2011dcsk1 death of the anaesthetist ……under anaesthesia anzca asm hong kong 2011 dr diana c...
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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
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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; 109:905-17
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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 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
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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 drugs1999 benzos, opiates2006 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
AnesthesiologistsDrug 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 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
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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 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
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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 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
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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 dependson the drug
Alcohol >20 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 CouncilMay 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 -> 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 you’re 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, 508–513
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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. 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 ?
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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); 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
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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 providerBryson & Hanza 2011 Int Anesth Clinics 49, 1:157-171
Ward et al survey 1983
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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