© Springer International Publishing AG 2018Ehab Farag, Maged Argalious, John E. Tetzlaff and Deepak Sharma (eds.)Basic Sciences in Anesthesiadoi.org/10.1007/978-3-319-62067-1_31
31. Special Problems in Anesthesia
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
John E. Tetzlaff
31.1.1 Substance Abuse
31.2.3 Patient Safety
31.2.4 Core Competencies
KeywordsAnesthesiaSubstance abuseFatigueAgingDisabilityEthicsPractice managementMedicolegal issuesDo-not-resuscitateJehovah’s WitnessInformed consentPatient safetyMedication errors
Substance Abuse – Substance use disorder and addiction to anesthesia drugs is an unpleasantly common occupational hazard for learning and practicing anesthesiology that has been known since the beginnings of the specialty. The causes are multifactorial, include all categories of providers, and mainly involve drugs from the fentanyl family, and to a lesser extent, propofol, inhaled agents, midazolam, and others. The syndrome is deadly, but self-reporting is uncommon; death as first presentation is unfortunately common; and detection is most common by auditing or changes in performance. Suicide and coma are independently more common than self-reporting. Rehabilitation is difficult and requires extended in-patient treatment, with challenges from failure of re-entry and relapse. Relapse is unfortunately very dangerous with a high mortality rate. Prevention approaches include education, auditing, verification of wastage and electronic user profiles. The syringe manipulations associated with diversion creates the risk of transmission of infectious diseases to patients as well as other providers. Random drug testing is controversial and not widely deployed.
Fatigue – Fatigue is widely known to be associated with issues in health care. Sleep deprivation influences both cognitive and procedural elements of clinical care, most in the least experienced members of the team, and maximally at the same level of fatigue at the low part of the circadian rhythm. At 24 h and beyond of sleep deprivation, impairment of task performance is equivalent to legal intoxication and increases the risks of auto accident while driving home. Fatigue decreases performance, increases needle stick injury, bodily fluid exposure, and incomplete pre-anesthesia assessment.
Aging – In a gradual manner, aging has the same impact on performance as fatigue. The variable impact influences cognitive as well as procedural skills, accentuated at the low point of the circadian rhythm. There is less stamina and lower resistance to the impact of sleep deprivation. Accommodation is possible with reduced call frequency or duration or assignment of alternate responsibilities.
Disability – The Americans with Disabilities Act requires that employers not discriminate based solely on illness. In the context of anesthesiology, this requires that an individual presenting with a physical or mental illness be allowed to train or continue to train with reasonable accommodation. Physical disabilities can be accommodated with mechanical devices or orthotics. Issues with special senses sometimes can be accommodated with electronic or mechanical devices. Mental illness can be difficult to accommodate.
Professionalism – Elements of professionalism apply to physicians in general as well as elements that are unique to each specialty. General concepts include altruism, beneficence, non-malfeasance, and a commitment to the betterment of health care. Failures involve self-interest, consequences of mental illness, fraud, or abusive behavior among others. In anesthesiology, collegial participation in team care and respect for the customs of consultative care are essential.
Ethics – Basic concepts of ethics include altruism, beneficence, and a commitment to excellence. Issues for ethics with anesthesiology arise from the obligations in the event of refusal to provide care, do-not-resuscitate (DNR) status, and the right of the patient to refuse any treatment, including blood products. The right to refuse to participate in lethal injection is acknowledged. The criteria for informed consent is identified as well as the ability to act “in loco parentis” when an impaired individual presents with a life-threatening condition.
Patient Safety – Medication errors are frequently the cause of medical error within anesthesiology because of the number of medications needed for a case, the urgency to act in clinical situations, and the similarity in labeling and appearance of vials and ampules. Universal labeling, standardizations of labels, and visual identification of the drug, dose, and other details are part of medication safety. Any unlabeled syringe should be discarded regardless of the content. Disclosure of medical error is an essential element of good patient care, and in many states, laws allow for disclosure of medical error without admission of liability.
Competencies – Traditional evaluation in GME (global evaluation, written examination) has been replaced by a system of assessment of competencies. Behaviorally based milestones are measured at 6-month intervals, and determined to have been achieved or not, independent of the level of training. Ultimately, the goal is to determine the completion of training by achievement of competency as opposed to time in training
31.1.1 Substance Abuse
One of the most prevalent occupational hazards for an anesthesia provider is addiction to anesthesia drugs. Numerous reports estimate the incidence at about 1% per year of training. The American Board of Anesthesiology (ABA) database reports an incidence of 0.86% for residents between 1975 and 2009 . The risk has been known since the beginning of anesthesiology. Males are victims more often than females, American medical school graduates more than international graduates, and younger more frequently than older residents. The incidence has not decreased over time, despite knowledge, resources, and educational efforts dedicated to prevention. The consequences are serious with death, near death, and coma as the initial presentation in 5–10% of cases; less than half of addicted residents finish residency, and of those who do, 43% relapse over a 30-year career .
The cause is multi-factorial and includes the stress level in the operating room, psychiatric co-morbidity, prior experimentation with illicit drugs, “start to finish” drug handling, and the natural attraction that draws physicians to anesthesiology from learning that there is a chemical solution to most clinical problems. One provocative hypothesis is the observation that during anesthesia administration the provider is exposed to drugs during handling ampules (aerosol), from expired gas of extubated patients, or contact with work surfaces that are contaminated with the drugs. Chronic exposure may lead to changes in brain chemistry with down-regulation of dopamine receptors in brain reward centers with the addictive drug becoming the preferred agonist. Depression is also associated with chemical dependence in anesthesiology with a genetic linkage to addiction and self-medication known to be a symptom of depression.
The syndrome most commonly involves members of the fentanyl family with lesser contribution from propofol, inhaled agents, nitrous oxide, ketamine, midazolam, with rare reports of many other drugs including lidocaine, ephedrine, and even curare.
Detection is difficult, as self-reporting is rare, access to drugs and diversion are unpleasantly possible, and advanced parenteral skills make it possible to conceal self-administration and chemical dependence for extended intervals. Unfortunately, suicide and accidental death are both more common than self-reporting. The commonest means of detection when death or coma is not the presentation is investigation based on suspicious behavior or direct observation (needle in arm).
Treatment is difficult and requires prolonged in-patient care—best provided at a site with experience in addiction for physicians. Intervention must be planned, organized, and include direct admission to a treatment unit with the leverage of termination, report to the state medical board and the police (felony-diversion of controlled substance).
Re-entry to the specialty is controversial, with some reports of success in staff physicians with supervision of Physician Health Programs (PHP), although the relapse rate is high and dangerous (5–10% mortality). The controversy is even more intense over re-entry for residents because of the high failure rate to finish the residency, the frequent relapse rate, and 9% mortality .
Increasing attention is being paid to prevention of diversion, related to the risk of transmission of diseases to patients or co-workers, especially hepatitis C, from handling of contaminated syringes for diversion in the clinical arena. Automated dispensing, electronic user profiles and alerts for mal-transactions are being developed, along with random testing of waste-solutions. Random drug testing has been tried for detection of diversion, also adding an element of prevention. There are costs involved, logistical interferences with clinical work flow, false positives, and a vast array of strategies to “beat-the-test.” Randomization anomalies and false-positives are less of an issue when the testing is conducted with the use of a medical review officer (MRO), an expert in random testing who conducts the randomization as directed by the employer and verifies the validity of each test by excluding positives with a legitimate medical excuse (a prescription).
Stress and fatigue has been a part of medical education from the start. When medical residency began, the resident lived in the hospital with 1 day off (after rounds) per month. Even with duty hour restrictions and work hour monitoring, residency is a life-disruptive pattern, requiring adjustment to fatigue, sleep deprivation, and stress. Fatigue has a dose-dependent impact on both cognitive as well as motor performance. More than 24 h of consecutive sleep deprivation impairs function as much as being legally intoxicated by alcohol. Fatigue is generally associated with medical error with errors of omission being most common. The impact of fatigue on clinical tasks negatively influences both speed and accuracy. Experience with fatigue improves performance, more in accuracy than speed. Fatigue in anesthesia training has been associated with decreased efficiency with laryngoscopy, incomplete pre-anesthesia assessment, needle sticks, body fluid exposure, and an increased wet tap rate at night compared to the daytime. Risk for fatigue-caused medical error is highest during the low point in the human circadian rhythm (1–7 AM) and greater at the same level of fatigue with less clinical experience. Limiting consecutive work to 16 h has been shown to possibly improve patient safety in postgraduate year (PGY)-1 residents (interns). More experienced residents have learned to adapt and can extend patient care to 24 h and beyond for continuity; although it is clear that beyond 24 h, new patients should not be assigned. Even personal safety is an issue, as the resident awake for 24 consecutive hours has a greatly increased risk of having an auto accident while driving home. Sustained fatigue has been associated with reduced immune function, irritable bowel syndrome, depression, and a variety of other diseases. Strategies to reduce the impact of fatigue include napping, caffeine, and breaks from clinical work. Combinations of these choices work best. The highest risk is experienced by the most junior residents, high acuity care, and during low points of the circadian rhythm.
In a much more gradual manner, aging causes decrease in brain function in a manner similar to fatigue. Although the evidence is scarce, it is clear that at some point in human aging, there is decreased fine motor control and decreased tolerance of fatigue, especially during the low point in the circadian rhythm. Some of the decrements in performances have been compensated by reduced call duration, frequency, or assignment of alternate responsibilities. With the aging of the anesthetic work force, the issue will undergo increasing scrutiny over the upcoming decade.
31.1.4 Disability and the Americans with Disabilities Act
The Americans with Disabilities Act requires that an employer not discriminate based on illness. This means that an illness—physical or mental—cannot be the sole reason to not hire or to fire an individual. In the context of anesthesiology residency, it means that an individual presenting with a physical or mental illness must be allowed to train or continue training with reasonable accommodations. For physical disabilities, mechanical devices and orthotics have allowed individuals with spine or limb issues to function clinically in the anesthesiology world. Issues with the special senses can sometimes be accommodated with mechanical or electronic devices. Ultimately, the individual must be able to perform the basic duties of clinical anesthesiology with reasonable accommodations. Eligibility for board certification is determined by the Credentials Committee of the American Board of Anesthesiology (ABA) using letters and medical records. The unfortunate truth is that some disabilities cannot be accommodated, while others, particularity mental illness, can be difficult to accommodate.
31.2 Ethics, Practice Management, Medicolegal Issues
The practice of medicine requires the highest standards of professionalism for personal behavior during clinical care education and research. Since the practice of anesthesiology is the practice of a medical specialty, this fully applies to anesthesiology. The anesthesiologist has the responsibility to place the needs of the patient above his/her own, and to practice with altruism, beneficence, and to fully respect the patient’s autonomy and diversity. This commitment includes personal well-being, respect for colleagues, and participation in the smooth functioning of the development, the hospital, and the health care system as a whole. Respect for rules is an expectation—especially requirements for medical licensure and board certification. Deadlines are absolute and missing deadlines is a serious breach of professionalism that can have adverse consequences. Hot button professionalism issues are found in cases of conflict-of-interest and fraudulent scientific conduct. The anesthesiologist is the leader of the anesthesia team and must show respect for the talents and training of all team members. Most of the clinical care provided by the anesthesia team is provided as consultative services, and the respect for the needs of the primary care physicians (surgeon or proceduralist) is an important element of professionalism. The need to respect resources and economical use of supplies, disposables, equipment, and drugs is an increasing reality of anesthesia practice. Determining risk and recommending interventions to improve surgical outcome are consultant tasks that are an expected part of professional anesthesiology duties. Some elements of hospital functioning, such as acute pain management, transfusion practice, and operating room scheduling can be tasks best performed by an anesthesiologist, and hence are responsibilities accepted as part of a consultative anesthesiology practice.
Bioethics is becoming a common component of medical education. Despite numerous ethical issues, ethics is not a common component of anesthesiology residency. Changes in the American Board of Anesthesiology Oral Examination format and the RRC guidelines for Anesthesiology residency curriculum have changed this rapidly. Accordingly, it is reasonable to focus on the applications of ethics to anesthesia practice.
The need to apply ethics to medicine is driven by numerous clinical realities. Ethics must influence the physician’s right to choose clinical care. It also drives the response to the patient’s absolute right to choose. Responses to issues that relate to the law also require an ethical decision. Personal morality of physicians may influence their clinical choices. This is the ultimate mandate for ethics, since there is a requirement to “do no harm.”
Conventional ethics is based on definitions of right and wrong. The 2 extremes are utilitarianism, which determines right by outcome, and deontology, which strives to define absolute definitions of right and wrong. Medical ethics-bioethics is more commonly based on case-based reasoning, with reference to paradigmatic cases, which function like legal precedents.
The language of ethics uses several words with specific meaning. Justice refers to giving people what they deserve. Autonomy requires that informed people have the right to follow a self-chosen plan and to refuse any treatment. This requires substantial ability to understand treatment options and freedom from controlling influences. Non-maleficence is the obligation to avoid doing harm. Beneficence requires active action to do good or avoid harm. The “slippery slope” is an ethical concept that identifies a small evil as something that makes large evil easier. Events in Europe during World War II are classic examples of the “slippery slope.” Physician-assisted suicide is a current issue where this is discussed.
Hospitals recognize the relevance of bioethics by the creation of bioethics committees. These committees are designed for service. They can be called to consult in clinical situations with ethical issues. Some hospitals give authority to bioethics committees to make these decisions. There is some benefit in the medicolegal arena when appropriate bioethical documentation supports a controversial clinical decision.
Practice Management and Ethics
Numerous changes in anesthesia practice have serious ethical issues. With the increasing emphasis on clinical work to sustain income, non-patient care issues become harder to support. These include resident education, national committee membership, community service, research, and support for charitable anesthesia entities such as the Foundation for Anesthesia Education and Research (FAER), the Anesthesia Patient Safety Foundation (APSF), and the Wood Anesthesia Library.
Managed care and health care reform have placed sharp focus on the costs of health care. The cost of anesthesia services, devices, and drugs are included. Choosing the least expensive option is tempting, but must be considered in the context of the best outcome for the patient. This has come to be known as “value-based anesthesia.”
A controversial moral issue that confronts anesthesiologists is the subtle pressure to participate in physician-assisted suicide and penal lethal injection. The “slippery slope” concept is frequently raised in this discussion. Equally controversial is the decision to provide care to a patient who lucidly refuses an element of anesthesia, thus placing their life at risk.
In 1976, the Quinlan case in New Jersey established the right of a surrogate to refuse life-saving treatment. In 1990, the Cruzan case in Missouri established the right of patients to pre-designate their wishes about medical care and established the foundation for written directives. As of January 1, 2000, Ohio law requires hospitals to take steps to actively identify patients with do-not-resuscitate (DNR) orders, so that resuscitation will not be initiated in error. This includes the option to have anesthesia with a valid DNR order still active. This is a complete reversal of the prior practice that required removal of DNR orders to enter the operating room. In the 1990s, the American Society of Anesthesiologists (ASA) issued a guideline that recommended that care of DNR patients be individualized. As a result, most hospitals have implemented a goal-directed DNR policy. This involves a frank discussion with the patient, identifying the routine elements of anesthesia care that have similarity to resuscitation. This allows the patient the right to choose to accept or refuse specific techniques. There is no longer any justification to support refusal of humane palliation for DNR patients, based only on their DNR status.
Anesthesia and the Jehovah’s Witness
The Jehovah’s Witness is a member of a Christian religion that believes in the literal interpretation of the Bible. They believe in modern health care, but because of several passages of the Old Testament (Genesis 9:3,4, and Leviticus 17:10–16) and New Testament (Acts 15: 19–21), they refuse to be exposed to significant amounts of blood and blood products. Most will accept crystalloid and synthetic colloid. Some will accept albumin, erythropoietin, or individual coagulation factors. Others will not accept these products.
Competent adults have the right to refuse life-saving health care as part of informed consent. Minors and those who are incapacitated are not in this category. When those responsible propose refusal of blood products, it may be necessary to obtain a court order to override their preference. Some states are less willing to support refusal of blood in primary caregivers of children or handicapped adults, and courts in these areas may issue orders to transfuse.
Several ethical issues emerge. If an anesthesiologist cannot accept the patient’s decision, it must be identified prior to care. The patient then has the right to another physician and the first physician must facilitate this change. This obligates the original anesthesiologist to provide an equivalent alternative in a timely manner. Some Jehovah’s Witness patients will identify that they do not want to be told about decisions to transfuse. Their belief is that the person who starts the blood commits the sin. In these patients, disclosure of risks for informed consent is still required.
Ethics in Research
Several ugly issues occurred in the 1990s that cause doubt in the scientific process. Anesthesiology is not immune. Plagiarism has been reported in Anesthesiology . Ghost writing has been identified, with the attempt to secure “name authors” for papers that they did not write, in exchange for money. Studies that are heavily funded by one company have advocated practice change before this can be established by independent investigators. This has led to guidelines by the American Medical Association (AMA), endorsed by the ASA, which require disclosure of conflict of interest and whether speakers or even whole symposia plan to refer to specific name-brand drugs. It is the ethical responsibility of the anesthesiologist to attempt to determine the validity or, at minimum, believability of scientific work.
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