Letters to the Editor - April 1, 2001 - American Family Physician

Letters to the Editor

No-Needle Anesthetic for No-Scalpel Vasectomy

TO THE EDITOR: Vasectomy continues to be underused compared with tubal sterilization among couples seeking permanent contraception in the United States. Fear of the procedure remains a barrier to increased acceptance of vasectomy. The no-scalpel vasectomy accounts for about one third of all vasectomies in the United States; however, many men have a fear of the local anesthetic. I would like to report my experience with no-needle anesthetic administration for the no-scalpel vasectomy as another step forward in reducing patient fear and hesitation in accessing vasectomy.

I have recently devised a method of using the MadaJet, a jet injection device, to administer the local anesthetic for no-scalpel vasectomy. This device has been commercially available for more than 20 years. It has been marketed for applications in dentistry, gynecology and podiatry, as well as other medical applications.

The MadaJet emits a fine stream of anesthetic solution, which normally penetrates about 4 mm into tissues and distributes throughout a circle of about 1.0 to 1.5 cm in diameter. Although the volume of a single discharge is a small 0.1 mL, the anesthetic effect is immediate, suggesting that the dispersion within the tissues is faster and more efficient than with a needle injection.

Caution is indicated with the MadaJet, because the stream can pass through the patient's tissues and exit with enough force to penetrate the operator's gloved finger. For the safety of the operator, it is important that the MadaJet be directed away from the operator's fingers, similar to the use of a hypodermic needle. The approach I have used is described here.

The three-finger grasp is modified from the usual no-scalpel vasectomy technique. The operator places the index finger next to the middle finger posterior to the scrotum, with the thumb anterior. As the vas is elevated, the tip of the MadaJet is placed against the scrotal skin next to the operator's thumb. It has been helpful to fashion a groove in the plastic tip to help hold the vas in position. The stream is directed posteriorly, between the operator's middle and index fingers.

The discharge button is actuated, releasing the instantaneous jet of 2 percent lidocaine. The sensation described by patients is comparable to the snap of a rubber band against the skin. The jet penetrates the skin at a single puncture site, which may be visible as a pinpoint mark. If the solution contains epinephrine, one can sometimes see a blanching effect on the skin surface.

The MadaJet is cocked again and the contralateral vas is brought into position under the anesthetized skin site and anesthetized. Anesthesia of the vasa deferentia is sufficient to complete the vasectomy without additional infiltration in 90 percent of cases. When augmentation is necessary, local infiltration is well tolerated and effective. This no-needle method obviates the small risk of spermatic cord hematoma that can occur when a needle is advanced along the vas in the usual administration of a perivasal block.

From informal inquiries among my colleagues, it seems to be infrequent that needleless devices are used in the family practice office. I believe the no-needle anesthetic described here is a useful choice for the administration of local anesthesia in vasectomy and in many other common office procedures.

CHARLES L. WILSON, M.D.
4326 53rd Ave., N.E.
Seattle, WA 98105

Family Physicians as Specialists

TO THE EDITOR: The patient information handout entitled, "When You Have Chronic Unexplained Medical Problems,"¹ poses the questions to readers: "Do I need an operation?" "Don't I need to see a 'specialist'?"

In answer to the question, the handout states, "Your family doctor will know you well and will know if you need an operation or if you should see a 'specialist'."

In response to this handout, [I want to clarify that . . . ] when a patient comes to see me they are seeing a specialist. [I feel that . . . ] they are getting the kind of specialty care they need and deserve. If they need to be referred to a consulting specialist, I will arrange for that.

The literature is full of misleading identities for family physicians. We are called PCPs, generalists and probably other not-so-nice acronyms. Remember the old "LMD" despairingly referred to on rounds at medical school?

I am a specialist, and my area of expertise is exactly what most patients need most of the time. Help me make this point by calling me a specialist when appropriate and emphasizing my special expertise in ambulatory medicine when giving information to patients.

JOSEPH J. BAUM, M.D.
Medpath
1261 Laural Branch Road, N.W.
Floyd, VA 24901

REFERENCES

When you have chronic unexplained medical problems [Patient Information]. Am Fam Physician 2000; 61:31-2.

EDITOR'S NOTE: Dr. Baum's points are well taken. The American Academy of Family Physicians (AAFP) has a policy regarding the use of the "specialist" designation for family practice physicians: AAFP defines a "specialist" in family practice as a physician who meets at least one of the following three criteria:

Current board certification by the American Board of Family Physicians (ABFP); or

Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)-approved family practice residency program, or a three-year American Osteopathic Association (AOA) approved postgraduate family practice residency program; or

Maintenance of eligibility requirements for active membership in the AAFP.

At AAFP, we are certainly sensitive to the points made by Dr. Baum. For example, as a matter of AFP style, we do not refer to family physicians (or any physician for that matter) as simply a "provider." And we certainly consider our family physician readers specialists in family practice.

The patient information handout that Dr. Baum refers to mentions "your family doctor" sending you [their patient] to see a "specialist." As used here, the term "specialist" is used in its more colloquial sense--that of a subspecialist in a given field. I think the context of the handout makes it clear that the family physician is the one in charge of the patient's care. And, certainly, it is not intended to disparage the skills or specialty status of family physicians. Being a practicing family physician myself, I can assure Dr. Baum that AFP will remain vigilant in promoting the ideals of our specialty.

Correction

The article "Use of Systemic Agents in the Treatment of Acne Vulgaris" (October 15, 2000, page 1823) contained an error in the dosage information for isotretinoin.

In two sentences on page 1828, the word "daily" should have been omitted. Those sentences should read as follows: (1) first column, ending sentence--"The average duration of therapy is five months, at which time most patients will have reached the desired goal of 120 to 150 mg per kg;" and (2) second column, second full paragraph, third sentence--"After reaching the goal dosage of 120 to 150 mg per kg, isotretinoin therapy should be discontinued even if the acne is not completely clear, because improvement continues for one to two months following cessation of treatment." The total cumulative dosage of isotretinoin should be 120 to 150 mg per kg. This level is generally reached over five to six months when using a daily dosage of 0.5 to 1.0 mg per kg. In practice, the desired total dosage should be calculated for each patient. Then, using the actual prescribed daily dose, the duration of therapy may be customized, if necessary.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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