DEATH OF THE ANAESTHETIST ……UNDER ANAESTHESIA

1. 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 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 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 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 DCSK

5. 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 DCSK

6. MORE STATISTICS Lutsky et al, 1992 • 16% of anaesthetic registrars or fellows reported problematic substance abuse during their training DCSK

7. 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 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 DCSK

9. MORE STATISTICS Booth et al (US) survey, 2002 Anesthesiologists Drug abuse: • 1% of faculty members • 1.6% of registrars DCSK

10. MORE STATISTICS Fry (Aus/NZ) survey, 2005 • 44 substance abuse cases in 100 responding programs • Death in 25% of cases 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 DCSK

12. 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 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] 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” DCSK

15. Why Anaesthetists? • Ease of diversion ? • High-stress environment ? • Proximity to highly addictive drugs ? • Direct administrationand their witnessed effect ? (“We know our drugs”) • Exposure to picograms of drugs ? 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 ? 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” ? 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 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” DCSK

20. Why so important ? And… Suicide accounts for up to 10% of anaesthetists’ deaths Some of these deaths are associated with substance abuse DCSK

21. So much for the theory What are we going to do about it ? 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 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 DCSK

24. PREVENTION - CONTROL SYSTEMS Agent control • Regulated 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 DCSK

25. PREVENTION • Monitoring use ? • Has been tried • Usage profiling ? • Has been tried Both time-consuming DCSK

26. Prevention • Random drug testing ? • Has been tried ? • Screening during recruitment ? • Has been tried ? Both also time consuming DCSK

27. Prevention… Disappointingly Does not appear to have reduced the incidence …. DCSK

28. PREPARATION - EDUCATION • Regular trainee & specialist seminars • Compulsory web based training • A visiting expert • Consultant – trainee mentoring • Consultant – consultant buddy systems DCSK

29. RESPONSE – EARLY SIGNS Time to detection of abuse depends on the drug Alcohol >20 years Fentanyl 6-12 months Propofol ? 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 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 DCSK

32. MAJOR SIGNS 3 • Falsification of records, misuse of anaesthetic drugs • Observation of tremors or other withdrawal symptoms • Observation of intoxicated behaviour 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 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 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 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 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 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 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 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 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 DCSK

42. Welfare of Anaesthetists SIG Substance Abuse Resource Document 20 DCSK

43. 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 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 DCSK

45. RECOVERY • Ongoing treatment • Ongoing monitoring • Ongoing mentoring • Staged through nonclinical -> supervised 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 ? 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 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 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 DCSK

50. Re-entry to anaesthesia ? In summary, for trainees: More junior trainees may be advised against re-entry but there have been successes DCSK