Illness and Drug Use
Every anesthetist is vulnerable to transient illnesses, which
in some cases probably reduce performance ability. All personnel are vulnerable
to chronic medical conditions, which could directly or indirectly affect their fitness
and performance capabilities. The culture of the caring professions often leads
individuals to continue to work with illnesses that would cause other professionals
to stay at home or to seek medical advice. The performance-shaping effects of the
illness can be exacerbated by the use of either over-the-counter or prescribed medications.
The degree to which illness and medications affect anesthetist performance is unknown.
A serious problem for anesthetists is that of drug abuse (see
Chapter 88
).[406]
[407]
[408]
[409]
[410]
[411]
It
is
estimated that up to 8% of physicians could be classified as alcoholics. In an anonymous
survey of anesthesia personnel from one institution, 75% of respondents reported
drinking alcohol on a regular basis.[412]
They
reported drinking an average of 1.6 drinks per day 2.7 days per week. Just less
than 10% of subjects reported having been "hung-over" while conducting anesthesia,
and 40% reported having given anesthesia within 12 hours of alcohol consumption;
84% stated that alcohol use never adversely affected their clinical performance.
The degree to which small doses of alcohol or hangovers affect
performance of complex, real-world tasks is uncertain. Some studies of general aviation
and navy pilots[403]
[413]
[414]
[415]
suggested
that hangover effects can degrade performance even when more than 8 hours have elapsed
since alcohol consumption and there is no detectable blood alcohol level. However,
although statistically significant, the performance changes seen in these studies
may not have been functionally significant. These studies[403]
[413]
[414]
[415]
also suggested an interaction among age, workload, and hangover in causing performance
decrements. However, the "aged" cohort was defined as 31 years of age or older and
was compared with a cohort of pilots in their early 20s. Extrapolating these results
to the anesthesia domain is difficult.
Nonetheless, the natural history of serious abuse of alcohol,
cocaine, sedatives, or narcotics by anesthetists is such that cognitive performance
will at some point be seriously compromised. However, addiction specialists frequently
report that job performance is one of the last areas of life to become impaired.
[410]
For this reason, the period of time in which
the addicted anesthetist's performance in the OR is significantly impaired is a relatively
small fraction of the total time during which drugs are abused. Although this in
no way excuses the practice of conducting anesthesia while under the influence of
drugs, it may account for the fact that reports of addicted anesthesiologists are,
unfortunately, common, whereas reports of overt patient risk or harm resulting from
an addicted physician's errors are unusual.
Anesthesiology has been at the forefront in dealing with impaired
medical personnel. The management of those discovered with drug impairment is fairly
standardized,[406]
[408]
but the question whether to return these individuals to anesthesia practice is increasingly
controversial, even when they return under carefully monitored reentry protocols.
[411]
The main risk appears to be to the addict's
own safety, although questions about patient safety can never be eliminated.
Ultimately, in the current medical system, the responsibility
rests with the anesthetist to ensure that his or her own performance level is sufficient
for the work at hand. Pilots utilize a mnemonic checklist to review the effects
of potential performance-shaping factors and are instructed not to fly if they are
impaired for any reason. The difficulty in anesthesiology (and to some degree in
aviation) is that the real-world organization and incentives of many practice settings
do not provide mechanisms for personnel to excuse themselves if they are temporarily
impaired. Ironically, there may now be better means to identify and support the
practitioner with a serious addiction than there are for the more common occurrences
of profound sleep deprivation or impairment by a transient or chronic illness.
