Transcript C13_Khursandi - Australian and New Zealand College of

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
2011
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Some of the risks to us in our profession
2011

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; 109:905-17
2011
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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 selfadministering propofol

Registrar found dead at home with intravenous cannula
and multiple drugs
2011
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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

2011
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MORE STATISTICS
Lutsky et al, 1992

2011
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
2011
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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
2011
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MORE STATISTICS
Booth et al (US) survey, 2002
Anesthesiologists
Drug abuse:
 1% of faculty members
 1.6% of registrars
2011
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MORE STATISTICS
Fry (Aus/NZ) survey, 2005
 44
substance abuse cases in 100
responding programs
 Death
2011
in 25% of cases
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Characteristics of Addicted Anaesthetists

67-88% male

76-90% use opioids (approx 1.6% in USA)

2011
(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


Anaesthetists account for 5% of all
doctors

2011
Anaesthetist trainees are 33.7% of those
presenting for treatment
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


2011
? 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


2011
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 ?
2011
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Why Anaesthetists?

Selection Bias ?

Choosing the speciality deliberately ?


2011
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 ?




2011
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 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
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Why is it so important ?
Because anaesthetists die from
intravenous drug overdose
(accidental or deliberate)



2011
“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
2011
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So much for the theory
What are we going to do about it ?
2011
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Sometimes we can do nothing
Because:

Abuse is not always recognised



2011
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
2011
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PREVENTION - CONTROL SYSTEMS
Agent control



Regulated dispensing – occurs with
opiates
Locking up the propofol & midazolam ?
– hasn’t worked with opiates !
Witnessed discarding – ditto


Always empty syringes

2011
good practice anyway
good practice anyway
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PREVENTION

Monitoring use ?


Has been tried
Usage profiling ?

Has been tried
Both time-consuming
2011
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Prevention

Random drug testing ?


Has been tried ?
Screening during recruitment ?

Has been tried ?
Both also time consuming
2011
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Prevention…
Disappointingly
Does not appear to have reduced the
incidence ….
2011
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PREPARATION - EDUCATION
2011

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 >20 years
Fentanyl 6-12 months
Propofol ?
2011
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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 selfadministration

Drugs, bloody swabs, tissues, pills, syringes,
ampoules, etc in any non-workspace environment,
eg at home, or in the change room
2011
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MAJOR SIGNS 2
2011

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
2011

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



2011
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
2011
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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
2011
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MINOR SIGNS 3

Wearing long-sleeved gowns in theatre or
warmer clothes than necessary


2011
conceal arms eg needle marks, in-dwelling
cannulae
sensitivity to temperature
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MINOR SIGNS 4
2011

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
2011
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MINOR SIGNS 6
2011

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
2011
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What to do if you suspect ?
Read RD 20
 Confirm evidence – Important



If confirmation:


Medical Board or Council must be informed
Structured team intervention


2011
How ?
Immediate therapeutic support
Initial inpatient care – in drug & alcohol
centre
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Welfare of Anaesthetists SIG
Substance Abuse
Resource Document 20
2011
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After the Intervention

Long term treatment – overseen
by Medical Board or Council


Engage with impaired registrants’
program

2011
May involve psychiatric help
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”


Return to work and conditions of work

2011
Bryson & Hanza 2011
determined by the Medical Board/Council or local
registration authority
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RECOVERY

Ongoing treatment

Ongoing monitoring

Ongoing mentoring

2011
Staged through nonclinical ->
supervised
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RECOVERY

Re-entry to anaesthesia ?



2011
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 you’re out” ?
Some think so
– high % of relapse and death
Some do not
– if good care & rehabilitation
2011
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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, 508–513
2011
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RETURN TO ANAESTHESIA - Trainees ?
Retraining in Australasia?
Fry et al 2005 survey (128 Aus/NZ programs)
2011

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
2011
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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
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RETURN TO ANAESTHESIA ?


2011
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
2011
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IN CONCLUSION - 2



2011
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); 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.

2011
J. Clin. Anesthesia (2009) 21, 508–513
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REFERENCES 2
Substance 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.
•
2011
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, 1:157-171
Ward et al survey 1983
2011
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REFERENCES 4
Chemical 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

2011
2009 July Mayo Clin Proc. 84:576-580
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2011
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