2011 DCSK 1

DEATH OF THE ANAESTHETIST ……UNDER ANAESTHESIA

ANZCA ASM HONG KONG 2011

Dr Diana C Strange KhursandiFRCA FANZCA

Director of Clinical Training

Acknowledgements: Dr Richard Morris, St. George Hospital, Sydney, AustraliaDrs. Michael Cooper & Erik Diaz, MD

2011 DCSK 2

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

2011 DCSK 3

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; 109:905-17

2011 DCSK 4

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

2011 DCSK 5

Statistics – not a new problem1983 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

2011 DCSK 6

MORE STATISTICS

Lutsky et al, 1992

16% of anaesthetic registrars or fellows reported problematic substance abuse during their training

2011 DCSK 7

MORE STATISTICS

Nurse anesthetists USA:2 surveys by Bell, 1999, 2006

10% admitted to self administration of controlled drugs1999 benzos, opiates2006 fentanyl, propofol

2011 DCSK 8

MORE STATISTICS

Collins et al (US) survey, 1991-2001

An impaired resident identified in 80% of 169 responding programs

20% experienced pre-treatment fatality

2011 DCSK 9

MORE STATISTICS

Booth et al (US) survey, 2002

AnesthesiologistsDrug abuse: 1% of faculty members 1.6% of registrars

2011 DCSK 10

MORE STATISTICS

Fry (Aus/NZ) survey, 2005

44 substance abuse cases in 100 responding programs

Death in 25% of cases

2011 DCSK 11

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

2011 DCSK 12

Anaesthetists vs. other doctorsTalbott 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

2011 DCSK 13

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]

2011 DCSK 14

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”

2011 DCSK 15

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 ?

2011 DCSK 16

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 ?

2011 DCSK 17

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” ?

2011 DCSK 18

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 brain’s 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

2011 DCSK 19

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”

2011 DCSK 20

Why so important ?

And…

Suicide accounts for up to 10% of anaesthetists’ deaths

Some of these deaths are associated with substance abuse

2011 DCSK 21

So much for the theory

What are we going to do about it ?

2011 DCSK 22

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

2011 DCSK 23

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

2011 DCSK 24

PREVENTION - CONTROL SYSTEMS

Agent controlRegulated dispensing – occurs with

opiates Locking up the propofol & midazolam ?

– hasn’t worked with opiates ! Witnessed discarding – ditto

good practice anyway Always empty syringes

good practice anyway

2011 DCSK 25

PREVENTION

Monitoring use ?Has been tried

Usage profiling ?Has been tried

Both time-consuming

2011 DCSK 26

Prevention

Random drug testing ?Has been tried ?

Screening during recruitment ?Has been tried ?

Both also time consuming

2011 DCSK 27

Prevention…

Disappointingly

Does not appear to have reduced the incidence ….

2011 DCSK 28

PREPARATION - EDUCATION

Regular trainee & specialist seminars

Compulsory web based training

A visiting expert

Consultant – trainee mentoring

Consultant – consultant buddy systems

2011 DCSK 29

RESPONSE – EARLY SIGNS

Time to detection of abuse dependson the drug

Alcohol >20 years

Fentanyl 6-12 months

Propofol ?

2011 DCSK 30

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

2011 DCSK 31

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

2011 DCSK 32

MAJOR SIGNS 3

Falsification of records, misuse of anaesthetic drugs

Observation of tremors or other withdrawal symptoms

Observation of intoxicated behaviour

2011 DCSK 33

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

2011 DCSK 34

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

2011 DCSK 35

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

2011 DCSK 36

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

2011 DCSK 37

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

2011 DCSK 38

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

2011 DCSK 39

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

2011 DCSK 40

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

2011 DCSK 41

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

2011 DCSK 42

Welfare of Anaesthetists SIG

Substance Abuse

Resource Document 20

2011 DCSK 43

After the Intervention Long term treatment – overseen by

Medical Board or CouncilMay involve psychiatric help

Engage with impaired registrants’ program MBA, MCNZ, local registration authority

2011 DCSK 44

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

2011 DCSK 45

RECOVERY

Ongoing treatment

Ongoing monitoring

Ongoing mentoring

Staged through nonclinical -> supervised

2011 DCSK 46

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 ?

2011 DCSK 47

RETURN TO ANAESTHESIA ?

Should the policy be

“One Strike and you’re out” ?

Some think so – high % of relapse and death

Some do not – if good care & rehabilitation

2011 DCSK 48

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, 508–513

2011 DCSK 49

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

2011 DCSK 50

Re-entry to anaesthesia ?

In summary, for trainees:

More junior trainees may be advised against re-entry

but there have been successes

2011 DCSK 51

RETURN TO ANAESTHESIA ?

Oreskovich & Caldeiro 2009 July Mayo Clin Proc. 84:576-580

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 ?

2011 DCSK 52

RETURN TO ANAESTHESIA ?

So - is it worth the risk to the doctors & the patients?

Probably, but we must choose carefully

2011 DCSK 53

IN CONCLUSION - 1

This is a serious issue

We need to look after each other

Prevention by closer control

Preparation with education

2011 DCSK 54

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

2011 DCSK 55

REFERENCES 1

Addiction and Substance Abuse in Anesthesiology. Bryson EO, Silverstein JH. Anesthesiology (2008); 109:905-17

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, 508–513

2011 DCSK 56

REFERENCES 2Substance Abuse by Anaesthetists in Australia and New

Zealand. Fry RA• Anaesthesia and Intensive Care; 2005; 33:248-255

The Medical Association of Georgia’s Impaired Physician’s Program: review of the first 1000 physicians: analysis of specialty. Talbot GD, Gallagos KV, Wilson PO, et al

• JAMA; 1987; 257:922-925

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

2011 DCSK 57

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 providerBryson & Hanza 2011 Int Anesth Clinics 49, 1:157-171

Ward et al survey 1983

2011 DCSK 58

REFERENCES 4Chemical dependency treatment outcomes of residents in

Anaesthesiology. Collins et al (US) survey • Anesth Analg. 2005:101(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. 84:576-580

2011 DCSK 59