusionary provision. Since that time there has been a substantial reduction in the number of alien foreign medical graduates but many alien physicians continue to enter the United States on visas issued under family and other preferential status, including refugee status. Furthermore, there has been an extraordinary increase in the number of United States citizens who have sought medical education in foreign countries and who then have returned to the United States for residency training to permit them to enter the physician work force here. In response to this demand to educate United States citizens who were not admitted to United States medical schools, a number of off-shore proprietary medical schools were created in the Caribbean basin and Mexico.
I
II
I
I
I I
II
The hazards of electrosurgery
Electrosurgery plays a role in nearly every dermatologic practice. The traditional Birtcher Hyfrecator and other high-frequency electrosurgical devices are office staples for dermatologists and numerous other medical specialists. These instruments are often viewed as trusted old friends who have proved their merit and safety by the test of time. However, we occasionally need to scrutinize our methods because the fact that we have had no problems does not necessarily imply that we are practicing with satisfactory standards of safety. What are the risks of electrosurgery? Two aspects of this issue need to be addressed. First, we must consider electrical and other risks to the patient. Second, we must consider the potential risks to the treating physician. This latter concern is relatively new to most practitioners. There is an increasing concern about the potential patient risk of contamination from electrosurgical treatment electrodes. This is largely due to the acute awareness of the risks of hepatitis and acquired immunodeficiency syndrome (AIDS). ~ As a result, several solutions have been offered. ~_.3 Many dermatologists use only disposable or resterilizable electrosurgical electrodes and cords. Others use handles that will accept sterile hypodermic needles, which can be discarded after use on each patient. 4 However, the majority of dermatologists still use a standard Birtcher Hyfrecator or similar electrosurgical generator with a reusable electrode, which is not sterilized and, at best, is only wiped with alcohol between procedures. Alcohol is a very marginal antiseptic when used in this manner? Is this an acceptable standard of care? This is a difficult question to answer. Many practitioners believe that the portion of the treatment electrode in contact with the patient is sterilized by the elecReprint requests to: Dr, Jack E, Sebben, 3009 K St., Suite 202, Sacramento, CA 95618.
trical energy passing through it. This may be true, but no studies have confirmed this self-sterilization concept. Picture an anxious patient sitting on a dermatologist's examination table waiting to have a seborrheic keratosis removed. Perhaps this patient works in the hospital operating room and is very well acquainted with the principles of asepsis. After nervously glancing at the Hyfrecator electrode tip that is encrusted with black char, the patient may ask, "Is that going to be used on me?" Is this dermatologist given the same level of respect as the surgeon observed using strict sterile technic in the operating room? The recent article in this journal by Sherertz et al 6 addresses the risks of hepatitis transmission from superficial electrodesiccation. This study does show that the hepatitis B virus can be transferred by an electrosurgical electrode, but this is not the key question that the practitioner needs to have answered. High-frequency electrical current does not generate any heat in the electrode. The heat and destruction occur in the tissue in the immediate area of the tip. The real question is whether or not a sterile electrode can transfer microorganisms from a contamined treatment site to another noncontaminated treatment site. In other words, does electrodesiccation sterilize the tissue at the point of electrode contact? The results of the study by Sherertz et al do not answer this specific question, but the article does focus muchneeded attention on an important subject for all dermatologists. The latest development in the risk factors associated with electrosurgery has been consideration for the physician. Physicians have become increasingly aware of the risks of exposure to hepatitis B. This has resulted in increased glove and mask usage by dermatologists for surgical procedures. 7 However, the risk of hepatitis B exposure from electrosurgery has been relatively overlooked. As electrodesiccation is being performed
869
870
Journal of the American Academy of Dermatology
Sebben
on tissue, small areas of moisture are vaporized, and the resulting gas expansion gives rise to an aerosol of blood droplets. These may travel a distance o f many centimeters and could be inhaled by the treating physician, s Dermatologists who doubt this aerosol effect should examine their hands after doing a procedure involving extensive electrodesiccation. It is easy to find numerous pinpoint blood stains. These are the larger visible droplets. What about the airborne microdroplets that are too small to be seen but are of sufficient size to carry hepatitis or AIDS? A long-standing debate on the subject of patient risk is the effect of high-frequency electrosurgical devices on patients who have cardiac pacemakers. There have been reports o f dangerous interactions in the past, ')'~° but these reports were about patients with the older model pacemakers who were subjected to levels of current not usually used by dermatologists. Modern pacemakers are quite resistant to outside electrical influence. ~ Guidelines for treating pacemaker patients have already been reviewed and it appears that there are very few risks if the practitioner observes established precautions. ~2.~3 For years many practitioners have avoided using electrosurgery on superficial lesions because of the risk o f hypertrophic scarring. With the advent of laser therapy, we are told that lasers tend to produce much less scarring than conventional electrosurgery. ~4,~5Because o f the increasing popularity of lasers, many practitioners have rediscovered electrosurgery. Perhaps we may find that when used with the same skillful approach, the differences between the effects of electrosurgery and laser surgery may be small. Time and comparative studies may provide some answers, t6 Smoke production from electrosurgery has recently been identified as a potential hazard for the physician. The amount of smoke and odor produced by normal electrodesiccation and electrocoagulation is usually no more than a minor annoyance. When very large areas are treated by electrodesiccation or when cutting current is used for large lesions, there may be a considerable amount of smoke and disagreeable odor. Animal studies have been performed with the smoke produced by electrosurgery. ~7 It has been shown that the smoke produced has a mutagenic potential.
This mutagenicity was determined to be comparable to that of cigarette smoke. The amount of smoke produced by the electrosurgical destruction of 1 gm of tissue has been estimated to be the equivalent of that produced by six to twelve cigarettes in terms of mutagenicity. This risk can easily be avoided by using some form of smoke evacuation. As in many fields of endeavor, we are left with many questions but few answers. However, an awareness of potential risks may change our actions sufficiently to decrease the hazards for physicians and patients alike. Guidelines have been established for the safe use of electrosurgical equipment.~8-2° Many of the guidelines apply to the use of high-output generators that are often used in hospital operating rooms. However, most of the same safety principles apply to the use of low-output generators in the private office. SAFETY GUIDELINES
1. The electrosurgical equipment should be in perfect working order. If the power output has been intermittent or of varying intensity, the machine should be serviced by a qualified technician. If the equipment has lights or audible tones associated with power activation, they should function appropriately. 2. All electrosurgical equipment should be properly grounded at the power source. A "cheater" plug that eliminates the grounding prong should never be used. 3. The electrode wire should be intact and show no signs of wear or damage. These wires should not be coiled because even a few coils may create enough electric impedance to alter the power output. 4. The treatment electrode should be clean and free of any charred material. To eliminate the risk of patientto-patient transfer of infection, the physician should consider the use of sterilized or disposable sterile electrosurgical electrodes. Adapters are available that allow the use of disposable hypodermic needles as electrodes.4 5. If a dispersive electrode is used, it should be clean, smooth, and free of any ridges. It should be placed against an area of clean, dry skin with uniform contact to a large skin surface area. It is best if the dispersive plate is as close to the operative site as possible. 2~It should not be placed over bony prominences, hairy areas, or scar tissue. It should not be in contact with any conductive surfaces other than the patient's
Volume 16 Number 4 April 1987
skin. There should be no contact with an earthed ground. 6. It is desirable to have the treatment table isolated from an earthed ground. This is not the case with most of the power examination tables used in private offices. This may not pose much of a hazard, but at the very least, the patient should be carefully placed so that there is no skin contact with conductive surfaces of the table. In addition, the patient should not be in contact with any other grounded electrical equipment or fixtures. If the examination or treatment table is equipped with a power outlet, the electrosurgical unit should not be plugged into this outlet. Both pieces of equipment may have different degrees of isolation from an earthed ground. 7. The patient should never be connected to any monitored equipment using needle electrodes while electrosurgery is being performed. If other forms of conductive electrodes are used on the patient, such as gel-impregnated electrocardiogram monitors, it is preferable to have these electrodes at a greater distance from the surgery site than the dispersive electrode for the electrosurgical unit. 8. Electrosurgery should never be perfbrmed on a patient who is in contact with an electric blanket or other form of heating pad. This is not likely to occur in the private office but could be overlooked when performing an electrosurgical procedure on a hospitalized patient in a hospital room. 9. Some electrosurgical units require the use of a dispersive electrode plate for proper operation. Sometimes these are incorporated with an incomplete-circuit alarm system. This is an excellent feature but may give a false sense of security. These alarm systems usually only monitor the competency of the electrical circuit between the machine and the dispersive electrode plate. They do not monitor the degree of skin contact between the patient and the plate. 10. Alcohol or any other flammable material should never be in close proximity to the electrosurgery treatment site. if an alcohol-based prep has been used, all alcohol-soaked sponges must be removed from the field. !n addition, there should be no residual antiseptic on the skin surface. 11. Electrosurgery should not be used in the presence of high concentrations of oxygen or other flammable gases. Patients with portable oxygen generators should have the oxygen flow briefly interrupted while electrosurgery is performed? 2 Caution is also necessary when electrosurgery is used in the treatment of anal warts because of the flammability of bowel gases, z~ 12. A fire extinguisher should always be available in any office where electrosurgery is being performed.
Hazards of electrosurgery
871
Liquid fire extinguishers should never be used on electrical fires. Many of the commonly used fire extinguishers deliver a fire-retardant powder. This is not acceptable for use around an open surgical wound. A fire extinguisher should be selected that delivers a nontoxic fire-retardant gas. 13. Cardiac pacemaker patients who are stable may be safely treated with light e!ectrodesiccation. The current should be limited to short bursts of less than 5 seconds. The cardiac status should be monitored with peripheral pulse. Cutting current usually involves higher power settings in prolonged bursts and should be avoided in pacemaker patients outside the hospital setting. ~'~
Jack E. Sebben, M.D., Sacramento, CA REFERENCES 1. Smith JG Jr, Chalker DK Jr, Should dermatologists be immunized against hepatitis B? J AM ACADDERMATOL 1983;8:252-4. 2. Stoner JG, Swanson NA, "Cargo N. Penrose sleeve. J Dermatol Surg Oncol 1983;9:523-4. 3. Sebben JE. Electroeoagulation in a sterile surgical field. J Dermatol Surg OncoI 1984;10:603-4, 4. Stegman S J, Tromovitch TA, Glogau RG. The Bernsco adapter. J Dermatol Surg Oneol 1984;10:680-1. 5. Sebben JE. Surgical antiseptics. J AM ACADDERMATOL 1982;9:759-65. 6. Sherertz EF, Davis GL, Rice RW, Harris BA, Franzini DA. Transfer of hepatitis B virus by contaminated reusable needle electrodes after electrodesiccation in simulated use, J AM ACAO DERMATOL1986;15:1242-6. 7. Smith JR Jr, Chalker DK Jr, A glove upon that hand. South Med J 1982; 15:129-31, 8. Berberian BJ, Bumett JW. The potential role of common dermatologic practice technics in transmitting disease [letter]. J AM ACADDERMATOL1986;15:1057-8. 9. O'Donoghue JK. inhibition of a demand pacemaker by electrosurgery, Chest 1973;64:664-6. t0. Schwingsehackl H, Maurer R, Amor H. Interfering influence of low frequency alternating currents on asynchronous and controlled pacemaker systems during the use of electrosurgical devices. Schweiz Med Wochenschr 1971;101:46-52. 11. Schultz W. Transurethral electro-resection in patients with cardiac pacemakers. Urologe !979;18:247-9. 12. Krull EA, Pickard SD, Hall JC. Effects of electrosurgery on cardiac pacemakers. J Dermatol Surg Oncol 1975; 1:43-5. 13. Sebben JE. Electrosurgery and cardiac pacemakers. J A~ ACAD DERMA'roL1983;9:457-63. 14. Bailin PL. Lasers in dermatology--1985. J Derrnatol Surg Oncol 1985;11:328-34. 15. Castro DJ, Abergel RP, Johnson K J, et al. Wound healing: biological effects of Nd: YAG laser on collagen metabolism in pig skin in comparison to thermal burn. Ann Plast Surg 1982;11:131-40. 16. Fry TL, Gerbe RW, Botros SB, Fischer ND. Effects of laser, scalpel, and electrosurgical excision on wound con-
Journal of the American Academy of Dermatology
Sebben
tracture and graft "take." Plast Reconstr Surg 1980; 65:729-3 l. 17. Tomita Y, Mibashi S, Nagata K, et al. Mutagenicity of smoke condensates induced by CO2-1aser irradiation and electrocauterization. Mutat Res 1981;89:145-9. 18. Recommended practices: e[ectrosurgery. AORN J 1985; 41:633-41. 19. Watson AB, Loughman J. The surgical diathermy: principles of operation and safe use. Anaesth Intensive Care 1978;6:310-21.
I
II
I
I
20. Lawson BN. A nurse's guide to electrosurgery. AORN J 1977;25:314-29. 21. Neufeld GR, Foster KR. Electrical impedence properties of the body and the problem of alternate site burns during electrosurgery. Med Instrum 1985;19:83-7. 22. Pearce J. Current electrosurgical practice: hazards. J Med Eng Technol 1985;9:107-11. 23. Miller JM. Explosion in sigmoid colon after cauterization. Va Med 1980;107:296-7.
• I
III
II
Ill Iltll
III II
Medical isolationism The potential exists for the United States to enter a period of medical isolationism whereby its substantial expertise in medical education and training cannot be shared with other nations. The reasons this unfortunate possibility has arisen are analyzed. The impending oversupply of physicians has been a matter of great concern to many in the medical profession and to a number of health policy experts. One important contributory factor to the physician oversupply has been the continuing influx of foreign medical graduates. At this time 112,005 (21.6%) of the 519,545 licensed physicians in the United States received their medical degrees in foreign countries, and, as of 1983, 13,221 (18.3%) of the 72,397 residents in training in the United States were foreign medical graduates. t This figure had decreased to 16.8% in 1985. Furthermore, the 12,509 foreign medical graduates in training in 1985 represents a 6% decrease from 1984 and an 11% decrease in first-year positions. 2 Of this group 6,149 (46.5%) were alien foreign medical graduates and 7,072 (53.5%) were United States citizens educated in foreign medical schools. To some extent, the heavy influx of foreign medical graduates represents a holdover from previous United States immigration policy. In 1965, the Congress bestowed preferential immigration status upon alien physicians because of Reprint requests to: Dr. Peyton E. Weary, Department of Dermatology, University of Virginia Medical Center, Box 134, Charlottesville, VA 22908.
872
a perceived shortage of physicians in this country. In 1970, the immigration laws were further amended to permit alien foreign medical graduates who were here on exchange visitor visas to receive permanent resident status without having to return to their countries of origin for the customary 2-year period prior to application for such status. In time it became increasingly apparent that this influx of alien foreign medical graduates was no longer needed and, in fact, might prove detrimental not only because of a potential oversupply of physicians practicing in the United States but also because it removed productive citizens from other countries. Therefore, in 1976, the Congress passed Public Law 94-484, rescinding the preferential status and reestablishing the 2-year exclusionary provision. Since that time there has been a substantial reduction in the number of alien foreign medical graduates but many alien physicians continue to enter the United States on visas issued under family and other preferential status, including refugee status. Furthermore, there has been an extraordinary increase in the number of United States citizens who have sought medical education in foreign countries and who then have returned to the United States for residency training to permit them to enter the physician work force here. In response to this demand to educate United States citizens who were not admitted to United States medical schools, a number of off-shore proprietary medical schools were created in the Caribbean basin and Mexico.