Commentary

Enterotomy can be a serious complication in abdominopelvic surgery, particularly if it is not immediately recognized and treated. Risk of visceral injury increases when complex dissection is required for treatment of cancer, resection of endometriosis, and extensive lysis of adhesions.

In a retrospective review from 1984 to 2003, investigators assessed intestinal injuries at the time of gynecologic operations. Of the 110 cases reported, about 37% occurred during the opening of the peritoneal cavity, 38% during adhesiolysis and pelvic dissection, 9% during laparoscopy, 9% during vaginal surgery, and 8% during dilation and curettage. Of the bowel injuries, more than 75% were minor.¹ Mortality from unrecognized bowel injury is significant, and as such, appropriate recognition and management of these injuries is critical.²

Methods of repair

The two main methods of bowel repair are primary closure and resection with re-anastamosis. The decision to employ each is influenced by multiple factors. Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. Additionally, resection and re-anastamosis should also be considered if the damaged segment of bowel has poor blood supply, integrity, or the repair would result in tension along the suture/staple line or luminal narrowing.

Simple small bowel closures

Serosal abrasions need not be repaired; however, small tears of the serosa and muscularis can be managed with a single layer of interrupted 3-0 absorbable or permanent silk suture on a tapered needle. The suture line should be perpendicular to the longitudinal axis of the bowel at 2-mm to 3-mm intervals in order to prevent narrowing of the lumen. The suture should pass through serosal and muscular layers in an imbricating (Lembert) stitch. For smaller defects of less than 6 mm, a single layer closure is typically adequate.

Small bowel resection

Some larger defects, thermal injuries, and segments with multiple enterotomies may be best repaired with resection and re-anastamosis technique. A segment of resectable bowel is chosen such that the afferent and efferent limbs to be re-anastamosed can be reapproximated in a tension-free fashion. A mesenterotomy is made at the proximal and distal portions of the involved bowel. A gastrointestinal anastomotic stapler is then inserted perpendicularly across the bowel. The remaining wedge of connected mesentery can then be efficiently excised with an electrothermal bipolar coagulator device ensuring that maximal mesentery and blood supply are preserved to the remaining limbs of intestine. The proximal and distal segments are then aligned at the antimesenteric sides.

Large bowel repair

Defects in the serosa and small lacerations can be managed with a primary closure, similar to the small intestine. For more extensive injuries that may require resection, diversion, or complicated repair, consultation with a gynecologic oncologist or general or colorectal surgeon may be indicated as colotomy repairs are associated with higher rates of breakdown and fistula. If fecal contamination is present, copious irrigation should be performed and placement of a peritoneal drain to reduce the likelihood of abscess formation should be considered. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.

Standard prophylaxis for hysterectomy (such as a first-generation cephalosporin like cefazolin) is not adequate for large bowel surgery, and either metronidazole should be added or a second-generation cephalosporin such as cefoxitin should be given. For patients with penicillin allergy, clindamycin or vancomycin with either gentamicin or a fluoroquinolone should be administered.⁶

Postoperative management

The potential for postoperative morbidity must be understood for appropriate management following bowel surgery. Ileus is common and the clinician should understand how to diagnose and manage it. Additionally, intra-abdominal abscess, anastomotic leak, fistula formation, and mechanical obstruction are complications that may require surgical intervention and must be vigilantly managed.

The routine use of postoperative nasogastric tube (NGT) does not hasten return of bowel function or prevent leak from sites of gastrointestinal repair. In fact, early feeding has been associated with reduced perioperative complications and earlier return of bowel function has been observed without the use of NGT.⁷ In general, for small and large intestinal injuries, early feeding is considered acceptable.⁸

Prolonged antibiotic prophylaxis, beyond 24 hours, is not recommended.⁶

Avoiding injury

Gynecologic surgeons should adhere to surgical principles with sharp dissection for adhesions, gentle tissue handling, adequate exposure, and light retraction to prevent bowel injury or minimize their extent. Laparoscopic entry sites should be chosen based on the likelihood of abdominal adhesions. When the patient’s history predicts a high likelihood of intraperitoneal adhesions, the left upper quadrant site should be strongly considered as the entry site. The likelihood of gastrointestinal injury is not influenced by open versus closed laparoscopic entry and surgeons should use the technique with which they have the greatest experience and skill.⁹ However, in patients who have had prior laparotomies, there is an increased risk of periumbilical adhesions, and consideration should be made for a nonumbilical entry site.¹⁰ Methodical sharp dissection and sparing use of thermal energy should be used with adhesiolysis. When injury occurs, prompt recognition, preparation, and methodical management can mitigate the impact.

Dr. Staley is a gynecologic oncology fellow at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.

References

1. Int Surg. 2006 Nov-Dec;91(6):336-40.

2. J Am Coll Surg. 2001 Jun;192(6):677-83.

3. Doherty, G. Current Diagnosis and Treatment: Surgery. Thirteenth Edition. New York: McGraw Hill, 2010.

4. Hoffman B. Williams Gynecology. Third Edition. New York: McGraw Hill, 2016.

5. Berek J, Hacker N. Berek & Hacker’s Gynecologic Oncology. Sixth Edition. Philadelphia: Wolters Kluwer, 2015.

6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156.

7. Br J Surg. 2005 Jun;92(6):673-80.

8. Am J Obstet Gynecol. 2001 Jul;185(1):1-4.

9. Cochrane Database Syst Rev. 2015 Aug 31;8:CD006583.

10. Br J Obstet Gynaecol. 1997 May;104(5):595-600.


 

Enterotomy can be a serious complication in abdominopelvic surgery, particularly if it is not immediately recognized and treated. Risk of visceral injury increases when complex dissection is required for treatment of cancer, resection of endometriosis, and extensive lysis of adhesions.

In a retrospective review from 1984 to 2003, investigators assessed intestinal injuries at the time of gynecologic operations. Of the 110 cases reported, about 37% occurred during the opening of the peritoneal cavity, 38% during adhesiolysis and pelvic dissection, 9% during laparoscopy, 9% during vaginal surgery, and 8% during dilation and curettage. Of the bowel injuries, more than 75% were minor.¹ Mortality from unrecognized bowel injury is significant, and as such, appropriate recognition and management of these injuries is critical.²

Methods of repair

The two main methods of bowel repair are primary closure and resection with re-anastamosis. The decision to employ each is influenced by multiple factors. Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. Additionally, resection and re-anastamosis should also be considered if the damaged segment of bowel has poor blood supply, integrity, or the repair would result in tension along the suture/staple line or luminal narrowing.

Simple small bowel closures

Serosal abrasions need not be repaired; however, small tears of the serosa and muscularis can be managed with a single layer of interrupted 3-0 absorbable or permanent silk suture on a tapered needle. The suture line should be perpendicular to the longitudinal axis of the bowel at 2-mm to 3-mm intervals in order to prevent narrowing of the lumen. The suture should pass through serosal and muscular layers in an imbricating (Lembert) stitch. For smaller defects of less than 6 mm, a single layer closure is typically adequate.

Small bowel resection

Some larger defects, thermal injuries, and segments with multiple enterotomies may be best repaired with resection and re-anastamosis technique. A segment of resectable bowel is chosen such that the afferent and efferent limbs to be re-anastamosed can be reapproximated in a tension-free fashion. A mesenterotomy is made at the proximal and distal portions of the involved bowel. A gastrointestinal anastomotic stapler is then inserted perpendicularly across the bowel. The remaining wedge of connected mesentery can then be efficiently excised with an electrothermal bipolar coagulator device ensuring that maximal mesentery and blood supply are preserved to the remaining limbs of intestine. The proximal and distal segments are then aligned at the antimesenteric sides.

Large bowel repair

Defects in the serosa and small lacerations can be managed with a primary closure, similar to the small intestine. For more extensive injuries that may require resection, diversion, or complicated repair, consultation with a gynecologic oncologist or general or colorectal surgeon may be indicated as colotomy repairs are associated with higher rates of breakdown and fistula. If fecal contamination is present, copious irrigation should be performed and placement of a peritoneal drain to reduce the likelihood of abscess formation should be considered. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.

Standard prophylaxis for hysterectomy (such as a first-generation cephalosporin like cefazolin) is not adequate for large bowel surgery, and either metronidazole should be added or a second-generation cephalosporin such as cefoxitin should be given. For patients with penicillin allergy, clindamycin or vancomycin with either gentamicin or a fluoroquinolone should be administered.⁶

Postoperative management

The potential for postoperative morbidity must be understood for appropriate management following bowel surgery. Ileus is common and the clinician should understand how to diagnose and manage it. Additionally, intra-abdominal abscess, anastomotic leak, fistula formation, and mechanical obstruction are complications that may require surgical intervention and must be vigilantly managed.

The routine use of postoperative nasogastric tube (NGT) does not hasten return of bowel function or prevent leak from sites of gastrointestinal repair. In fact, early feeding has been associated with reduced perioperative complications and earlier return of bowel function has been observed without the use of NGT.⁷ In general, for small and large intestinal injuries, early feeding is considered acceptable.⁸

Prolonged antibiotic prophylaxis, beyond 24 hours, is not recommended.⁶

Avoiding injury

Gynecologic surgeons should adhere to surgical principles with sharp dissection for adhesions, gentle tissue handling, adequate exposure, and light retraction to prevent bowel injury or minimize their extent. Laparoscopic entry sites should be chosen based on the likelihood of abdominal adhesions. When the patient’s history predicts a high likelihood of intraperitoneal adhesions, the left upper quadrant site should be strongly considered as the entry site. The likelihood of gastrointestinal injury is not influenced by open versus closed laparoscopic entry and surgeons should use the technique with which they have the greatest experience and skill.⁹ However, in patients who have had prior laparotomies, there is an increased risk of periumbilical adhesions, and consideration should be made for a nonumbilical entry site.¹⁰ Methodical sharp dissection and sparing use of thermal energy should be used with adhesiolysis. When injury occurs, prompt recognition, preparation, and methodical management can mitigate the impact.

Dr. Staley is a gynecologic oncology fellow at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.

References

1. Int Surg. 2006 Nov-Dec;91(6):336-40.

2. J Am Coll Surg. 2001 Jun;192(6):677-83.

3. Doherty, G. Current Diagnosis and Treatment: Surgery. Thirteenth Edition. New York: McGraw Hill, 2010.

4. Hoffman B. Williams Gynecology. Third Edition. New York: McGraw Hill, 2016.

5. Berek J, Hacker N. Berek & Hacker’s Gynecologic Oncology. Sixth Edition. Philadelphia: Wolters Kluwer, 2015.

6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156.

7. Br J Surg. 2005 Jun;92(6):673-80.

8. Am J Obstet Gynecol. 2001 Jul;185(1):1-4.

9. Cochrane Database Syst Rev. 2015 Aug 31;8:CD006583.

10. Br J Obstet Gynaecol. 1997 May;104(5):595-600.


 

Enterotomy can be a serious complication in abdominopelvic surgery, particularly if it is not immediately recognized and treated. Risk of visceral injury increases when complex dissection is required for treatment of cancer, resection of endometriosis, and extensive lysis of adhesions.

In a retrospective review from 1984 to 2003, investigators assessed intestinal injuries at the time of gynecologic operations. Of the 110 cases reported, about 37% occurred during the opening of the peritoneal cavity, 38% during adhesiolysis and pelvic dissection, 9% during laparoscopy, 9% during vaginal surgery, and 8% during dilation and curettage. Of the bowel injuries, more than 75% were minor.¹ Mortality from unrecognized bowel injury is significant, and as such, appropriate recognition and management of these injuries is critical.²

Methods of repair

The two main methods of bowel repair are primary closure and resection with re-anastamosis. The decision to employ each is influenced by multiple factors. Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. Additionally, resection and re-anastamosis should also be considered if the damaged segment of bowel has poor blood supply, integrity, or the repair would result in tension along the suture/staple line or luminal narrowing.

Simple small bowel closures

Serosal abrasions need not be repaired; however, small tears of the serosa and muscularis can be managed with a single layer of interrupted 3-0 absorbable or permanent silk suture on a tapered needle. The suture line should be perpendicular to the longitudinal axis of the bowel at 2-mm to 3-mm intervals in order to prevent narrowing of the lumen. The suture should pass through serosal and muscular layers in an imbricating (Lembert) stitch. For smaller defects of less than 6 mm, a single layer closure is typically adequate.

Small bowel resection

Some larger defects, thermal injuries, and segments with multiple enterotomies may be best repaired with resection and re-anastamosis technique. A segment of resectable bowel is chosen such that the afferent and efferent limbs to be re-anastamosed can be reapproximated in a tension-free fashion. A mesenterotomy is made at the proximal and distal portions of the involved bowel. A gastrointestinal anastomotic stapler is then inserted perpendicularly across the bowel. The remaining wedge of connected mesentery can then be efficiently excised with an electrothermal bipolar coagulator device ensuring that maximal mesentery and blood supply are preserved to the remaining limbs of intestine. The proximal and distal segments are then aligned at the antimesenteric sides.

Large bowel repair

Defects in the serosa and small lacerations can be managed with a primary closure, similar to the small intestine. For more extensive injuries that may require resection, diversion, or complicated repair, consultation with a gynecologic oncologist or general or colorectal surgeon may be indicated as colotomy repairs are associated with higher rates of breakdown and fistula. If fecal contamination is present, copious irrigation should be performed and placement of a peritoneal drain to reduce the likelihood of abscess formation should be considered. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.

Standard prophylaxis for hysterectomy (such as a first-generation cephalosporin like cefazolin) is not adequate for large bowel surgery, and either metronidazole should be added or a second-generation cephalosporin such as cefoxitin should be given. For patients with penicillin allergy, clindamycin or vancomycin with either gentamicin or a fluoroquinolone should be administered.⁶

Postoperative management

The potential for postoperative morbidity must be understood for appropriate management following bowel surgery. Ileus is common and the clinician should understand how to diagnose and manage it. Additionally, intra-abdominal abscess, anastomotic leak, fistula formation, and mechanical obstruction are complications that may require surgical intervention and must be vigilantly managed.

The routine use of postoperative nasogastric tube (NGT) does not hasten return of bowel function or prevent leak from sites of gastrointestinal repair. In fact, early feeding has been associated with reduced perioperative complications and earlier return of bowel function has been observed without the use of NGT.⁷ In general, for small and large intestinal injuries, early feeding is considered acceptable.⁸

Prolonged antibiotic prophylaxis, beyond 24 hours, is not recommended.⁶

Avoiding injury

Gynecologic surgeons should adhere to surgical principles with sharp dissection for adhesions, gentle tissue handling, adequate exposure, and light retraction to prevent bowel injury or minimize their extent. Laparoscopic entry sites should be chosen based on the likelihood of abdominal adhesions. When the patient’s history predicts a high likelihood of intraperitoneal adhesions, the left upper quadrant site should be strongly considered as the entry site. The likelihood of gastrointestinal injury is not influenced by open versus closed laparoscopic entry and surgeons should use the technique with which they have the greatest experience and skill.⁹ However, in patients who have had prior laparotomies, there is an increased risk of periumbilical adhesions, and consideration should be made for a nonumbilical entry site.¹⁰ Methodical sharp dissection and sparing use of thermal energy should be used with adhesiolysis. When injury occurs, prompt recognition, preparation, and methodical management can mitigate the impact.

Dr. Staley is a gynecologic oncology fellow at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.

References

1. Int Surg. 2006 Nov-Dec;91(6):336-40.

2. J Am Coll Surg. 2001 Jun;192(6):677-83.

3. Doherty, G. Current Diagnosis and Treatment: Surgery. Thirteenth Edition. New York: McGraw Hill, 2010.

4. Hoffman B. Williams Gynecology. Third Edition. New York: McGraw Hill, 2016.

5. Berek J, Hacker N. Berek & Hacker’s Gynecologic Oncology. Sixth Edition. Philadelphia: Wolters Kluwer, 2015.

6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156.

7. Br J Surg. 2005 Jun;92(6):673-80.

8. Am J Obstet Gynecol. 2001 Jul;185(1):1-4.

9. Cochrane Database Syst Rev. 2015 Aug 31;8:CD006583.

10. Br J Obstet Gynaecol. 1997 May;104(5):595-600.


 

It depends on whom you ask. But if you ask me, obesity should not be labeled a disease.

I understand the rationale for calling obesity a disease—it helps legitimize the time we spend treating obesity and aids in getting paid for that time. Some people have distinct diseases, such as Prader-Willi syndrome, hypothyroidism, and Cushing’s syndrome that can cause obesity, and perhaps massive obesity is best categorized and treated as a disease. But the “garden variety” obesity that affects nearly 40% of the US adult population¹ behaves more like a risk factor than a disease. Think of other continuous variables like blood pressure and cholesterol—the higher the measurement, the higher the risk of a plethora of medical problems.

Obesity is a global public health problem that is due largely—at least in this country—to the widespread availability of inexpensive, calorie-packed foods, as well as a desire by a screen-addicted society to stay home and “play” online rather than outdoors. Obesity is a health risk factor produced by our current social milieu and modified by genetics and personal health habits.

Remember that a 5% to 10% weight loss is beneficial—especially for patients with diabetes.

So what can we do? We need to recognize our limited, but important, role and remain nonjudgmental with our overweight and obese patients when they are unsuccessful at losing weight. It is easy to play the blame game, even in subtle ways. Recognizing that obesity is more of a social issue than a personal behavioral issue is a great place to start. Asking patients what they want to do and helping them set goals and find the resources to reach their goals can be helpful. Celebrating even small decreases in weight or increases in physical activity is always good medicine. Remember that a 5% to 10% weight loss has medically beneficial effects, especially for patients with diabetes.²

In addition to recommendations (and referrals) to help patients reduce calories and increase exercise, we have other weight-loss tools to draw upon. Gastric bypass surgery is certainly effective—especially for obese patients with diabetes. And while medication is no replacement for proper diet and exercise, it is another option to consider. Randomized trials have demonstrated some effectiveness for up to 4 years, although no long-term trials (lasting ≥5 years) have been performed. (See “Obesity: When to consider medication.”)

So whether you consider obesity a disease, or not, we now have even more ways with which to combat it.

It depends on whom you ask. But if you ask me, obesity should not be labeled a disease.

I understand the rationale for calling obesity a disease—it helps legitimize the time we spend treating obesity and aids in getting paid for that time. Some people have distinct diseases, such as Prader-Willi syndrome, hypothyroidism, and Cushing’s syndrome that can cause obesity, and perhaps massive obesity is best categorized and treated as a disease. But the “garden variety” obesity that affects nearly 40% of the US adult population¹ behaves more like a risk factor than a disease. Think of other continuous variables like blood pressure and cholesterol—the higher the measurement, the higher the risk of a plethora of medical problems.

Obesity is a global public health problem that is due largely—at least in this country—to the widespread availability of inexpensive, calorie-packed foods, as well as a desire by a screen-addicted society to stay home and “play” online rather than outdoors. Obesity is a health risk factor produced by our current social milieu and modified by genetics and personal health habits.

Remember that a 5% to 10% weight loss is beneficial—especially for patients with diabetes.

So what can we do? We need to recognize our limited, but important, role and remain nonjudgmental with our overweight and obese patients when they are unsuccessful at losing weight. It is easy to play the blame game, even in subtle ways. Recognizing that obesity is more of a social issue than a personal behavioral issue is a great place to start. Asking patients what they want to do and helping them set goals and find the resources to reach their goals can be helpful. Celebrating even small decreases in weight or increases in physical activity is always good medicine. Remember that a 5% to 10% weight loss has medically beneficial effects, especially for patients with diabetes.²

In addition to recommendations (and referrals) to help patients reduce calories and increase exercise, we have other weight-loss tools to draw upon. Gastric bypass surgery is certainly effective—especially for obese patients with diabetes. And while medication is no replacement for proper diet and exercise, it is another option to consider. Randomized trials have demonstrated some effectiveness for up to 4 years, although no long-term trials (lasting ≥5 years) have been performed. (See “Obesity: When to consider medication.”)

So whether you consider obesity a disease, or not, we now have even more ways with which to combat it.

It depends on whom you ask. But if you ask me, obesity should not be labeled a disease.

I understand the rationale for calling obesity a disease—it helps legitimize the time we spend treating obesity and aids in getting paid for that time. Some people have distinct diseases, such as Prader-Willi syndrome, hypothyroidism, and Cushing’s syndrome that can cause obesity, and perhaps massive obesity is best categorized and treated as a disease. But the “garden variety” obesity that affects nearly 40% of the US adult population¹ behaves more like a risk factor than a disease. Think of other continuous variables like blood pressure and cholesterol—the higher the measurement, the higher the risk of a plethora of medical problems.

Obesity is a global public health problem that is due largely—at least in this country—to the widespread availability of inexpensive, calorie-packed foods, as well as a desire by a screen-addicted society to stay home and “play” online rather than outdoors. Obesity is a health risk factor produced by our current social milieu and modified by genetics and personal health habits.

Remember that a 5% to 10% weight loss is beneficial—especially for patients with diabetes.

So what can we do? We need to recognize our limited, but important, role and remain nonjudgmental with our overweight and obese patients when they are unsuccessful at losing weight. It is easy to play the blame game, even in subtle ways. Recognizing that obesity is more of a social issue than a personal behavioral issue is a great place to start. Asking patients what they want to do and helping them set goals and find the resources to reach their goals can be helpful. Celebrating even small decreases in weight or increases in physical activity is always good medicine. Remember that a 5% to 10% weight loss has medically beneficial effects, especially for patients with diabetes.²

In addition to recommendations (and referrals) to help patients reduce calories and increase exercise, we have other weight-loss tools to draw upon. Gastric bypass surgery is certainly effective—especially for obese patients with diabetes. And while medication is no replacement for proper diet and exercise, it is another option to consider. Randomized trials have demonstrated some effectiveness for up to 4 years, although no long-term trials (lasting ≥5 years) have been performed. (See “Obesity: When to consider medication.”)

So whether you consider obesity a disease, or not, we now have even more ways with which to combat it.

Most physicians are likely familiar with guidelines relating to physician impairment, but they may not be aware that these guidelines typically conflict with the Americans with Disabilities Act (ADA), which protects all employees against unwarranted requests for mental health information or evaluations.

Under the ADA, employers cannot request mental health information from their employees or refer them for mental health evaluations without objective evidence showing that either the employee:

• is unable to perform essential job functions because of a mental health condition
• poses a high risk of substantial, imminent harm to himself (herself) or others in the workplace because of a mental health condition.¹

Employers cannot rely on speculative evidence or generalizations about these conditions when making these determinations,¹ and common mental disorders (eg, depressive disorders, anxiety disorders, attention-­deficit/hyperactivity disorder, specific learning disorders, etc.) should almost never form the basis of such requests.²

In contrast, the American Medical Association (AMA) does not distinguish between the presence of a mental health condition and physician impairment,^3,4 which may result in unwarranted requests and referrals for mental health evaluations. Some state laws on impairment, which all derive from AMA policies,⁵ even state outright that, “‘Impaired’ or ‘impairment’ means the presence of the diseases of alcoholism, drug abuse, or mental illness”⁶ and directly discriminate against physicians with these conditions.

State physician health programs (PHPs) also may describe impairment in problematic ways (eg, “Involvement in litigation against hospital”).⁷ Their descriptions also are overly inclusive in that they could be used to describe most physicians (N.D.L., J.W.B., unpublished data, 2017), and they rarely represent sufficient legal indications for a mental health evaluation under the ADA (N.D.L., J.W.B., unpublished data, 2017). Even the APA’s Clinical Guide to Psychiatric Ethics describes physician impairment as synonymous with mental illness.⁸

Requests for mental health information or evaluations not only can include referrals to state PHPs but also “suggestions” to see a psychologist, professional job coach, or any provider who may ask for mental health information. Under the ADA's guidelines, obtaining “voluntary” consent from an employee who could be fired for not cooperating does not change the involuntary nature of these requests.^2,9

Employers who hire psychiatrists, physicians, and medical residents should comply with the ADA and disregard the AMA’s policies, state laws, PHPs, other institutional guidelines,¹⁰ and guidance from some articles published in Current Psychiatry^11,12 when requesting mental health information, evaluations, and referrals for their employees.

Most physicians are likely familiar with guidelines relating to physician impairment, but they may not be aware that these guidelines typically conflict with the Americans with Disabilities Act (ADA), which protects all employees against unwarranted requests for mental health information or evaluations.

Under the ADA, employers cannot request mental health information from their employees or refer them for mental health evaluations without objective evidence showing that either the employee:

• is unable to perform essential job functions because of a mental health condition
• poses a high risk of substantial, imminent harm to himself (herself) or others in the workplace because of a mental health condition.¹

Employers cannot rely on speculative evidence or generalizations about these conditions when making these determinations,¹ and common mental disorders (eg, depressive disorders, anxiety disorders, attention-­deficit/hyperactivity disorder, specific learning disorders, etc.) should almost never form the basis of such requests.²

In contrast, the American Medical Association (AMA) does not distinguish between the presence of a mental health condition and physician impairment,^3,4 which may result in unwarranted requests and referrals for mental health evaluations. Some state laws on impairment, which all derive from AMA policies,⁵ even state outright that, “‘Impaired’ or ‘impairment’ means the presence of the diseases of alcoholism, drug abuse, or mental illness”⁶ and directly discriminate against physicians with these conditions.

State physician health programs (PHPs) also may describe impairment in problematic ways (eg, “Involvement in litigation against hospital”).⁷ Their descriptions also are overly inclusive in that they could be used to describe most physicians (N.D.L., J.W.B., unpublished data, 2017), and they rarely represent sufficient legal indications for a mental health evaluation under the ADA (N.D.L., J.W.B., unpublished data, 2017). Even the APA’s Clinical Guide to Psychiatric Ethics describes physician impairment as synonymous with mental illness.⁸

Requests for mental health information or evaluations not only can include referrals to state PHPs but also “suggestions” to see a psychologist, professional job coach, or any provider who may ask for mental health information. Under the ADA's guidelines, obtaining “voluntary” consent from an employee who could be fired for not cooperating does not change the involuntary nature of these requests.^2,9

Employers who hire psychiatrists, physicians, and medical residents should comply with the ADA and disregard the AMA’s policies, state laws, PHPs, other institutional guidelines,¹⁰ and guidance from some articles published in Current Psychiatry^11,12 when requesting mental health information, evaluations, and referrals for their employees.

Most physicians are likely familiar with guidelines relating to physician impairment, but they may not be aware that these guidelines typically conflict with the Americans with Disabilities Act (ADA), which protects all employees against unwarranted requests for mental health information or evaluations.

Under the ADA, employers cannot request mental health information from their employees or refer them for mental health evaluations without objective evidence showing that either the employee:

• is unable to perform essential job functions because of a mental health condition
• poses a high risk of substantial, imminent harm to himself (herself) or others in the workplace because of a mental health condition.¹

Employers cannot rely on speculative evidence or generalizations about these conditions when making these determinations,¹ and common mental disorders (eg, depressive disorders, anxiety disorders, attention-­deficit/hyperactivity disorder, specific learning disorders, etc.) should almost never form the basis of such requests.²

In contrast, the American Medical Association (AMA) does not distinguish between the presence of a mental health condition and physician impairment,^3,4 which may result in unwarranted requests and referrals for mental health evaluations. Some state laws on impairment, which all derive from AMA policies,⁵ even state outright that, “‘Impaired’ or ‘impairment’ means the presence of the diseases of alcoholism, drug abuse, or mental illness”⁶ and directly discriminate against physicians with these conditions.

State physician health programs (PHPs) also may describe impairment in problematic ways (eg, “Involvement in litigation against hospital”).⁷ Their descriptions also are overly inclusive in that they could be used to describe most physicians (N.D.L., J.W.B., unpublished data, 2017), and they rarely represent sufficient legal indications for a mental health evaluation under the ADA (N.D.L., J.W.B., unpublished data, 2017). Even the APA’s Clinical Guide to Psychiatric Ethics describes physician impairment as synonymous with mental illness.⁸

Requests for mental health information or evaluations not only can include referrals to state PHPs but also “suggestions” to see a psychologist, professional job coach, or any provider who may ask for mental health information. Under the ADA's guidelines, obtaining “voluntary” consent from an employee who could be fired for not cooperating does not change the involuntary nature of these requests.^2,9

Employers who hire psychiatrists, physicians, and medical residents should comply with the ADA and disregard the AMA’s policies, state laws, PHPs, other institutional guidelines,¹⁰ and guidance from some articles published in Current Psychiatry^11,12 when requesting mental health information, evaluations, and referrals for their employees.

It seemed appropriate this month for me to step aside for the Editor’s commentary and provide a forum for one of our associate editors to talk about his experience during Hurricane Harvey.

John I. Allen, MD, MBA, AGAF
Editor in Chief

We knew that a powerful storm was coming, but very few anticipated the widespread destruction Hurricane Harvey would bring. Houston is no stranger to floods, but the amount of water that Harvey unleashed was record-breaking. Areas that had never flooded were underwater, evacuations were commonplace; the devastation was heart-breaking. In the midst of significant personal tragedy, Houston came together. Neighbors took in flooded colleagues, personal boats were used for rescues, and many braved impassable roads to donate clothes, food, labor and medical aid. Shelters across the city were assisted by volunteers; community groups collected and coordinated distribution of supplies. Medical teams were mobilized to treat chronically ill patients who evacuated without their medications or those injured while escaping the floods.

At one of the largest medical centers in the world, floodgates constructed after Tropical Storm Allison kept the waters at bay. And physicians, nurses, janitors, and other employees slept in hospitals for days to provide care to our patients during the worst of the floods. Those who relieved them worked long hours to see the many patients rescheduled in the aftermath of the storm. After-work crews of neighbors continue to go from house to house removing flooded floor boards and ripping out drywall. Houston came together.

Dr. Ketwaroo is an assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an advanced endoscopist at the Michael E. Debakey VA Medical Center in Houston. He is an associate editor for GI & Hepatology News.

It seemed appropriate this month for me to step aside for the Editor’s commentary and provide a forum for one of our associate editors to talk about his experience during Hurricane Harvey.

John I. Allen, MD, MBA, AGAF
Editor in Chief

We knew that a powerful storm was coming, but very few anticipated the widespread destruction Hurricane Harvey would bring. Houston is no stranger to floods, but the amount of water that Harvey unleashed was record-breaking. Areas that had never flooded were underwater, evacuations were commonplace; the devastation was heart-breaking. In the midst of significant personal tragedy, Houston came together. Neighbors took in flooded colleagues, personal boats were used for rescues, and many braved impassable roads to donate clothes, food, labor and medical aid. Shelters across the city were assisted by volunteers; community groups collected and coordinated distribution of supplies. Medical teams were mobilized to treat chronically ill patients who evacuated without their medications or those injured while escaping the floods.

At one of the largest medical centers in the world, floodgates constructed after Tropical Storm Allison kept the waters at bay. And physicians, nurses, janitors, and other employees slept in hospitals for days to provide care to our patients during the worst of the floods. Those who relieved them worked long hours to see the many patients rescheduled in the aftermath of the storm. After-work crews of neighbors continue to go from house to house removing flooded floor boards and ripping out drywall. Houston came together.

Dr. Ketwaroo is an assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an advanced endoscopist at the Michael E. Debakey VA Medical Center in Houston. He is an associate editor for GI & Hepatology News.

It seemed appropriate this month for me to step aside for the Editor’s commentary and provide a forum for one of our associate editors to talk about his experience during Hurricane Harvey.

John I. Allen, MD, MBA, AGAF
Editor in Chief

We knew that a powerful storm was coming, but very few anticipated the widespread destruction Hurricane Harvey would bring. Houston is no stranger to floods, but the amount of water that Harvey unleashed was record-breaking. Areas that had never flooded were underwater, evacuations were commonplace; the devastation was heart-breaking. In the midst of significant personal tragedy, Houston came together. Neighbors took in flooded colleagues, personal boats were used for rescues, and many braved impassable roads to donate clothes, food, labor and medical aid. Shelters across the city were assisted by volunteers; community groups collected and coordinated distribution of supplies. Medical teams were mobilized to treat chronically ill patients who evacuated without their medications or those injured while escaping the floods.

At one of the largest medical centers in the world, floodgates constructed after Tropical Storm Allison kept the waters at bay. And physicians, nurses, janitors, and other employees slept in hospitals for days to provide care to our patients during the worst of the floods. Those who relieved them worked long hours to see the many patients rescheduled in the aftermath of the storm. After-work crews of neighbors continue to go from house to house removing flooded floor boards and ripping out drywall. Houston came together.

Dr. Ketwaroo is an assistant professor in the division of gastroenterology and hepatology at Baylor College of Medicine, Houston, and an advanced endoscopist at the Michael E. Debakey VA Medical Center in Houston. He is an associate editor for GI & Hepatology News.

This is the second in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Family physicians increasingly recognize the importance of shared decision making, where the patient and provider work together to make a health care decision. Shared decision making means the decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences. More and more patients and providers want to participate in shared decision making, but the “how” often is neglected in standard medical and graduate medical education. AHRQ provides two resources to assist in your practice’s use of shared decision making.

The SHARE Approach is a five-step process for shared decision making:

• Seek your patient’s participation.
• Help your patient explore & compare treatment options.
• Assess your patient’s values and preferences.
• Reach a decision with your patient.
• Evaluate your patient’s decision.

AHRQ’s SHARE Approach curriculum provides both a quick overview (for the busy clinician) and an extensive course (complete with slides and a trainer’s module). The website provides the clinician the opportunity to learn the key elements of the SHARE Approach, while providing the educator a full curriculum with slides, handouts, and a video in order to demonstrate the approach. Complementing the SHARE curriculum, AHRQ’s Effective Health Care Program offers excellent, easy-to-read summaries of evidence reports to help clinicians and consumers make informed health care decisions. AHRQ recently released Lung Cancer Screening Tools, including a decision aid, for patients and clinicians to facilitate discussions about lung cancer screening with low-dose computed tomography.

The SHARE Approach and other tools can be found at the NCEPCR website.

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

This is the second in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Family physicians increasingly recognize the importance of shared decision making, where the patient and provider work together to make a health care decision. Shared decision making means the decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences. More and more patients and providers want to participate in shared decision making, but the “how” often is neglected in standard medical and graduate medical education. AHRQ provides two resources to assist in your practice’s use of shared decision making.

The SHARE Approach is a five-step process for shared decision making:

• Seek your patient’s participation.
• Help your patient explore & compare treatment options.
• Assess your patient’s values and preferences.
• Reach a decision with your patient.
• Evaluate your patient’s decision.

AHRQ’s SHARE Approach curriculum provides both a quick overview (for the busy clinician) and an extensive course (complete with slides and a trainer’s module). The website provides the clinician the opportunity to learn the key elements of the SHARE Approach, while providing the educator a full curriculum with slides, handouts, and a video in order to demonstrate the approach. Complementing the SHARE curriculum, AHRQ’s Effective Health Care Program offers excellent, easy-to-read summaries of evidence reports to help clinicians and consumers make informed health care decisions. AHRQ recently released Lung Cancer Screening Tools, including a decision aid, for patients and clinicians to facilitate discussions about lung cancer screening with low-dose computed tomography.

The SHARE Approach and other tools can be found at the NCEPCR website.

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

This is the second in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Family physicians increasingly recognize the importance of shared decision making, where the patient and provider work together to make a health care decision. Shared decision making means the decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences. More and more patients and providers want to participate in shared decision making, but the “how” often is neglected in standard medical and graduate medical education. AHRQ provides two resources to assist in your practice’s use of shared decision making.

The SHARE Approach is a five-step process for shared decision making:

• Seek your patient’s participation.
• Help your patient explore & compare treatment options.
• Assess your patient’s values and preferences.
• Reach a decision with your patient.
• Evaluate your patient’s decision.

AHRQ’s SHARE Approach curriculum provides both a quick overview (for the busy clinician) and an extensive course (complete with slides and a trainer’s module). The website provides the clinician the opportunity to learn the key elements of the SHARE Approach, while providing the educator a full curriculum with slides, handouts, and a video in order to demonstrate the approach. Complementing the SHARE curriculum, AHRQ’s Effective Health Care Program offers excellent, easy-to-read summaries of evidence reports to help clinicians and consumers make informed health care decisions. AHRQ recently released Lung Cancer Screening Tools, including a decision aid, for patients and clinicians to facilitate discussions about lung cancer screening with low-dose computed tomography.

The SHARE Approach and other tools can be found at the NCEPCR website.

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

If you graduated from medical school after 1990, you may be surprised to learn that there was a time when the typical general pediatrician could go through an entire day of seeing patients and not write a single prescription for a stimulant medication. In fact, he or she could go for several months without writing for any controlled substance.

ADHD is a modern phenomenon. There always have been children with “ants in their pants” who couldn’t sit still. And there always were “daydreamers” who didn’t pay attention in school. But in the 1970s, the number of children who might now be labeled as having ADHD was nowhere near the 11% often quoted for the prevalence in the current pediatric population.

Eva-Foreman/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Email him at [email protected].
 

If you graduated from medical school after 1990, you may be surprised to learn that there was a time when the typical general pediatrician could go through an entire day of seeing patients and not write a single prescription for a stimulant medication. In fact, he or she could go for several months without writing for any controlled substance.

ADHD is a modern phenomenon. There always have been children with “ants in their pants” who couldn’t sit still. And there always were “daydreamers” who didn’t pay attention in school. But in the 1970s, the number of children who might now be labeled as having ADHD was nowhere near the 11% often quoted for the prevalence in the current pediatric population.

Eva-Foreman/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Email him at [email protected].
 

If you graduated from medical school after 1990, you may be surprised to learn that there was a time when the typical general pediatrician could go through an entire day of seeing patients and not write a single prescription for a stimulant medication. In fact, he or she could go for several months without writing for any controlled substance.

ADHD is a modern phenomenon. There always have been children with “ants in their pants” who couldn’t sit still. And there always were “daydreamers” who didn’t pay attention in school. But in the 1970s, the number of children who might now be labeled as having ADHD was nowhere near the 11% often quoted for the prevalence in the current pediatric population.

Eva-Foreman/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Email him at [email protected].
 

For the most part pediatricians are insulated from death. Our little patients are surprisingly resilient. Once past that anxiety-provoking transition from placental dependence to air breathing, children will thrive in an environment that includes immunizations, potable water, and adequate nutrition. But pediatric deaths do occur infrequently in North America, and they are particularly unsettling to us because we are so unaccustomed to processing the emotions that swirl around the end of life. When a child’s death is unexpected and unexplained, we are likely to find ourselves tortured by feelings of guilt and inadequacy. Did I miss something at the last health maintenance visit? Should I have taken more seriously that call last week about what sounded like a simple viral prodrome? Should I have asked that mother to make an appointment?

germi_p/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

For the most part pediatricians are insulated from death. Our little patients are surprisingly resilient. Once past that anxiety-provoking transition from placental dependence to air breathing, children will thrive in an environment that includes immunizations, potable water, and adequate nutrition. But pediatric deaths do occur infrequently in North America, and they are particularly unsettling to us because we are so unaccustomed to processing the emotions that swirl around the end of life. When a child’s death is unexpected and unexplained, we are likely to find ourselves tortured by feelings of guilt and inadequacy. Did I miss something at the last health maintenance visit? Should I have taken more seriously that call last week about what sounded like a simple viral prodrome? Should I have asked that mother to make an appointment?

germi_p/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

For the most part pediatricians are insulated from death. Our little patients are surprisingly resilient. Once past that anxiety-provoking transition from placental dependence to air breathing, children will thrive in an environment that includes immunizations, potable water, and adequate nutrition. But pediatric deaths do occur infrequently in North America, and they are particularly unsettling to us because we are so unaccustomed to processing the emotions that swirl around the end of life. When a child’s death is unexpected and unexplained, we are likely to find ourselves tortured by feelings of guilt and inadequacy. Did I miss something at the last health maintenance visit? Should I have taken more seriously that call last week about what sounded like a simple viral prodrome? Should I have asked that mother to make an appointment?

germi_p/Thinkstock

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

Do you practice as a team member? How is your team defined? Is it made up solely of physicians? Does it include mid-level providers? Does it extend to mental health and social service providers in your office? Do you consider nonproviders such as receptionists as team members? Do you consider the whole office “your team”? Or, is it a smaller team with just yourself and one or two other physicians along with a mid-level provider or two?

There has been a lot written about primary care teams as a natural consequence of the medical home model. In an article in AAP News, Gonzalo J. Paz-Soldán, MD, a member of the American Academy of Pediatrics Council on Community Pediatrics and regional executive medical director, pediatrics, at Reliant Medical Group, Worcester, Mass., suggests that pediatricians should be taking on leadership roles in directing these teams. He claims that in addition to improving the “quality, value, patient experience,” our leadership also will benefit “provider and staff wellness and engagement.” In other words, taking charge will return the joy of pediatrics, and make us more resilient in the face of burnout.

Copyright thinkstockphotos.com

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Do you practice as a team member? How is your team defined? Is it made up solely of physicians? Does it include mid-level providers? Does it extend to mental health and social service providers in your office? Do you consider nonproviders such as receptionists as team members? Do you consider the whole office “your team”? Or, is it a smaller team with just yourself and one or two other physicians along with a mid-level provider or two?

There has been a lot written about primary care teams as a natural consequence of the medical home model. In an article in AAP News, Gonzalo J. Paz-Soldán, MD, a member of the American Academy of Pediatrics Council on Community Pediatrics and regional executive medical director, pediatrics, at Reliant Medical Group, Worcester, Mass., suggests that pediatricians should be taking on leadership roles in directing these teams. He claims that in addition to improving the “quality, value, patient experience,” our leadership also will benefit “provider and staff wellness and engagement.” In other words, taking charge will return the joy of pediatrics, and make us more resilient in the face of burnout.

Copyright thinkstockphotos.com

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Do you practice as a team member? How is your team defined? Is it made up solely of physicians? Does it include mid-level providers? Does it extend to mental health and social service providers in your office? Do you consider nonproviders such as receptionists as team members? Do you consider the whole office “your team”? Or, is it a smaller team with just yourself and one or two other physicians along with a mid-level provider or two?

There has been a lot written about primary care teams as a natural consequence of the medical home model. In an article in AAP News, Gonzalo J. Paz-Soldán, MD, a member of the American Academy of Pediatrics Council on Community Pediatrics and regional executive medical director, pediatrics, at Reliant Medical Group, Worcester, Mass., suggests that pediatricians should be taking on leadership roles in directing these teams. He claims that in addition to improving the “quality, value, patient experience,” our leadership also will benefit “provider and staff wellness and engagement.” In other words, taking charge will return the joy of pediatrics, and make us more resilient in the face of burnout.

Copyright thinkstockphotos.com

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

The Food and Drug Administration is concerned about incidents of overheating, fires, and explosions of e-cigarettes, or “vapes,” which in some cases have resulted in serious injuries. The agency is reviewing these types of incidents and has taken steps to protect the public.

The FDA recently developed resources for consumers, including tips to help avoid e-cigarette overheating and explosions, as well as social media tools to help spread the word about protective steps. The agency also has a reporting system to collect information about adverse experiences associated with e-cigarettes and other tobacco products. Comprehensive and accurate reports could provide evidence to help inform future actions to protect the public.

For e-cigarette users: Tips to help prevent fires and explosions

Learn about your device.

The best protection against battery explosions may be knowing about your device and how to handle and charge its batteries appropriately. Read and follow the manufacturer’s use and care recommendations. If the e-cigarette did not come with instructions or you have additional questions, contact the manufacturer.

Consider using e-cigarettes with protective features.

Some e-cigarettes have features such as firing button locks, vent holes, and protection against overcharging. These features are designed to prevent battery overheating and explosions, so do not remove or disable them.

Choose batteries carefully and replace them if necessary:

• Use only the batteries recommended for your device. Do not mix different brands, different charge levels, or old and new batteries in the same device.

• Replace the batteries if they get damaged or wet. If your e-cigarette is damaged and the batteries are not replaceable, contact the manufacturer.

• Stop using the device under certain circumstances. Although battery explosions can occur with no warning, you should immediately stop using your e-cigarette and get a safe distance from it if you notice any of these during use or while charging: strange noises; unusual smells; a leaking battery; the e-cigarette becoming unusually hot; or the device beginning to smoke, spark, emit flashes, or catch fire.

Be aware when charging your e-cigarette:

• Use only the charger that came with your device, and never charge it with a phone or tablet charger.

• Charge the device on a clean, flat surface, in a place you can clearly see it, and away from anything that can easily catch fire. Do not leave the e-cigarette charging on a surface such as a couch or pillow, where it may be more likely to overheat or turn on unintentionally.

• Do not charge the device overnight or leave it charging unattended.

Know this about carrying and storing your e-cigarette:

• Keep your e-cigarette covered. If you are carrying it in your pocket, avoid having it come in contact with coins or loose batteries.

• Protect the e-cigarette from extreme temperatures. Do not leave it in direct sunlight or in your car in extremely cold or hot temperatures.

Report any problems.

If something goes wrong with an e-cigarette, please submit a report to https://www.safetyreporting.hhs.gov

To make it easy to share the FDA’s top tips, the agency has developed a 5 Tips to Help Avoid “Vape” Battery Explosion infographic.

This infographic and other public-health resources can be found on a dedicated CTP webpage, which offers shareable and downloadable content to help spread the word about e-cigarette battery issues, as well as a video on how to report adverse experiences related to tobacco products to the FDA.
 

When a fire or explosion does occur: The Safety Reporting Portal

The CTP identified 143 reported incidents of e-cigarette overheating, fires, and explosions during 2009-2015, and 20 additional reports during 2016. Based on the FDA’s experience with underreporting of adverse events for other regulated products, the number of actual events is probably higher.

The FDA is working to collect more information to identify the true number of events and why these incidents are occurring. The agency has a Safety Reporting Portal (SRP) dedicated to receiving reports of issues associated with FDA-regulated products, including e-cigarettes and other tobacco products.

The FDA strongly encourages any physicians, other health care professionals, or those with firsthand knowledge about an unexpected e-cigarette incident to report it through the SRP. Family physicians can play a valuable reporting role by informing patients about the reporting system, helping people submit complete information about incidents related to e-cigarettes, or providing information about an incident on a patient’s behalf.

To report an e-cigarette failure or other tobacco-related adverse event, please go to the SRP and follow the instructions in each section. Those unable to use the SRP to submit a report can call 877-CTP-1373 or email [email protected].

The more complete and accurate a report is, the more helpful it can be to the FDA and, in turn, to public health. When submitting a report about an e-cigarette, please include:

• E-cigarette manufacturer’s name.

• E-cigarette’s brand name, model, and serial number.

• Battery’s brand name and model.

• Place the e-cigarette was purchased.

• Whether, and how, the product was being used at the time of the incident.

• Whether the product was used differently than intended by the manufacturer.

• Whether the product was modified in any way.

To collect as much detail as possible, the FDA encourages those submitting reports to upload photos or other files, such as police or hospital reports. They also appreciate submission of contact information, such as a phone number or email address, which will help the agency follow up with any questions related to the report. Personal information will not be shared or used for any additional matter and is protected by security practices. The HHS Privacy Policy contains more information.
 

Ongoing public health protection efforts

The FDA continues to evaluate possible ways to protect the public from device-related fires and explosions. During a public workshop in April, the FDA heard from experts including scientists, engineers, and e-cigarette manufacturers and retailers, as well as from the general public, about hazards and possible solutions related to batteries in e-cigarettes and other electronic nicotine delivery systems. Also, the agency’s premarket review process for electronic nicotine delivery systems includes an assessment of device operation and any features that may reduce the risks associated with product use, including testing related to overheating and exploding batteries.

Through these and other measures, the FDA is committed to identifying and addressing factors leading to e-cigarette overheating and any subsequent injuries. Health care professionals can help by spreading the word about the agency’s user tips and reporting portal.

To learn more broadly about the FDA’s ongoing efforts to protect the public health by regulating the manufacture, marketing, and distribution of tobacco products, please visit the Center for Tobacco Products website.

Dr. Holman is director of the office of science at the FDA’s Center for Tobacco Products.

The Food and Drug Administration is concerned about incidents of overheating, fires, and explosions of e-cigarettes, or “vapes,” which in some cases have resulted in serious injuries. The agency is reviewing these types of incidents and has taken steps to protect the public.

The FDA recently developed resources for consumers, including tips to help avoid e-cigarette overheating and explosions, as well as social media tools to help spread the word about protective steps. The agency also has a reporting system to collect information about adverse experiences associated with e-cigarettes and other tobacco products. Comprehensive and accurate reports could provide evidence to help inform future actions to protect the public.

For e-cigarette users: Tips to help prevent fires and explosions

Learn about your device.

The best protection against battery explosions may be knowing about your device and how to handle and charge its batteries appropriately. Read and follow the manufacturer’s use and care recommendations. If the e-cigarette did not come with instructions or you have additional questions, contact the manufacturer.

Consider using e-cigarettes with protective features.

Some e-cigarettes have features such as firing button locks, vent holes, and protection against overcharging. These features are designed to prevent battery overheating and explosions, so do not remove or disable them.

Choose batteries carefully and replace them if necessary:

• Use only the batteries recommended for your device. Do not mix different brands, different charge levels, or old and new batteries in the same device.

• Replace the batteries if they get damaged or wet. If your e-cigarette is damaged and the batteries are not replaceable, contact the manufacturer.

• Stop using the device under certain circumstances. Although battery explosions can occur with no warning, you should immediately stop using your e-cigarette and get a safe distance from it if you notice any of these during use or while charging: strange noises; unusual smells; a leaking battery; the e-cigarette becoming unusually hot; or the device beginning to smoke, spark, emit flashes, or catch fire.

Be aware when charging your e-cigarette:

• Use only the charger that came with your device, and never charge it with a phone or tablet charger.

• Charge the device on a clean, flat surface, in a place you can clearly see it, and away from anything that can easily catch fire. Do not leave the e-cigarette charging on a surface such as a couch or pillow, where it may be more likely to overheat or turn on unintentionally.

• Do not charge the device overnight or leave it charging unattended.

Know this about carrying and storing your e-cigarette:

• Keep your e-cigarette covered. If you are carrying it in your pocket, avoid having it come in contact with coins or loose batteries.

• Protect the e-cigarette from extreme temperatures. Do not leave it in direct sunlight or in your car in extremely cold or hot temperatures.

Report any problems.

If something goes wrong with an e-cigarette, please submit a report to https://www.safetyreporting.hhs.gov

To make it easy to share the FDA’s top tips, the agency has developed a 5 Tips to Help Avoid “Vape” Battery Explosion infographic.

This infographic and other public-health resources can be found on a dedicated CTP webpage, which offers shareable and downloadable content to help spread the word about e-cigarette battery issues, as well as a video on how to report adverse experiences related to tobacco products to the FDA.
 

When a fire or explosion does occur: The Safety Reporting Portal

The CTP identified 143 reported incidents of e-cigarette overheating, fires, and explosions during 2009-2015, and 20 additional reports during 2016. Based on the FDA’s experience with underreporting of adverse events for other regulated products, the number of actual events is probably higher.

The FDA is working to collect more information to identify the true number of events and why these incidents are occurring. The agency has a Safety Reporting Portal (SRP) dedicated to receiving reports of issues associated with FDA-regulated products, including e-cigarettes and other tobacco products.

The FDA strongly encourages any physicians, other health care professionals, or those with firsthand knowledge about an unexpected e-cigarette incident to report it through the SRP. Family physicians can play a valuable reporting role by informing patients about the reporting system, helping people submit complete information about incidents related to e-cigarettes, or providing information about an incident on a patient’s behalf.

To report an e-cigarette failure or other tobacco-related adverse event, please go to the SRP and follow the instructions in each section. Those unable to use the SRP to submit a report can call 877-CTP-1373 or email [email protected].

The more complete and accurate a report is, the more helpful it can be to the FDA and, in turn, to public health. When submitting a report about an e-cigarette, please include:

• E-cigarette manufacturer’s name.

• E-cigarette’s brand name, model, and serial number.

• Battery’s brand name and model.

• Place the e-cigarette was purchased.

• Whether, and how, the product was being used at the time of the incident.

• Whether the product was used differently than intended by the manufacturer.

• Whether the product was modified in any way.

To collect as much detail as possible, the FDA encourages those submitting reports to upload photos or other files, such as police or hospital reports. They also appreciate submission of contact information, such as a phone number or email address, which will help the agency follow up with any questions related to the report. Personal information will not be shared or used for any additional matter and is protected by security practices. The HHS Privacy Policy contains more information.
 

Ongoing public health protection efforts

The FDA continues to evaluate possible ways to protect the public from device-related fires and explosions. During a public workshop in April, the FDA heard from experts including scientists, engineers, and e-cigarette manufacturers and retailers, as well as from the general public, about hazards and possible solutions related to batteries in e-cigarettes and other electronic nicotine delivery systems. Also, the agency’s premarket review process for electronic nicotine delivery systems includes an assessment of device operation and any features that may reduce the risks associated with product use, including testing related to overheating and exploding batteries.

Through these and other measures, the FDA is committed to identifying and addressing factors leading to e-cigarette overheating and any subsequent injuries. Health care professionals can help by spreading the word about the agency’s user tips and reporting portal.

To learn more broadly about the FDA’s ongoing efforts to protect the public health by regulating the manufacture, marketing, and distribution of tobacco products, please visit the Center for Tobacco Products website.

Dr. Holman is director of the office of science at the FDA’s Center for Tobacco Products.

The Food and Drug Administration is concerned about incidents of overheating, fires, and explosions of e-cigarettes, or “vapes,” which in some cases have resulted in serious injuries. The agency is reviewing these types of incidents and has taken steps to protect the public.

The FDA recently developed resources for consumers, including tips to help avoid e-cigarette overheating and explosions, as well as social media tools to help spread the word about protective steps. The agency also has a reporting system to collect information about adverse experiences associated with e-cigarettes and other tobacco products. Comprehensive and accurate reports could provide evidence to help inform future actions to protect the public.

For e-cigarette users: Tips to help prevent fires and explosions

Learn about your device.

The best protection against battery explosions may be knowing about your device and how to handle and charge its batteries appropriately. Read and follow the manufacturer’s use and care recommendations. If the e-cigarette did not come with instructions or you have additional questions, contact the manufacturer.

Consider using e-cigarettes with protective features.

Some e-cigarettes have features such as firing button locks, vent holes, and protection against overcharging. These features are designed to prevent battery overheating and explosions, so do not remove or disable them.

Choose batteries carefully and replace them if necessary:

• Use only the batteries recommended for your device. Do not mix different brands, different charge levels, or old and new batteries in the same device.

• Replace the batteries if they get damaged or wet. If your e-cigarette is damaged and the batteries are not replaceable, contact the manufacturer.

• Stop using the device under certain circumstances. Although battery explosions can occur with no warning, you should immediately stop using your e-cigarette and get a safe distance from it if you notice any of these during use or while charging: strange noises; unusual smells; a leaking battery; the e-cigarette becoming unusually hot; or the device beginning to smoke, spark, emit flashes, or catch fire.

Be aware when charging your e-cigarette:

• Use only the charger that came with your device, and never charge it with a phone or tablet charger.

• Charge the device on a clean, flat surface, in a place you can clearly see it, and away from anything that can easily catch fire. Do not leave the e-cigarette charging on a surface such as a couch or pillow, where it may be more likely to overheat or turn on unintentionally.

• Do not charge the device overnight or leave it charging unattended.

Know this about carrying and storing your e-cigarette:

• Keep your e-cigarette covered. If you are carrying it in your pocket, avoid having it come in contact with coins or loose batteries.

• Protect the e-cigarette from extreme temperatures. Do not leave it in direct sunlight or in your car in extremely cold or hot temperatures.

Report any problems.

If something goes wrong with an e-cigarette, please submit a report to https://www.safetyreporting.hhs.gov

To make it easy to share the FDA’s top tips, the agency has developed a 5 Tips to Help Avoid “Vape” Battery Explosion infographic.

This infographic and other public-health resources can be found on a dedicated CTP webpage, which offers shareable and downloadable content to help spread the word about e-cigarette battery issues, as well as a video on how to report adverse experiences related to tobacco products to the FDA.
 

When a fire or explosion does occur: The Safety Reporting Portal

The CTP identified 143 reported incidents of e-cigarette overheating, fires, and explosions during 2009-2015, and 20 additional reports during 2016. Based on the FDA’s experience with underreporting of adverse events for other regulated products, the number of actual events is probably higher.

The FDA is working to collect more information to identify the true number of events and why these incidents are occurring. The agency has a Safety Reporting Portal (SRP) dedicated to receiving reports of issues associated with FDA-regulated products, including e-cigarettes and other tobacco products.

The FDA strongly encourages any physicians, other health care professionals, or those with firsthand knowledge about an unexpected e-cigarette incident to report it through the SRP. Family physicians can play a valuable reporting role by informing patients about the reporting system, helping people submit complete information about incidents related to e-cigarettes, or providing information about an incident on a patient’s behalf.

To report an e-cigarette failure or other tobacco-related adverse event, please go to the SRP and follow the instructions in each section. Those unable to use the SRP to submit a report can call 877-CTP-1373 or email [email protected].

The more complete and accurate a report is, the more helpful it can be to the FDA and, in turn, to public health. When submitting a report about an e-cigarette, please include:

• E-cigarette manufacturer’s name.

• E-cigarette’s brand name, model, and serial number.

• Battery’s brand name and model.

• Place the e-cigarette was purchased.

• Whether, and how, the product was being used at the time of the incident.

• Whether the product was used differently than intended by the manufacturer.

• Whether the product was modified in any way.

To collect as much detail as possible, the FDA encourages those submitting reports to upload photos or other files, such as police or hospital reports. They also appreciate submission of contact information, such as a phone number or email address, which will help the agency follow up with any questions related to the report. Personal information will not be shared or used for any additional matter and is protected by security practices. The HHS Privacy Policy contains more information.
 

Ongoing public health protection efforts

The FDA continues to evaluate possible ways to protect the public from device-related fires and explosions. During a public workshop in April, the FDA heard from experts including scientists, engineers, and e-cigarette manufacturers and retailers, as well as from the general public, about hazards and possible solutions related to batteries in e-cigarettes and other electronic nicotine delivery systems. Also, the agency’s premarket review process for electronic nicotine delivery systems includes an assessment of device operation and any features that may reduce the risks associated with product use, including testing related to overheating and exploding batteries.

Through these and other measures, the FDA is committed to identifying and addressing factors leading to e-cigarette overheating and any subsequent injuries. Health care professionals can help by spreading the word about the agency’s user tips and reporting portal.

To learn more broadly about the FDA’s ongoing efforts to protect the public health by regulating the manufacture, marketing, and distribution of tobacco products, please visit the Center for Tobacco Products website.

Dr. Holman is director of the office of science at the FDA’s Center for Tobacco Products.