DEATH OF THE ANAESTHETIST ……UNDER ANAESTHESIA

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DEATH OF THE ANAESTHETIST UNDER ANAESTHESIA

• ANZCA ASM HONG KONG 2011
• Dr Diana C Strange Khursandi
• FRCA FANZCA
• Director of Clinical Training
• Acknowledgements
• Dr Richard Morris, St. George Hospital,
• Sydney, Australia
• Drs. Michael Cooper Erik Diaz, MD

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Some of the risks to us in our profession

• Toxicity of anaesthesia agents
• Blood borne infections
• Fire electrocution
• Ionising radiation
• Latex allergy
• Stress mental illness
• Substance abuse

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RECOGNITION OF SUBSTANCE ABUSE

• All anesthesia personnel should be
• aware of the basic nature of the problem,
• and possess the necessary information
• to recognize and assist an impaired
• colleague.
• Addiction and Substance Abuse in Anesthesiology.
• Bryson EO, Silverstein JH. Anesthesiology.2008
  109905-17

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EXAMPLES

• Theatre cleaner found dead in a cupboard with a
  hanky bottle of halothane
• Registrar found dead at home with fentanyl self
  treating his migraines
• Anaesthetist found unconscious in toilet after
  self-administering propofol
• Registrar found dead at home with intravenous
  cannula and multiple drugs

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Statistics not a new problem

• 1983 Ward et al survey
• 334 drug-dependent persons in 184/247 (74) of
  responding US anaesthesia programs
• Pethidine fentanyl most common
• Long term follow-up available for 201 persons
• 55 rehab
• 2/3 of these (71) offered return to original
  place of employment
• 30/201 (15) dead of drug overdose

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MORE STATISTICS

• Lutsky et al, 1992
• 16 of anaesthetic registrars or fellows reported
  problematic substance abuse during their training

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MORE STATISTICS

• Nurse anesthetists USA
• 2 surveys by Bell, 1999, 2006
• 10 admitted to self administration of controlled
  drugs
• 1999 benzos, opiates
• 2006 fentanyl, propofol

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MORE STATISTICS

• Collins et al (US) survey, 1991-2001
• An impaired resident identified in 80 of 169
  responding programs
• 20 experienced pre-treatment fatality

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MORE STATISTICS

• Booth et al (US) survey, 2002
• Anesthesiologists
• Drug abuse
• 1 of faculty members
• 1.6 of registrars

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MORE STATISTICS

• Fry (Aus/NZ) survey, 2005
• 44 substance abuse cases in 100 responding
  programs
• Death in 25 of cases

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Characteristics of Addicted Anaesthetists

• 67-88 male
• 76-90 use opioids (approx 1.6 in USA)
• (propofol x 10 less common, 0.1 in USA)
• 33-50 are poly-drug users
• 33 have family history of addictive disease
• 65 associated with academic departments
• Often associated with psychiatric illness

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Anaesthetists vs. other doctors

• Talbott et al, JAMA 1987
• Anaesthetic trainees comprise 4.6 of trainee
  population
• Anaesthetist trainees are 33.7 of those
  presenting for treatment
• Anaesthetists account for 5 of all doctors
• 13-15 of physician treatment population

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Why does it happen to some people?

• Themes common to general population, as well as
  other doctors
• Genetic predisposition
• Psychiatric co-morbidities
• ? Self medication of symptoms
• Social factors alienation, family issues

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Why does it happen to some people?

• Experimentation Risk-takers
• Self-medication - acceptable
• Regulation of sleep patterns night shifts
• Escape from pain of traumatic events drugs will
  numb memories

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Why Anaesthetists?

• Ease of diversion ?
• High-stress environment ?
• Proximity to highly addictive drugs ?
• Direct administration and their witnessed effect
  ? (We know our drugs)
• Exposure to picograms of drugs ?

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Why Anaesthetists?

• Selection Bias ?
• Choosing the speciality deliberately ?
• Medical students/residents with predisposition to
  drug abuse more likely to enter anaesthetic
  training ?
• do medical students/doctors choose anaesthesia as
  a speciality because of ease of access to
  powerful drugs ?

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Why Anaesthetists ?

• Do risk-takers choose anaesthesia more frequently
  because of the buzz of the theatre environment ?
• Does the risky nature of our professional
  activities brain death in 5 minutes if you get
  it wrong encourage risk-taking activity ?
• I can get away with it, because I know how to
  use these drugs ?
• I am clever enough to hide what I am doing ?

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Exposure-related theories

• Increased risk is related to opioid or propofol
  sensitization through inhalation or absorption of
  picograms of these agents ?
• Low-dose exposures sensitize brains reward
  pathways to promote substance use ?
• Anaesthetists may use drugs to alleviate the
  withdrawal they feel when away from the exposure
  ?
• Gold et al 2006, McAuliffe et al 2006

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Why is it so important ?

• Because anaesthetists die from intravenous drug
  overdose (accidental or deliberate)
• 20 experienced pre-treatment fatality
• Death in 25 of cases
• 15 dead of drug overdose

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Why so important ?

• And
• Suicide accounts for up to 10 of
• anaesthetists deaths
• Some of these deaths are
• associated with substance abuse

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• So much for the theory
• What are we going to do about it ?

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Sometimes we can do nothing

• Because
• Abuse is not always recognised
• Addicts are extremely clever at hiding their use
• So
• Sometimes the first indication of abuse is the
  death of the abuser

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What can we do ?

• Prevention - difficult
• Preparation essential education
• Response - planned
• Recovery - prolonged
• A strategy to prevent substance abuse in an
  academic
• anesthesiology department.
• Tetzlaff et.al J. Clin. Anesthesia. (2010) 22
  143 150

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PREVENTION - CONTROL SYSTEMS

• Agent control
• Regulated dispensing occurs with opiates
• Locking up the propofol midazolam ? hasnt
  worked with opiates !
• Witnessed discarding ditto
• good practice anyway
• Always empty syringes
• good practice anyway

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PREVENTION

• Monitoring use ?
• Has been tried
• Usage profiling ?
• Has been tried
• Both time-consuming

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Prevention

• Random drug testing ?
• Has been tried ?
• Screening during recruitment ?
• Has been tried ?
• Both also time consuming

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Prevention

• Disappointingly
• Does not appear to have reduced the
• incidence .

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PREPARATION - EDUCATION

• Regular trainee specialist seminars
• Compulsory web based training
• A visiting expert
• Consultant trainee mentoring
• Consultant consultant buddy systems

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RESPONSE EARLY SIGNS

• Time to detection of abuse depends
• on the drug
• Alcohol gt20 years
• Fentanyl 6-12 months
• Propofol ?

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MAJOR SIGNS 1

• Finding an intravenous needle or cannula in situ
  observation of injection marks on the body
• Direct observation of diversion or
  self-administration
• Drugs, bloody swabs, tissues, pills, syringes,
  ampoules, etc in any non-workspace environment,
  eg at home, or in the change room

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MAJOR SIGNS 2

• Signing out increasing quantities of (usually
  opiate) drugs, or quantities of drug which are
  inappropriately high for the use specified
• Inconsistencies in recording drug use for
  patients, or unaccountably missing drugs
• Increasingly illegible, inaccurate, altered, or
  otherwise inadequate or unusual record-keeping

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MAJOR SIGNS 3

• Falsification of records, misuse of anaesthetic
  drugs
• Observation of tremors or other withdrawal
  symptoms
• Observation of intoxicated behaviour

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MAJOR SIGNS 4

• A consistent pattern of complaints regarding
• Excessive pain, by recovery or ward staff, in
  patients of a particular anaesthetist
• The patients pain is out of proportion to the
  recorded amounts of analgesic drugs given.
• Reports of a major change in attitudes or
  behaviours

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MINOR SIGNS 1

• Willing to relieve others in theatre,
  volunteering for more cases, more on call
• Working alone, refusing breaks
• Unavailability, irregular hours, decrease in
  reliability, poor punctuality
• Increasing time in toilet/bathroom

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MINOR SIGNS 2

• Being in the hospital when not working, off duty,
  and not on call, especially out of hours
• Increased sick leave, and/or absenteeism
• Spots of blood on clothing, carrying syringes or
  ampoules in clothing

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MINOR SIGNS 3

• Wearing long-sleeved gowns in theatre or warmer
  clothes than necessary
• conceal arms eg needle marks, in-dwelling
  cannulae
• sensitivity to temperature

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MINOR SIGNS 4

• Leaving the patient unattended in theatre
• Being found in unusual places in the theatre
  complex when expected to be in theatre.
• Personally administering medication normally
  others' responsibility
• Significant changes in behaviour, presentation,
  personality or emotions

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MINOR SIGNS 5

• Elaborate rationalisations of bizarre conduct
• Obtaining an unusual medical diagnosis for
  bizarre conduct or symptoms (arising from drug
  usage)
• Increase in accidents or mistakes
• Deterioration in personal hygiene

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MINOR SIGNS 6

• Wide mood swings, periods of depression,
  euphoria, caginess or irritability, social
  withdrawal, increased isolation or elusiveness
• Intoxicated behaviour, pin point pupils, weight
  loss, pale skin
• Deterioration of personal relationships,
  development of domestic turmoil, decrease in
  sexual drive

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MINOR SIGNS 7

• Numerous health complaints, impulsive behaviour
• Frequent moving or changing jobs, unsatisfactory
  work records
• Health concerns expressed by partner or family
• Other inappropriate conduct, eg overspending

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What to do if you suspect ?

• Read RD 20
• Confirm evidence Important
• How ?
• If confirmation
• Medical Board or Council must be informed
• Structured team intervention
• Immediate therapeutic support
• Initial inpatient care in drug alcohol centre

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Welfare of Anaesthetists SIG

• Substance Abuse
• Resource Document 20

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After the Intervention

• Long term treatment overseen by Medical Board
  or Council
• May involve psychiatric help
• Engage with impaired registrants program
• MBA, MCNZ, local registration authority

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After the Intervention

• Because of the association between chemical
  dependence and other psychopathology, successful
  treatment for addiction is less likely when
  comorbid psychopathology is not treated
• Bryson Hanza 2011
• Return to work and conditions of work
• determined by the Medical Board/Council or local
  registration authority

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RECOVERY

• Ongoing treatment
• Ongoing monitoring
• Ongoing mentoring
• Staged through nonclinical -gt supervised

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RECOVERY

• Re-entry to anaesthesia ?
• A high risk but high gain decision
• More junior trainees may be advised against this
  but there have been successes
• Retraining outside anaesthesia ?

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RETURN TO ANAESTHESIA ?

• Should the policy be
• One Strike and youre out ?
• Some think so
• high of relapse and death
• Some do not
• if good care rehabilitation

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RETURN TO ANAESTHESIA - Trainees ?

• Should anesthesia residents with a history of
• substance abuse be allowed to continue training
• in clinical anesthesia?
• 135 trainees needing treatment -10 years
• 73 (99) returned to training (36 did not)
• 29 (29) of these relapsed (70 did not)
• 14 (4) of these died
• Bryson E. Journal of Clinical Anesthesia (2009)
  21, 508513

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RETURN TO ANAESTHESIA - Trainees ?

• Retraining in Australasia?
• Fry et al 2005 survey (128 Aus/NZ programs)
• 16 registrars (44 total)
• 5/7 returning relapsed - 1 died
• 19 (1 out of 5) of abusers made a long-term
  recovery within the specialty

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Re-entry to anaesthesia ?

• In summary, for trainees
• More junior trainees may be advised against
  re-entry
• but there have been successes

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RETURN TO ANAESTHESIA ?

• Oreskovich Caldeiro 2009
• July Mayo Clin Proc. 84576-580
• A guarded yes,
• but it depends significantly on the
• quality of the intervention and rehabilitation
• What is the quality of these processes in
• Australia, New Zealand and HK ?

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RETURN TO ANAESTHESIA ?

• So - is it worth the risk to the doctors the
  patients?
• Probably, but we must choose carefully

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IN CONCLUSION - 1

• This is a serious issue
• We need to look after each other
• Prevention by closer control
• Preparation with education

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IN CONCLUSION - 2

• Recognition and/or suspicion of substance abuse
  major and minor signs
• Respond in a pre-planned way
• Think carefully about recovery re-entering
  training

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REFERENCES 1

• Addiction and Substance Abuse in Anesthesiology.
• Bryson EO, Silverstein JH.
• Anesthesiology (2008) 109905-17
• A strategy to prevent substance abuse in an
  academic anesthesiology department.
• Tetzlaff et al.
• J. Clin. Anesthesia (2010) 22 143 150.
• Should anesthesia residents with a history of
  substance abuse be allowed to continue training
  in clinical anesthesia?
• Bryson E.
• J. Clin. Anesthesia (2009) 21, 508513

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REFERENCES 2

• Substance Abuse by Anaesthetists in Australia and
  New Zealand. Fry RA
• Anaesthesia and Intensive Care 2005 33248-255
• The Medical Association of Georgias Impaired
  Physicians Program review of the first 1000
  physicians analysis of specialty. Talbot GD,
  Gallagos KV, Wilson PO, et al
• JAMA 1987 257922-925
• Psychoactive Substance Use among American
  Anesthesiologists a 30 year retrospective study.
  
• Lutsky I et al.
• Can J Anaes 1993, Vol 40, no 10 3060-3062

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REFERENCES 3

• A survey of propofol abuse in academic anesthesia
  programs. Wischmeyer et al.
• International Anesth Research Society vol 105,
  no4, Oct 2007 1066-1071
• The Drug Seeking Anesthesia Care provider
• Bryson Hanza 2011
• Int Anesth Clinics 49, 1157-171
• Ward et al survey 1983

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REFERENCES 4

• Chemical dependency treatment outcomes of
  residents in Anaesthesiology. Collins et al (US)
  survey
• Anesth Analg. 2005101(5) 1457-1462.
• Substance abuse among physicians a survey of
  academic anesthesiology programs. Booth et al
  (US) survey
• Anesth Analg , 2002 95(4) 1024-1030
• Anesthesiologists recovering from chemical
  dependency Can
• they safely return to the operating room ?
  Oreskovich Caldeiro
• 2009 July Mayo Clin Proc. 84576-580

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