occupational well-being

8/10/2019 Occupational Well-Being

http://slidepdf.com/reader/full/occupational-well-being 1/289



Sociedade Brasileira de Anesesiologia

Conselho Federal de Medicina

Occupational Well-being in Anesthesiologists

Edior

Gasão F. Duval Neo

Rio de Janeiro2014



Copyrigh © 2014 – Brazilian Sociey o Aneshesiology

Brazilian Sociey o Aneshesiologyua Proessor Alredo Gomes, 36

Boaogo – io de Janeiro/JCEP 22251-080Phone: 55 21 3528 1050Fax: 55 21 3528 1099E-mail: [email protected]

Federal Council o Medicine o BrazilSGAS 915, loe 72 – CEP 70390-150 – Brasília/DFPhone: 55 61 3445 5900 – Fax: 55 61 3346 0231E-mail: [email protected]

Publicaion also available a: htp://www.poralmedico.org.brEdiorial Board Anônio Fernando CarneiroDesiré Carlos CallegariHammer Nasasy Palhares Alvesonaldo Laranjeira

Insiuional SupporBrazilian Sociey o Aneshesiology (Sociedade Brasileira de Anesesiologia (SBA))Federal Council o Medicine o Brazil (Conselho Federal de Medicina (CFM))

Lain American Conederaion o Socieies o Aneshesiology (ConederacionLainoamericana de Sociedades de Anesesiología (Clasa))

World Federaion o Socieies o A naeshesiologiss (WFSA)

Supervision – Maria de Las Mercedes Azevedo

Supervision/Review/ranslaion – Geulio odrigues Oliveira Filho, Gabriela Nerone,Maria Eduarda Brinhosa, João Felipe Locaelli

Graphic design and layou– Marcelo de Azevedo Marinho

S678o Occupaional Well-being in Aneshesiologiss / Edior: Gasão F. Duval Neo. Auores: Gasão F.Duval Neo e al .io de Janeiro: Sociedade Brasileira de Anesesiologia/SBA, 2014.286 p.

ISBN 978-85-98632-24-7

1- Occupaional healh and principles. 2- insiuional responsabiliies and

physicians. 3- Biological hazards. 4- inerdisciplinar aspecs o occupaional well-being. I – Duval Neo, Gasão F.CDD 617.96

mailto:sba%40sba.com.br?subject=

mailto:cfm%40portalmedico.org.br?subject=

http://www.portalmedico.org.br/

http://www.portalmedico.org.br/

mailto:cfm%40portalmedico.org.br?subject=

mailto:sba%40sba.com.br?subject=



Summary

Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05

Preface SBA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

Preface WFSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 09

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Part 1 - Principles and basis of occupational health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

1.1 Evaluaion o aneshesiologiss occupaional well-being around he world ........................15Gusavo Calabrese orchiaro

1.2 e sress caused by medical emergencies. Faigue and is correlaion wih diseases, suicide andmedical malpracice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Flavio Veinemilla Sig - ú

1.3 Facors involved in he developmen o chemical dependency in aneshesia personnel . . . . . . . . . . . . 57oger Addison Moore

1.4 Burnou syndrome in anaeshesiologiss- he acual realiy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97 Prayush Gupa e Florian Nuevo

1.5 Measuring proessional well-being among aneshesiologiss: Concepual srucures andatribues o he insrumens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Geúlio odrigues de Oliveira Filho

1.6 Aneshesiology residens – e imporance o occupaional well-being . . . . . . . . . . . . . . . . . . . . . . . . . .127 Maria-Helena Arenson Pandikow e Florenino Fernandes Mendes

1.7 e Proessional well-being o aneshesiologiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143 Pirjo Lindors

Part 2 - Institutional responsibility for physician (anesthesiologist) occupational well-being . .1652.1 Correlaion beween aneshesiologiss’ occupaional well-being and surgical paien saey . . . . . .167

Gasão Fernandes Duval Neo

Part 3 - Biological risks and occupational health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191

3.1 adioproecion or aneshesiologiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Anonio Fernando Carneiro e Onoe Alves Neo

3.2 Mechanical occupaional risks in aneshesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199 Anenor de Muzzio Gripp e Luiza Alves de Casro Arai

3.3 Ergonomic occupaional risks in aneshesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207 Luiz Aledo Jung

3.4 Biological occupaional r isks in aneshesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221 Anonio Fernando Carneiro e Fabiana Ferreira AP Bosco Bosco

3.5 Exposure o inhaled anesheics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .231 Maria Angela ardelli, Carlos ogério Oliveira Degrandi e Edno Magalhães

3.6 Exposure o chemical agens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243ogean odrigues Nunes e Cris iane Gurgel Lopes Farias

3.7 Sharps injuries: Guidance or he aneshesiologis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253Oscar César Pires

Part 4 - Interdisciplinary aspects of occupational health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257

4.1 Addicion among aneshesiologiss: rom diagnosis o inervenion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .259Hamer Nasasy Palhares Alves, Luiz Anonio Nogueira Marins, Daniel Sócraes e onaldo Larnajeira

4.2 Ehical and legal aspecs o medical malpracice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277 Desiré Carlos Callegari



Presenaion | 5

Presenaion

e occupaional healh and welare o Brazilian physicians are poins o concern ohe Federal Council o Medicine (CFM). Nowadays, we live in imes o grea social,

culural, economic and poliical changes ha direcly impac on he physician-paien relaionship, on he way medicine is exered and on personal and proessionallives o colleagues who ulfill heir mission in hospials, emergency rooms, and ou-paien aciliies.

In general, he absence o public policies ha value he role o he docor in assisanceassociaed wih he lack o invesmen in healh evenually produce a scenario o dis-incenive and pressure on he proessional who, unorunaely, in some siuaions, becomes vicim o his neglec. A mid he real needs o paiens and he indifference

o he managers, he docor has been pushed owards he brualizaion o his/herposures, physical and emoional disress and he search or inadequae soluions omiigae daily difficulies.

is issue assumes relevan proporions among aneshesiologiss due o he char-acerisics o he specialy. However, he phenomenon is no isolaed and should bereaed. Aware o he implici severiy o his ac, he CFM - in an unprecedenedparnership wih he Brazilian Sociey o Aneshesiology (SBA) - creaed a NaionalCommission or Ehics and Medical Assisance o he Chemically Dependen Physi-cian Paien, announced a he conclusion o he Firs Inernaional Symposium onOccupaional Healh o Aneshesiologiss, held in Brasilia in Sepember 2013.

is book is one o he firs producs o his group. e compiled aricles providedaa relevan o he ormulaion o a diagnosis o he problem and sugges pahs oruure coping sraegies. A firs, aneshesiologiss make up he ocus group, bu sooni is expeced hese benefis and services are expeced o be exended o he enirepopulaion o physicians.

As occurred wih a similar iniiaive, conduced by he egional Medical Council o

he Sae o São Paulo (Cremesp), which served as a mirror o he curren proposal, boh SBA and CFM are confiden ha hey can conribue decisively o assis physi-cians in crisis, giving hem new opporuniies. us, our eniies will make a differ-ence as suppors o rebuil lives and careers.

Luiz Robero d’ AvilaPresiden o CFM

Desiré Carlos CallegariFirs secreary o CFM



Preace SBA | 7

Preace by he Brazilian Sociey o Aneshesiology

e Brazilian Sociey o Aneshesiology (SBA) provides is members - and he medi-cal lieraure - wih his book on he condiions necessary o ensure a high degree o

saey and qualiy o lie a work, cal ling ino atenion he urgen need or proecinghe healh o physicians, eaching o promoe physical, menal, social and moral wel-are, as well as he prevenion, deecion, approach / reamen measures and conrolo accidens and / or illnesses resuling rom he pracice o medicine, hus enablinghe reducion o risky siuaions.

We can say ha he Commission on Occupaional Healh o he SBA reaches hismajoriy a his ime, when i overcomes he inernal perimeers o aneshesia and, inparnership wih he Federal Council o Medicine, he Lain American Conedera-

ion o Socieies o Aneshesiology and he World Federaion o Socieies o Anaes-hesiologiss, envisions, designs and implemens he descripion o many relevanopics o he healh o physicians in a single book, published in hree languages -Poruguese, Spanish and English .

We have effecive awareness o he imporance o his book, which is why i has become so pleasurable. We hope o raise he readers undersanding o he need orchanges in personal atiudes, especially oward heir behaviors in hospials, clinicsand a home, enabling hem aided by he recommendaions conained in his publi-caion, o achieve proessional welare associaed wih personal happiness.

Airon BagainiPresiden o he Brazilian Sociey o Aneshesiology, 2013



Preace WFSA | 9

Preace WFSA

All people will experience sress during heir lives. Sress aer all is concomian wih modern liv ing and whaever your job, i is likely ha you will suffer momens

o exreme sress. Sadly his seems o be beginning in childhood and when a schoolpressures are applied o ‘succeed’ and ‘do well’ by being able o pain, read, play amusical insrumen and ac in a play all beore you are 6 years o age!! Lie has becomeanasically compeiive so ha parens seek o push heir children and boas abouimpossible goals achieved which in urn increases he sress in ohers.

Sress is naurally relaed o income sreams, housing, educaion, work, perceivedsuccess and hen illness and dying. A imes or many here seems no escape and hisis rue all over he globe in almos all culures and counries. So i we now add onohis he sress o being responsible almos oally or someone’s lie (as he anaes-hesiologis oen is!) i is no really surprising ha many people in our proessionsuccumb o he pressures o his sress.

Human beings are allible by definiion and so all o us make misakes. Modern liedoes no allow his as everyhing ha goes wrong mus be he aul o somebody orsome organisaion and hey mus pay recompense or he misake. is compoundssress or he individual who, oen or no obvious reason, errs.

So by acceping ha all anaeshesiologiss are under sress o varying degrees wehave o find ways o recognise and hen deal wih ha condiion. I has been my expe-rience ha some people go and play he violin, some ry o punish a squash ball byflatening i agains a wall and ohers find kindred souls o whom hey can alk andexplore he siuaion in which hey are placed. Ohers misakenly deny hemselveshis respie and ignore i or urn o alcohol or drugs o ry o remove he problem.is never works in he medium or long erm. O even more concern are he culures, which may be naional or jus insiuional, who consider i a ailure o voice sressulexperiences and his will cause suppression and laer errible problems.

In he pas ew decades more and more anaeshesiologiss have looked o find ways o

ease sress in hemselves and in colleagues. I is now a regular opic a Inernaional Anaeshesiology Conerences and numerous aricles have appeared in prin. Sadlyhis is no enough and here is sill an unaccepable rae o ‘burn ou’ or even suicideamongs our proession.

Gasão Duval Neo, who chairs he WFSA Proessional Well-being Commitee,has wih he help o he Brazillian Sociey o Aneshesiology, he Conederaion oLain American Socieies o Aneshesiologiss and he WFSA, creaed a wonderul book o ry and help our proession urher. He has brough ogeher he oremos

leaders in he field who have writen careully researched chapers which will showhow sress can be recognised, lived wih and finally overcome. Bu his book goes beyond jus looking a sress and encompasses he whole o proessional well-being



10 | Occupaional Well-being in Aneshesiologiss

in all is orms. We hope ha he book will be read by colleagues, wives, husbands,managers and oher medical disciplines o permi an insigh ino he errible sressesha can occur wihin our proession. I recall being old by one senior colleague asI sared my anaeshesia raining ha “anaeshesia was eiher awully simple or sim-

ply awul!”Alhough a rie saemen i does have a cerain basic ruh bu wha is

more worrying is ha i is easy o subsiue he word ‘lie’ or ha o ‘anaeshesia’in ha saemen. is is hen a subjec which requires careul consideraion by all who work in anaeshesiology o ensure ha l ie or work evens do no swamp eiher young or old lives.

We hope ha his book will help people realise ha hey are no a lone in experienc-ing hard imes, ha help is available and ha aking his help will no be deleeriouso heir uure careers; in ac i may save hem.

David J WilkinsonPresiden, World Federaion o Socieies o Anaeshesiologiss



Inroducion | 11

Inroducion

he publicaion Occupaional Welare in Aneshesiologiss is based on hedeiniion o he erm, issued by he World Healh Organizaion in 2005: “he

percepion o an individual abou heir posiion in lie in he conex o culureand value sysems in which his and in relaion o heir goals, expecaions , san-dards and concerns”.

he main objecive o his book is o address he pahological di sorders o occu-paional well being in a neshesiologiss (diagnosis, prevalence, prevenion andreamen), based on epidemiological ev idence, which a ec in a complex man-ner and someimes seriously he physical and menal healh, personal beliesand social relaions o he aneshesiologis, as well a s he ca re o paiens under

heir responsibiliy.e conen has been grouped ino hree basic secions: (1) principles and unda-menals o occupaional healh, (2) insiuional responsibiliies wih aneshesiolo-giss’ occupaional wellness, and (3) biological hazards and occupaional healh andinerdisciplinary aspecs o occupaional healh.

I is imporan o acknowledge ha research on he pahological changes regardingoccupaional welare in aneshesiology eiher in experimenal or clinical environ-mens, is highly complex and difficul due o is muliacorial naure, especially

in regard o occupaional aigue and is consequences, which vary over ime indifferen individuals (individualiy characer o he pahology), and he clinicaloverlap wih oher condiions associaed wih i, such as depression/psychogenicsress, burnou, subsance abuse, suicidal ideaion, among ohers .

I is vial o acknowledge ha physicians, including aneshesiologiss, are rained oexercise his pracice ocused on he healh o paiens, so ha hey oen neglec heirown healh issues as well as he condiions o heir occupaional well-being.

o aneshesiologiss, his book should be considered a big sep oward he under-

sanding o occupaional healh problems secondary o changes in he saus o occu-paional well-being ha require atiudes and soluions based on he premise: “o beaware o he problem is he firs sep o is soluion”.

hereore, his book aims o simulae he developmen o eec ive acion on hepar o world eniies involved wih aneshesiology, in avor o he occupaionalhealh o aneshesiologiss and saey o heir paiens. In his opporun iy I wisho hank he Brazilian Sociey o Aneshesiology (SBA), he Federal Council oMedicine o Brazil (CFM), he Lain American Conederaion o Socieies o

Aneshesiolog iss (Cla sa) and he World Federaion o Socie ies o Anaeshesi-ologiss (WFSA) or realizing he imporance o his projec and u lly supporedis developmen.




I wish o acknowledge he volunary and highly compeen work all auhors whoaced he proposed challenges; he high qualiy o he work done by he SBA inorma-ion echnology eam, under he leadership o heir manager, Mercedes Azevedo; heCFM saff responsible or he prining o his book; and he excellen review o heexs and heir ranslaions, under he responsibiliy o Pro. Dr. Geulio odrigues

de Oliveira Filho.

Gasão F. Duval NeoEdior



- Part 1 -Principles and basis of

occupational health



1.1 - Evaluaion o aneshesiologiss’ occupaional well-being around he world | 15

Evaluaion O Aneshesiologiss’ Occupaional Well-Being Around Te World

Gusavo Calabrese orchiaro

Presiden o Lain American Conederaion o Aneshesiology Socieies (CLASA), 2013.

1. Inroducion

e World Federaion o Socieies o Anaeshesiologiss (WFSA) and is affiliaesare increasingly concerned abou he liesyle and occupaional hazards relaed ohe pracice o aneshesiology. ereore, in order o warn aneshesiologiss abouoccupaional risks and develop sraegies o improve qualiy o lie, he WFSA Pro-essional Well-being Comitee conduced he worldwide survey Proessional Well-

being Work Pary.

2. Hisory

In he early 20h cenury, fires and explosions inside he operaing room caused byinhaled anesheics were he major occupaional risk associaed wih aneshesiology.Laer, problems relaed o chronic inhalaion o anesheic gases and conaminaiono he surgery room were highlighed.

During he 80s, ocus shied o he risk o exposure o biological agens and chemi-

cal dependency among aneshesiologiss. Currenly, many occupaional risk acorsare under sudy, including biohazard, opiod abuse, occupaional sress, burnou and working paterns. Long working hours, sressul environmen, pressure o obaingreaer produciviy and requen exposure o physical, chemical, biological andergonomical risks are par o aneshesiologiss’ curren rouine.

ese acors resul in healh, saey and perormance hazards o praciioners andaffec heir qualiy o lie as well as ha o heir amilies. is is why anesesiologyoffers “high occupaional risk” compared o oher healhcare proessions.

3. Classificaion

Currenly, aneshesiology occupaional risks are classified according o he ype oagen or siuaion ha riggers he hazard, including1:

Risks relaed o aneshesiology pracice:

• Chronic occupational stress

• Psychosocial disorders

• Drug addiction• Ergonomics




Risks relaed o biological agens - Inecions ransmited by paiens wihhe ollowing pahogens:

• Viruses: hepatitis B, hepatitis C, HIV

• Bacteria

• Fungi

• Others

Risks relaed o saey and physical agens:

• Ionizing radiation ( RX )

• Non-ionizing radiation (laser)

• Noise and vibration

• Temperature

• Ventilation

• Lighting

• Electric charges (high and low voltage)

• Fires

• Compressed gas (cylinders)

Risks relaed o work sandards (organizaion):

• Organization and type of work

• Work paern

• Calendar, workload, density of tasks

• Violence

Risks relaed o chemical agens:

• Latex allergy

• Exposure to inhaled anesthetics (reproductive hazards)

4. Which o hese acors has he greaes impac on aneshesiologis’s lie?

he Proessional Well-being Work Pary 2 research, conduced by he WFSAProessional Well-being Comiee, led by Proessor Dr. Gason Duval Neo,rom Brazil, repored worldwide siuaions concerning aneshesiologiss’

occupaional problems. I also ideniied regional dierences and highlighedoccupaional sress issues, including burnou syndrome and problems relaed oorganizaional work paerns.




Tese are he ollowing issues.

Do you believe ha “Physician Burnou Syndrome” is a problem oconcern in your sociey?

Are he members o your Sociey aware o he concep o “Workingime Regulaions”?

Do you believe ha subsance abuse is a subsanial problem amorganeshesiologiss in your Sociey?




Does your Sociey have a paricular group working on he subjec“Proessional Well-being o Aneshesiologiss?

Occupaional SressOccupaional sress is defined as he physical and emoional reacions ha occur when demands a work exceed he capaciy, olerance, resources and needs o heaneshesiologis. 3 Excessive sress can lead o serious consequences such as worsen-ing work perormance, having huge impac on he saey o paiens and aneshesi-ologiss alike, and compromising proessionals’ healh and amily lives. 3- 6

Incidence

While he incidence o occupaional sress among all docors is 28%,7

i is evenhigher among aneshesiologiss, reaching 50% in Europe and 59% 9- 64% 10 - 96% inLain America.11

Similar resuls were ound in oher sudies ha relae occupaional sress o many differenacors in he complex rouine o aneshesia. ecen research showed ha he mos sress-ul acors in aneshesiologiss’ opinions were: lack o conrol over heir workday (83%), jeopardized amily lie (75%), medical and legal aspecs (66%), communicaion problems(63%), clinical problems (61%).12 Oher sudies repored: work sandards (58%), man-

agemen o criical paiens (28%), crisis managemen (23%), dealing wih deah (13%),

9

problems relaed o work patern (organizaional, 42%), adminisraive responsibiliies(41%), personal conflics (35%), conflics in proessional relaionships (25%), conflicsouside he work environmen (23%), medical and legal problems (2,8%).13 Among anes-hesiology residens, he main concerns were managing criical paiens, dealing wihpaiens’ deahs and balancing personal lie wih proessional demands.14

Mechanism o acion:

Sress cycle

Chronic occupaional sress is dynamic and insidious. e coninuous cycle o sresscauses gradual and permanen damage o he body.3 Among aneshesiologiss, manyacors can rigger occupaional sress, especially (5-6)(16-21):




• Specialty type

• Work complexity

• Stressful environment

• Lack of control over the work routine

• Jeopardized family li fe• Possible legal and medical problems

• Professional expectations

• Job insecurity

Impac o occupaional sress

When he previously repored sressors accumulae and overcome one’s olerance, exces-sive sress setles in and can have a major impac on healh, work and amily lie. (5-6)

Healh Impac

Occupaional sress exers major impac on one’s healh, gradually bu permanenlycompromising biological sysems and even causing physical diseases, inellecualchanges, menal and behavioral disorders.(3,5,6)

A) Physical diseases: chronic aigue, gasroduodenal ulcer, gasriis, hyperension,arrhyhmia, angina, musculoskeleal diseases, neurological disorders, decreasedimmuniy, reproducive disorders and increased risk o sponaneous aborion. (3,5,6)

In Lain America, he mos prevalen effecs are:(9) • Gastrointestinal tract, with the incidence of gastritis and gastroduodenal ulcero 45% and 11%, respecively;• Cardiovascular, especially hypertension in 23%, arrhythmia 13%, angina 5 %and myocardial inarcion in 3 %.(9)

B) Psychological disorders: psychic emoional deerioraion, such as anxiey (19 %),disress (43 %) and depression (31%). Increased risk o suicide.(9)

I should be noed ha he incidence o depression among aneshesiologiss and aneshe-siology residens is higher han in general populaion, 11% , 31% and 40% , respecively.(9)

C) Behavioral disorders: alcohol abuse (44%), psychoropic drug use (16 %), drugabuse (1,7%) and aggressive behavior.(9)

D) Inellecual changes: difficuly o concenrae, impairmen o vigilance, reduced work perormance.

Family impac

I is characerized by difficulies in balancing work and amily lie, ailure in esab-lishing or mainaining relaionships wih one’s children, difficulies in marial rela-ionship, lack o emoional suppor, isolaion, divorce and amily breakdown.(1-4)




Work impac

Imporan eaures are lack o ineres in work, abseneeism, dissaisacion, low-qualiy work, possibiliy o medical malpracice, which may occur hrough negli-gence and resul in legal problems. All hese siuaions denigrae he proessional’simage and may someimes resul in career abandonmen, premaure reiremen and,in exreme cases, civil or criminal issues ha can even lead o suicide.(3,5,6)

Wha should we do abou occupaional sress?

Early diagnosis, medical and psychological reamen in sympomaic cases areessenial. reamen should aim or significan changes in qualiy o lie, includingchanges in eaing habis, sleep, res, saisacion and greaer work opporuniies.Possible insr umens o achieve hese changes are appropriae work schedules, work,amily and social li e balance, adequae work inrasrucure, occupaional proecion

and improvemens o he workplace.

Recommendaions

“e major obsacle is he physicians’ resisance o recognize heir problemsand accep heir posiion as paiens.” Prevenive measures are recommended inorder o reduce he prevalence o chronic occupaional sress and is devasai ngconsequences. Occupaional diseases are a “shared responsibiliy”; hereore, prevenion should be approached rom hree perspecives: personal, work ea m andinsiuional level.(15) Primary prevenion consiss in el iminaing and/or reducingpossible sressors, whi le secondary prevenion is characerized by early deeciono depression and anxiey sympoms and eriary prevenion involves recoveryand rehabiliaion. (3,5,6,15)

Individual level: (15)

An individual adjusmen process o daily expecaions is recommended:

• Not denying the situation

• Avoiding isolation

• Decreasing the intensity of routine

• Reaching balance between family, friends, work and rest

• If necessary, seeking for professional psychological counseling

eam level: (15)

Co-workers are key o early diagnosis and suppor.

Aneshesiologiss should require heir employers (hospials and clinics) o have an

occupaional healh program, a place o share experiences, proessional suppor oimprove inerpersonal relaionships and o seek or a more humanized, compassion-ae and less compeiive workplace.




Insiuional level: (15)

Hospials and clinics mus have an occupaional healh program ocused on anes-hesiologiss, o preven sressors and o offer psychological counseling, suppor orphysical diseases, prevenion and reamen o possible behavioral changes and drugabuse. A specific menal healh program is also helpul. (15)

Insiuional posiive atiudes:

• Trying to assure balance between the amount of work and anesthesiologist’sskil ls and resources;

• Providing opportunities for professionals to use all their skills - there must be ameaning or each aciviy accomplished;

• Dening roles and responsibilities of the anesthesiologist clearly;

• Involving anesthesiologists in the decision-making when potential changesaffec heir rouine;

• Optimizing communication;

• Reducing uncertainty - seing career plans and exploring future job opportunities;

• Providing opportunities for social network among workers;

• Establishing schedules (working hours) that match anesthesiologists’ demandsand responsibiliies;

• Fostering balance between work, family and social life;

• Improving safety measures inside the operating suite;• Improving infrastructure.

Burnou Syndrome

Many differen physical and menal illnesses may be associaed wih occupaionalsress. Burnou syndrome is defined as a physical and emoional response o occupa-ional sress (8,22-24) , characerized by emoional exhausion, depersonal izaion, eel-ings o incompeence and ailure o mee arges. (5,6,24-34) Burnou syndrome affecs

qualiy o lie and proessional perormance. Aneshesiology is a high risk proessionor burnou. (1,8,24-34)

Risk acors:

Burnou syndrome is associaed wih chronic and cumulaive imbalance beweenpsychological and proessional demands, along wih oher issues relaed o workorganizaion, such as (22,23,24-34)

- Work overload

- Injusice- Lack o proessional recogniion




- Conflics o principles

- elaionship conflics wih co-workers

- Loss o conrol over asks

- Excessive bureaucracy and oher insiuional, environmenal and

personal pariculariiesCauses

e mos imporan deerminans o occupaional sress include: hisory o 7-10 years o employmen, long working hours, nigh shis, work overload (35-40) , proes-sional commimen, responsabiliy roles (he posiion o head o aneshesiologyservices is an imporan risk acor, as i increases in 51% he incidence o Burnousyndrome (33)) , lack o conrol over rouine, personal lie and amily relaionships,chronic aigue and unulfil ling relaionships a work. (24-34)

Developmen

Burnou is a gradual, cumulaive and chronic process, commonly associaed wihdenial. As i develops, acors like lack o proessional recogniion and achievemensruin he aneshesiologis’s idealism, leading o emoional exhausion, depersonaliza-ion and proessional indifference ha affecs he qualiy o healhcare provided, as well as he proessional’s qualiy o lie. (24-34) ere is a cerain irony in he burnouprocess – he once-enhused, commited, energeic proessional ha was once ull o

innovaive ideas and high expecaions ges rusraed aer being conroned wih somany obsacles or a long period wihou enough resuls. Bunou syndrome may pres-en many physical, psychological, behavioral, proessional and personal sympoms.

Sympoms (24-34)

• Physical: fatigue, sleep disorders, headache, impotence, gastrointestinal disorders.

• Psychological: irritability, anxiety, depression, hopelessness.

• Behavior: aggressiveness, defensive behavior, cynicism, drug abuse.

• Professional: absenteeism, decreased performance, lack of commitment.

• Personal: poor communication, isolation and poor concentration.

As i develops, burnou syndrome may cause serious consequences, such as:

• Car accidents related to heavy workload, especially at night.

• Several psychological/psychiatric disorders, mainly anxiety, distressand depression.

• Drug abuse (escape mechanism).

• Suicidal ideatione prevalence o suicide among paiens in advanced burnou sages is six imeshigher han general populaion. (6)




Recommendaions

ecognizing he concep o shared responsabiliy is essenial in he managemeno occupaional illnesses. Prevenive measures should be aken in hree rons: per-sonal, eam and insiuional level. (15)

Personal level (15)

Individual prevenion is accomplished hrough he associaion o knowledge, edu-caion, anicipaion and conrol o poenial sressor acors. Denial will only delaydiagnosis and inervenion, so i should be avoided. Proessionals mus learn how osay “no”, how o delegae and o reduce heir own workload. In his process, he maindifficuly is usually he physians’ resisance o admi he exisence o an emoionaland/or psychological problem.

Behavioral changes, prioriizing proecive acors agains burnou syndrome arenecessary or an improvemen in qualiy o lie. Adjusmens in eaing and sleepinghabis, ime or leisure and amily are he main goals. (15)

eam level (15)

Co-workers have an imporan role:

1. Usually he firs ones o noice and make an early diagnosis.

2. Coleagues can help each oher o reflec on heir experiences.

3. Coleagues can provide psychological suppor in or ou o he workplace, sincehey experience similar siuaions.

Insiuional level (15)

Companies ha deal wih aneshesiologiss in heir saff should develop occupa-ional healh programs ha include menal healh and counseling or proessionalsha develop burnou sympoms.

Insiuions mus devise sraegies or early recogniion and diagnosis o individualsa risk and provide medical and psychological suppor in sympomaic cases.

Work organizaion

Aneshesiologiss’ work environmen and condiions underwen major changes inhe pas years, hanks o globalizaion, new marke rends and new healh manage-men models. (41, 42) In his conex, occupaional risks relaed o work organizaionare highl ighed, especially in erms o working hours. (1,37-40)

Risk Facorse imbalance beween workload and ime or res and leisure underlines a majorrisk acor: inadequae work schedules. (1,15,37-40)




Causal acors

Aneshesiology is a career ha requires excessive working hours, a day and nigh, wih a lo o overime and nigh shis ollowed by a ough day o work, leading oinense workload wihou adequae places o res. (1,37-40)

Effecs

Inappropriae work schedules may rigger sleep and circadian rhyhm disor-ders, aigue, cardiovascular and digesive changes, and compromise ami ly lie.Iniially, he impac will show on he proessional’s healh and laer i will bereleced on his perormance, occupaional well-being and paien saey. (43-45)

Circadian rhyhm changes lead o aleraions in digesion, sleep, body empera-ure, adrenalin secreion, blood pressure, hear rae and behavior. (46) Faiguecan cause mood disorders, depression, headaches, dizziness, loss o appeie and

diges ive problems.(46-47)

I can also cause g ynecological problems such as irregu-lar mensrua l cycle, premaure labor (48-50) , inrauerine grow h resricion resul-ing in SGA (small or gesaional age(51)), pregnancy-induced hyperension(52).Faigue reduces paien sae y, as i aecs docor’s decision-maki ng skil ls, whichincreases he probabiliy o “ human error” (1). In aneshesia, “huma n error” is sorelevan ha sudies repored i as he cause o criical siuaions in 83% o hecases(53,43). epors show a conribuion o aigue in 50% o medical errors (55) and in 60% o malpracice cases among aneshesiologiss (56). Oher sudies showha aigue conribued o errors in he managemen o aneshesia in 86% o he

cases. (43) Fur hermore, aigue was associaed wih criical evens in aneshesiamanagemen in 2% (53) , 3% (57) and 6% (58) o cases and wih drug adminisraionerrors in 10% (54).

Schedule changes and he absence o a sleep rouine may rigger sleep disorders. Cumu-laive sleep deprivaion and reduced EM sleep period - resoring sleep - can resul ina “sleep defici” and hen progress o a sae o chronic sleep deprivaion. (59) is maycause immune (60) , gasroinesinal(61) and endocrine disorders(62) and decrease psycho-moor perormance(63) , conribuing o medical malpracice.(46) e period beween 2

and 7 a.m is he one o mos vulnerabiliy o sleep.(64)

ese are he key momens whensleep deprivaion, lack o proper sleep during nigh shis and inappropriae schedulesincrease he chances o human errors in aneshesiology.

Faigue can also be associaed wih occupaional accidens during nigh shis, increas-ing by 50% the risk of exposure to contaminated blood (HIV, hepatitis B and C). (65)

Recommendaions

Develop a work sysem wih predefined limis: working-hour limi per day/week,

breaks beween long working periods, overime and nigh shis, ime o res beweenshis, weekly res schedule, annual vacaions. (1,66) I’s recommended ha aneshesi-ologiss volunarily sar he ollowing prevenive measures: (1,15,66)




aigue and sleep deprivaion cause chronic occupaional sress and may riggerhe burnou syndrome.

2 . Availabiliy, easy access and lack o conrol over drugs.

3 . Addicive poenial o opioids

4 . Lack o conrol over psychoacive medicaions.5 . Curiosiy o experience is effecs.

6 . Lack o sel-eseem.

7 . Denial o he siuaion.

Consequences

e inire evoluion o he problem saring rom he use, abuse, addicion andfinally dependency on drugs mus be unsdersood, because once i deerioraes heaneshesiologis’s lie, serious personal, amily, proessional and legal problemsmay occur. (71-73)

Personal consequences

In some cases, personal consequences are very imporan and serious, leading oa progressive deerioraion o living and healh condiions, wihdrawal syndrome,possibiliy o relapse, comorbidiies, psychiaric disorders (anxiey and depression)and deah by overdose or suicide. (71,73,85-88)

Deah and suicidee incidence o relapse is high among previously opioid-dependen aneshesi-ologiss, much higher han among non-opioid drug addics and alcoholics. (89) eincidence o relapse among aneshesiologiss ha reurn o heir daily praciceranged rom 19 %, 26 % (90) up o 40% (91) , and dea h was he oucome in 16% ohose firs relapses (92).

e specific risk o deah by suicide relaed o drug overdose was wo imes higheramong aneshesiologiss, and he risk o drug-relaed deah was hree imes higher

among aneshesiologiss compared o clinicians, especially during he firs five yearso residence. (93)

e 2013 repor o he CLASA Proessional isk Commission revealed ha in helas 10 years here were 141 drug-relaed deahs, including 94 cases o suicide and47 cases o overdose; six deahs by propool and 135 by opiaes (118 specialiss and15 residens). (84)

Saxon counries developed a 10-year survey and ound a similar siuaion, wih 285deahs 10% o which were relaed o overdose (94). In a 5-year period, overdose cor-

responded o 16% o 44 deah cases (92); in a 2-year period, here were 26 drug relaeddeahs in he New York Hospial(95). ecenly, in Ausralia and New Zealand, 44cases o opiae abuse were recorded, 24% o which resuled in deah. (88) Ulimaely,




drug-relaed deah or suicide by overdose are one o he mos significan occupa-ional risks in aneshesiology. (1)

Family consequences

Drug abuse also affecs amily lie, and divorce raes can reach 24% among addicedaneshesiologiss, compared o 5 % in non-addiced. Family members o addicedaneshesiologiss are more prone o drug use and abuse. (71-73, 95)

Consequences a Work

his problem can aec he proessional ’s capaciy o work and even preven pro-essionals rom perorming heir dai ly aciv iies, as well as compromise paiensae y and raise he raes o malpracice. Drug dependency may require he aban-donmen o he specialy, as i may be quie hard o reurn o aneshesia daily

pracice.(71-73, 95)

Legal Consequences

Legal consequences are conroversial, due o he complexiy o he disease and legis-laive differences among counires. Cerain counries consider he addiced proes-sional as uncapable and demand a recovery process ollowed by changing medicalspecialy. In case he aneshesiologis presens a successul reamen and recovery,showing normal conrol exams, hey can’ have heir job denied. (71-73)

Behavior (15,97, 97) How should a suspeced case o drug addicion be approached?

In case o suspicion o drug addicion, adminisraive, clinical and pharmaceuicalinormaion mus be obained in order o ideniy he addiced proessional andproceed wih he invesigaion. Aer confirmaion o drug dependency, an inerven-ion is needed because ha person has a disease ha requires reamen. e hospialcommitee associaed wih a commitee organized by he aneshesiology socieymus reer he proessional o reamen programs.

is reamen should be guided by a mulidisciplinary eam: psychiaris, generalpraciioner, neurologis, nuriionis, social worker and i should also involve amilymembers. is process may ake several monhs or years, depending on he case andhe amily.

Reurn o work

is is a crucial sage, he decision abou uure proessional aciviies. e reinegra-ion process conemplaes differen scenarios: work, amily and sociey. eurning

o aneshesia pracice is a difficul process or opioid-addiced aneshesiologiss haare sill in heir recovery process, so decisions are conroversial and cases mus beindividualized. (86, 96)




Recommendaions (15, 96, 97)

ere is no way o guaranee ha he use o psychoacive drugs will no cause depen-dency, so he only guaraneed proecive measure is o avoid he firs use o any ille-gal drug. ereore, a comprehensive sraegy involving anesheiss, socieies and/

or associaions o Aneshesiology, healh auhoriies and employers is crucial.Prevenive policies

Programs should be based on join prevenion sraegies:

• Dissemination of education and information.

• Identication of anesthesiologists potentially at risk for addiction.

• Management of occupational stress.

• Beer work schedules.

• Strict and continuous control of psychoactive medications.

• Policies to support anesthesiologists and their family.

Conclusions

Occupaional hazards associaed wih aneshesia pracice are responsible or hecurren harsh and disurbing realiy aced by aneshesiologiss ha have heir lie,healh and amily condiions comprimised. In his scenario, shared responsabiliymus be highl ighed under hree perspecives:

1. Aneshesiologiss should always be updaed abou occupaional healh issues.

2. Medical insiuions mus develop prevenion and proecion programs wihhe objecive o ideniying poenial addics, conrolling risk acors and drugdisribuion.

3. Socieies o aneshesiology mus ac hrough comprehensive policies:

- Inormaion and educaion

- Suppor sysems

- ehabiliaion programs- Economical endorsemen or colleagues and heir amily, when needed.

For ha, an Occupaional Healh Program is vial.

Reflecions:

Drug addicion is a lielong disease. Is acue effecs can be overcome, bu is conse-quences leave heir marks orever in each vicim.

Despie significan advances on he basis o drug abuse, echnological supporand curren herapeuic approach, his disease sill represens a major occupa-ional problem or aneshesiologiss. (96)




5 . Sraegies

e Proessional Well-being Work Pary conduced by he WFSA Proessional Well-being Commitee showed he lack o insiuional sraegies relaed o anes-hesiologiss’ occupaional well-being - 81% o insiuions deny having a dedicaedoccupaional well-being commitee. ereore, i is recommended ha Aneshesiol-ogy Socieies or Federaions develop an insiuional policy ha allows he sudy ooccupaional hazards and he improvemen o sraegies.

1. Each aneshesiology sociey or ederaion should have an OccupaionalHealh Commitee. (15, 98)

e main sraegy aims o ideniy and quaniy he risk acors, develop ways oreduce hose risks, esablish educaional and prevenive policies, make good rea-mens easible, i possible, organize a und o help aneshesiologiss and heir ami-

lies wih financial suppor.

2. Occupaional Healh Inegraed Program(98)

An Inegraed Occupaional Healh Program aims o achieve beter working condi-ions. e Occupaional Healh Commitee o Aneshesiology Socieies mus deviseimprovemen acions and each insiuion mus execue i respecing heir work andregional pariculariies.

e main goal should be he promoion o beter physical, psychological and social con-

diions or aneshesiologiss, in order o preven occupaional accidens and illnesses.

Te program mus have specific goals, such as:

a) Analyzing work condiions o ideniy possible risk acors in aneshesiolo-giss’ daily work.

b) eeping rack o risk acors. Esablishing prioriies.

c) Monioring and conrolling risks. Medical examinaion once a year.

d) Esablishing a sysem o gaher periodic inormaion or an updaed daa basis.

e) Planning and organizing work aciviies o reduce he main risk acors, con-sidering he workplace and people involved on i. Guidelines o coordinae workand res hours, analysis o workplace inrasrucure and securiy.

) Organizing raining aciviies according o he insiuion’s risk acors.

g) Shared responsibiliies among differen organizaional levels o ensure con-inuous improvemens or worker’s healh and saey.

h) Creaing saey and surveillance sandards o preven occupaional accidens

and diseases.i) Assessing he impac o hose acions on he incidence o occupaional acci-dens and diseases.




j) Defining prevenive measures o improve working condiions and aneshesi-ologiss’ healh and qualiy o lie. Prevenion and saey guidelines, as well asproocols abou Managemen o isks are necessary.

k) Planning, organizing and developing raining meeings.

l) Asking or proper medical atenion in case o occupaional accidens, diseasesor disorders. Imporance o agreemens beween medical insiuions or menalhealhcare, subsance abuse , ec. .

Final houghs

Despie improvemens in saey sandards, echnology and new drugs, aneshesiolo-giss coninue o suffer he occupaional hazards associaed wih his specialy. eremus be a genuine concern abou his opic and effecive sraegies o avoid occu-paional problems mus be esablished, prioriizing coninuous educaion, preven-

ion policies, proessional proecion and suppor, sandardizaion and, ulimaely,improvemen in he condiions o pracice aneshesiology are necessary o guaraneeaneshesiologiss’ healh and qualiy o lie. us, physicians become specialiss inorder o help and ake care o paiens’ healh, bu hey oen orge o ake care oheir own healh. (1-2, 96, 99)

Reerences

1. Calabrese G: :iesgos Proesionales. En exo de Anesesiología eórico Pracico, J. A.A ldree. Manual Moderno, México. 2003:pp.1477-1498.

2. Calabrese G: ¿ A que riesgos proesionales esamos expuesos los anesesiólogos ? ev. Anes. Mex. 2004:16;3 .En Inerne: htp://www.anesesiaenmexico.org/RM3/in-dexRM3.hml.

3. Jackson SH. e role o sress in anaesheiss’ healh and well-being. Aca AnaeshesiolScand 1999; 43(6): 583-602.

4. Calabrese G: In fluencia del Esilo de vida Laboral del Anesesiólogo en la salud. En Anes-tesiólogos Mexicanos en Internet .Ciberconferenci;a En: II Congreso Virtual Mexicanode Anestesiología. I Congreso Virtual Latinoamericano de Anestesiología ww w.aneste-sia.com.mx/congreso 2002 ; 1-30 de noviembre 2002.

5. Calabrese G: Esrés crónico en el anesesiólogo acual .Acas Peruanas 2001:14;1;10-13.

6. Calabrese G: Impaco del esrés laboral en el anesesiólogo. ev. Col. Anes. 2006;34: 4:233-240.

7. Firh-Cozens J. e psychological problems o docors. In: Firh-Cozens J, Payne , eds.Sress inhealh proessionals: psychological and organizaional causes and inervenions.London: Wiley, 1999.

8. Nyssen AS, Hansez I, Baele P, Lamy M, DE eyserv Occupaional sress and burnou inanaeshesia. Br JAnaesh 2003 Mar; 90(3):333-7.

9. Calabrese G.: Inorme CLASA 2000 «Encuesa de iesgos Proesionales del Anesesiólogoen Lainoamérica. Comisión de iesgos Proesionales .Conederación Lainoamericana deSociedades de Anestesiología. En Actas de la XXI Asamblea de delegados de CLASA. XX VI




Congreso Lainoamericano de Anesesiología. San Salvador. El Salvador.2001htp://www.clasa-anesesia.org./serch/comisiones/condiciones_laborales .pd.

10. riana M. A. Huergo J..: Esudio de esrés en los anesesiólogos de La Habana. ev. Esp Anes. ean.1994;41:273-77.

11. Calabrese G.: rasornos psíquicos relacionados al rabajo del anesesiólogo. En acas del

IV Congreso Sudamericano de Anestesiología. Montevideo-Uruguay 1996:4.12. luger M, ownend , Laidlaw . Job saisacion, sress and burnou in Ausralian

specialisanaesheiss. Anaeshesia 2003 Apr;58(4):339-45.

13. am P.C.: Occupaional sress in anaeshesia Anesh.Inen. Care 1997; 686-90.

14. Abdelmalak B. Sress in American Aneshesiologyesidencies. ASA Newsleter. En in-erne: www.asahq.org/Newsleters/1999/12 99/ residen1299.hml.

15. Calabrese G: Guía de Prevención y Proección de los iesgos Proesionales del Anese-siólogo. Anes Analg ean . dic -2006;20 (2) 4- 40.

16. Chassot PG. Stress in European operating room personnel. En Actas del XII CongresoMundial de Anesesiología. Monreal, Canadá 4-9 de junio de 2000. p. 63-4 .

17. Gaba DM, Howard Sk, Jump B. Producion pressure in he work environmen. Caliorniaaneshesiologiss’ atiudes and experiences. Aneshesiology 1994; 81(2): 488-500.

18. Seeley HF. e pracice o anaeshesia--a sressor or he middle-aged?. Anaeshesia1996; 51(6): 571-4.

19. Curry SE. Sress and he aneshesiolgis. Anesesiology epor 1990; 2: 375-80.

20. Granger CE, Shelly MP. Sressing ou, or ouing sress? Eur J Anaeshesiol 1996;13(6):543-5.

21. Axelsson G, Ahlborg G J, Bodin L. Shi work, nirous oxide exposure, and sponaneousaborion among Swedish midwives. Occup Environ Med 1996; 53(6): 374-8.

22. Freudenberger HJ. e issues o saff burnou in herapeuic communiies. J PsychoaciveDrugs 1986; 18(3): 247-51.

23. Malasch C, Jackson SE, Leier MP. Malasch Burnou Invenory Manual. 3rd ed. Palo Alo, CA: Consul Psychology Press; 1996.

24. luger M, ownend , Laidlaw . Job saisacion, sress and burnou in Ausralianspecialis anaesheiss. Anaeshesia 2003; 58(4): 339-45.

25. Coomber S, odd C, Park G, Baxer P, Firh-Cozens J, Shore S. Sress in U inensivecare uni docors. Br J Anaesh 2002; 89(6): 873-81.

26. McManus IC, Winder BC, Gordon D. e causal links beween sress and burnou in alongiudinal sudy o U docors. Lance 2002; 359(9323): 2089-90.

27. Lederer W, inzl JF, real E, raweger C, Benzer A. Significance o working condiionson burnou in anesheiss. Aca Anaeshesiol Scand 2006; 50(1): 58-63.

28. Fernández TB, Roldán PLM, Guerra VA., Roldán RT., Gutiérrez A, De Las Mulas BM.Prevalencia del síndrome de Burnou en los anesesiólogos del Hospial Universiario Virgen Macarena de Sevil la Rev Esp Anestesiol Reanim 2006:53:359-362.

29. Morais A, Maia P, Azevedo A, Amaral C, avares J :Sress and burnou among Poru-guese anaeshesiologiss. Eur J Anaeshesiol. 2006 May;23(5):433-9. Epub 2006 Feb 10.




30. Lindfors PM, Nurmi KE, Mere Toja OA, Luukkonen , Viljanen AM, Leino TJ, HarmaMI. On-call sress among Finnish anaesheiss ; Anaeshesia. 2006 Sep;61(9):856-66.

31. Palmer-Morales LY, Gómez-Vera A, Cabrera-Pivaral C, Prince-Vélez R, Searcy-Bernal. Prevalencia del síndrome de agoamieno proesional en médicos anesesiólogos en laciudad de Mexicali, Baja Caliornia, Mexico. Gac Med Méx 2005:141;181-183.

32. Hyman SA, Michaels, D,Berry JM, Schildcrou JS, Mercaldo ND, Weinger MB: isk o burnou in perioperaive clinicians: A survey sudy and lieraure review. Aneshesiology2011; 114:194–204.

33. De Oliveirags J, Ahmad S, Sock MS, Harer L, Almeida MD, Fizgerald PC Highincidence o burnou in academic chairs o aneshesiology: Should: Should we be aking beter care o our leaders? Aneshesiolog y 2011; 114:1–2.

34. Shanael : Burnou in aneshesiology: A call o acion. Ediorial Aneshesiology 2011; 114:1-2.

35. inzl JF, nozer H, raweger C, Lederer W, Heidegger , Benzer A. e influence o work-ing condiions on job saisacion in anaeshesiologiss. Br J Anaesh 2005; 94: 211-15.

36. azuyoshi awasaki, Miho Sekimoo, asuro Ishizaki, and Yuichi Imanak: Work sressand workload o ull-ime aneshesiologiss in acue carehospials in Japan: J Anesh(2009) 23:235–241.

37. Calabrese G. Impaco de los calendarios laborales del Anesesiólogo en la salud, el ren-dimieno y la seguridad .ev. Arg. Anes. 2004, 62; 5: 356-363.

38. Calabrese G. iesgos proesionales relacionados a la organización laboral. ev AnesMex [en línea]. 2004 [acceso el 6 de mayo de 2006];16 Supl 1: ): [30 panallas]. Dis-ponible en: htp://www.anesesia-dolor.org/ram/suplemeno/sup1/index.hm.

39. Calabrese G. Implicaciones laborales en el anesesiólogo. ev Col Anes [en línea]. 2005[acceso el 6 de mayo de 2006];33(3):[30 panallas]. Disponible en: htp://ww w.scare.org.co/rca/archivos/ariculos/2005/vol_3/PDF/v33n3a07.pd.

40. Calabrese G. Impaco de las horas de rabajo en la salud del anesesiólogo. Ponencia en elIII Congreso Virtual Mexicano de Anestesiolgía 1-15 de diciembre de 2004. AnestesiolMex Inerne (ww.anesesia.com.mx); 2002.

41. Calabrese G. Escenario laboral del anesesiólogo en Lainoamérica. (en línea) CLASA.Comisiones. Disponible en: htp://www.clasa-anesesia.org/ htp://www.clasa-anese-sia.org./serch/comisiones/proyeco_escenario_laboral%202003.pd.

42. Calabrese G. Condiciones laborales del anesesiólogo en Lainoamérica. (en línea)CLASA. Comisiones. Disponible en: htp://www.clasa-anesesia.org/ htp://www.clasa-anesesia.org./serch/comisiones/condiciones_laborales%20.pd.

43. Gander PH, Merry A, Millar MM, Weller J. Hours o work and aigue-relaed error: asurvey o New Zealand anaesheiss. Anaesh Inensive Care 2000; 28(2): 178-83.

44. Howard S, osekind M, az JD, Berry AJ. Faigue in aneshesia: implicaions andsraegies or paien and provider saey. Aneshesiology 2002; 97(5): 1281-94.

45. Howard S, Healzer JM, Gaba DM. Sleep and work schedules o aneshesia residens: anaional survey. Aneshesiology 1997; 87(3): A932.

46. Naional Occupaional Healh & Saey (NOHS). OHS Implicaions o Shiwork andIrregular Hours o Work. Guidelines or Managing Shiwork. (en línea) Canberra,




AU:NOHS;2005. Disponibleen: htp://www.nohsc.gov.au/researchcoordinaion/shiwork/conens.hm

47. Canadian Cenre or Occupaional Healh and Saey (CCOHS). OSH Answers: Exend-ed Workday: Healh & Saey Issues. (en linea) Onario,CA: CCOHS; 1999. Disponibleen: www.ccohs.ca/oshanswers/work_schedules/workday.hml.

48. Mozurkewich EL, Luke B, Avni M, Wol FM. Working condiions and adverse pregnancyoucome: a mea-analysis. Obse Gynecol 2000; 95(4): 623-35.

49. Phelan S. Pregnancy during residency: II Obseric complicaions. Obse Gynecol1988; 72(3 P 1): 431-6.

50. lebanoff MA, Shiono PH, hoads GG. Oucomes o pregnancy in a naional sample oresiden physicians. N Engl J Med 1990; 323(15): 1040-5.

51. Miller NH, Katz VL, Cefalo RC. Pregnancies among physicians: A historical cohortsudy. J eprod Med 1989; 34(10): 790-6.

52. Grunebaum A, Minkoff H, Blake D. Pregnancy among obsericians: a comparison o birhs beore, during, and aer residency. Am J Obse Gynecol 1987; 157(1): 79-83.

53. Webb , Currie M, Morgan CA, Williamson JA, Mackay P, ussell WJ, e al. e Ausralian Inciden Monioring Sudy: an analysis o 2000 inciden repors. AnaeshInensive Care 1993; 21(5): 520-8.

54. Will iamson JA, Webb R K, Sellen A, Runciman WB, Van Der Walt JH. e AustralianInciden Monioring Sudy, Human ailure: an analysis o 2000 inciden repors. AnaeshInensive Care 1993; 21(5): 678-83.

55. Gaba DM. Human error in anesheic mishaps. In Aneshesiol Clin 1989; 27(3): 137-47.

56. Gravensein, J S. APSF Survey eveals Long Work Hours in Aneshesia 60% o espon-dens Admi Faigue Caused Errors. APFS Newsleter (en línea) 1990-91 (acceso 23 deMayo de 2006); 5(4). Disponible en: htp://www.aps.org/resource_cener/newsle-er/1990/winer/#ar10.

57. Morris GP, Morris W. Anaeshesia and aigue: an analysis o he firs 10 years o he Ausralian Inciden Monioring Sudy 1987-1997. Anaesh Inensive Care 2000; 28(3):300-4.

58. Cooper JB, Newbower S, Long CD, McPeek B. Prevenable aneshesia mishaps: a sudyo human acors. Aneshesiology 1978; 49(6): 399-406.

59. Dinges DF, Pack F, Will iams , Gillen K, Powell JW, Ot GE, e al.. Cumulaive sleepi-ness, mood disurbance, and psychomoor vigilance perormance decremens during a week o sleep resriced o 4-5 hours per nigh. Sleep 1997; 20(4): 267-77.

60. Dinges DF, Douglas SD, Hamarman S, Zaugg L, apoor S. Sleep deprivaion and humanimmune uncion. Adv Neuroimmunol 1995; 5(2): 97-110.

61. Vener KJ, Szabo S, Moore JG. e eect of shi work on gastrointestinal (GI) function: areview. Chronobiologia 1989; 16(4): 421-39.

62. Spiegel K, Leproult R, Van Cauter E. Impact of sleep debt on metabolic and endocrine

uncion. Lance 1999; 354(9188): 1435-9.63. rueger GP. Susained work, aigue, sleep loss and perormance: A review o he issues.

Work Sress 1989; 3(2): 129-141.




64. Van Dongen, Hans P A; Dinges, David F. Circadian rhythms in fatigue, alertness, andperormance. In: ryger, Meir H; oh, (om); Demen, William C. Principles andpracice o sleep medicine. 3rd ed. Philadelphia: Saunders; 2000. p. 391-9.

65. Parks D, Yeman J, Mcneese MC, Burau , Smolensky MH. Day-nigh patern inaccidenal exposures o blood-borne pahogens among medical sudens and residens.

Chronobiol In 2000; 17(1): 61-70.66. Calabrese G. Direcivas de Horas de rabajo y descanso CLASA. En Inerne: www.

clasa-anesesia.org./serch/comisiones/mp.pd.

67. Calabrese G.: Fármaco dependencia en los Anesesiólogos de Lainoamérica» Una prob-lemáica preocupane y en aumeno «.Proyeco de la Comisión de iesgos Proesionales.Conederación Lainoamericana de Sociedades de Anesesiología. En Inerne: www.clasaanesesia.org/serch/comisione/proyeco_armacondependencia_2003.pd.

68. Calabrese G: Visión actual de la Fármaco dependencia en Anestesiólogos. Rev. Arg. Anes. 2004;62,2: 106-13.

69. Calabrese G: Fármaco dependencias en anesesiólogos. ealidad preocupane. ev. Anes. Mex. 2004: 16;supl. 1. En Inerne: htp://ww w.anesesiaenmex ico.org/suple-meno/sup1/index.hm.

70. Calabrese G: Fármaco dependencia en anesesiólogos lainoamericanos. ealidad Preo-cupane. Ediorial del boleín vir ual de CLASA 2005. En Inerne: www.clasaanesesia.org./serch/boleìn_virual_007.hm.

71. Calabrese G. Fármaco dependencia en Anesesiólogos. Un grave problema ocupacionalacual. ev. Col. Anes. 2006; 34: 103-111.

72. Calabrese G: Anesesiólogos adicos a drogas que iene la responsabilidad de adminis-rar. ev. Paraguaya de Anesesiología. 2007; 11-21.

73. Calabrese G: Abuso de drogas en anesesiólogos .Una realidad preocupane .ev..Mex. Anest.. Vol. 33. Supl. 1, Abril-Junio 2010 pp S206-S208.

74. Barreiro G, Benia W, Francolino C, Dapueo J , Ganio M.:Consumo de susancias psico-acivas: Esudio comparaivo enre anesesiólogos e inernisas en Uruguay. Anes Analgean 2001;17(1): 20-25.

75. Hughes P, Sorr CL, Brandemburg NA, Balwin DC Jr: Physician susance use by medicalspecialy. J Addic Dis 1999;18 (2):23-27.

76. Paris , Canavan DI. Physician subsance abuse impairmen: Aneshesiologiss vsoher special ies. J Addicive Diseases. 1999; 18:1-7.

77. Ward C F. :Drugs abuse in anaeshesia raining programs: sur vey 1970-1980. jama1983;250 :922-5.

78. Gravensein J. S. :Drug abuse by anaeshesia personnel. anaesh. analg. 1983 ; 62:467-72 .

79. Lusky I. e al : Psychoacive subsance sudy use among American anaeshesiologiss- a30 year rerospecive sudy. . Can. J. Anaesh : 1993;40.915-921.

80. Gallegos K. V.: Addition in anaesthesiologists: Drug access and paerns of substance

abuse. Q B 1988;14:11.81. Booh J. Susance abuse among physicians : A survey o Academic Programs. Anesh

Analg 2002;95 1024-1030.




82. Talbo GD, Gallegos KV, Wilson PO, Porter TL. e Medical Association of Georgia’simpaired physicians program review o he firs 1,000 physicians: Analysis o specialy. JAMA. 1987; 257:2927-2930.

83. A.S.A (American Sociey o Aneshesiologiss ). ask Force on Chemical Dependence.Model Curriculum on Drug Abuse and Addicion or esidens in Aneshesiology.En

inerne: ww w.ASAhq.org/Proino/Curriculum.hm.84. Calabrese G.: eporer 2013 de la Comisión de iesgos Proesionales de CLASA. En

Inerne: ww w.clasa-anesesia.org./serch/comisiones/mp.pd.

85. ose GL, Brown E. e impaired aneshesiologis: no jus abou drugs and alcoholanymore. J Clin Anesh 2010;22:379-84.

86. Bryson EO, Silversein JH. Addicion and subsance abuse in aneshesiology. Aneshesi-ology 2008;109:905-17.

87. Arnold W. ask Force on Chemical Dependence in Anaeshesiologiss: Wha you need oknow when you need o know i. Illinois: ASA; 1998.

88. Fry R. Subsance abuse by anaesheiss in Ausralia and New Zealand. Anaesh Inen-sive Care 2005; 33(2): 248-55.

89. Domino B, Hornbein F, Polissar NL, enner G, Johnson J, Aalberi S, e al. isk ac-ors or relapse in healh care proessionals wih subsance use disorders. JAMA 2005Mar 23; 293(12): 1453-60.

90. Pelon C, Ikeda M. e Caliornia Physicians Diversion Program’s experience wihrecovering aneshesiologiss. J Psychoacive Drugs 1991; 23(4): 427-143.

91. Paris , Canavan DI. Physician subsance abuse impairmen: aneshesiologiss vs.

oher specialies. J Addic Dis 1999; 18(1): 1-7.92. Menk EJ, Baumgaren , ingsley CP, Culling D, Middaugh . Success o reenry

ino aneshesiology raining programs by residens wih a hisory o subsance abuse. JAMA 1990; 263(22): 3060-2.

93. Alexander BH, Checkoway H, Nagahama SI, Domino B. Cause-specific morali y riskso aneshesiologiss. Aneshesiology 2000; 93(4): 922-30.

94. Ward CF, Ward GC, Saidman LJ. Drug abuse in aneshesia raining programs: A survey,1970 hrough 1980. JAMA 1983; 250(7): 922.

95. Silversein JH, Silva DA, Iberi J. Opioid addicion in aneshesiology. Aneshesiology1993; 79(2): 354-75.

96. Calabrese G: Fármaco dependencia en anesesiólogos. En libro Manejo Perioperaoriodel paciene consumidor de drogas. Jaime ivera Flores 2009.Ediorial Alfil –MéxicoCap.32 pag. 473-489.

97. Calabrese G. Guía de Manejo de Abuso de Drogas en Anesesiólogo de CLASA. En Iner-ne: ww w.clasa-anesesia.org./serch/comisiones/mp.pd.

98. Calabrese G. Programa de Salud Ocupacional de Anesesiólogo de CLASA. En Inerne: www.clasa-anesesia.org./serch/comisiones/mp.pd.

99. Calabrese G. : En raado de Anesesia y eanimación. orres Luis 2012.España Cap 2;Enermedades Proesionales del Anesesiólogo pag. 32-37.



1.2 - e sress caused by medical emergencies. Faigue and is correlaion wih diseases, ... | 37

Te sress caused by medical emergencies. Faigue and iscorrelaion wih diseases, suicide and medical malpracice

Flavio Veinemilla Sig - ú

Aneshesiology Depar men, Grupo Hospialario Kennedy , Guayaquil, Ecuador

Inroducion

Paiens should be reaed by exper healhcare eams ha perorm as well as possiblein effors or good oucomes.

Wha ses aneshesiology apar rom oher medical specialies is he need or consan vigilance or possible emergencies. is poses excepional pressure on perorming wihin sric sandards and hereore impacs aneshesiologiss’ occupaional healh.

Physicians mus exer all heir knowledge, manual skills, dexeriy and atiude(echnical and non-echnical skills) in clinical pracice, even (and especially) inadverse siuaions, a any ime o day or nigh, in order o mainain sandard o care.

Aneshesiologiss commi o remaining aler and being able o manage crises hamay arise a any momen in he operaing room. However, physicians’ degrees oateniveness vary hroughou 12 or 24-hour shis and susaining a high level o wachulness is difficul. For ha reason, here is worldwide concern regarding hesaey o surgical paiens. Such high proessional expecaions lead o diminishedoccupaional well-being, so he aim o his chaper is o invesigae a manner o offer-ing paiens he bes healhcare possible wihou imposing on physician well-being.

Faigue in medical pracice

Aneshesiologiss are highly skilled proessionals, rained o make quick decisionsand perorm complex procedures under pressure. Due o echnology advances indiagnosic and reamen opions, he number o paiens is ever-growing, and so ishe expecaion or good resuls. Daily workload requires consisen perormance,

which is challenging or overworked proessionals who have o be available or emer-gency calls, eiher in he hospial or a home.

Burnou syndrome has been defined by psychologis Freudenberger and psycho-analys Maslach3 as he combinaion o specifically work-relaed aigue, emoionalexhausion and depersonalizaion1,2 , unlike depression, which is relaed boh opeople’s proessional and personal lives.

Leaders in differen areas, such as uors in aneshesiology raining programs, areexposed various orms o occupaional sress ha can rigger burnou syndrome.

A survey o 102 aneshesiologiss ound ha 28% o hem have had he syndromeand, based on he Human Services Survey quesionnaire, a version o he MaslachBurnou Invenory (MBI - HSS)4-7 , 59% o respondens were a high risk o burnou8.




Alhough hey don’ necessarily pracice clinical aneshesiology anymore, heseproessionals are grealy predisposed o occupaional sress. is highlighs he ex is-ence o oher sressors, such as worries abou he betermen o paien care, ever-reducing salaries, research and educaion budge consrains, medicolegal concerns,osering he search or excellence in rainees, unprepared or insufficien saff and

lack o collaboraion rom adminisraive auhoriies.

In comparison wih oher specialies, such as obserics-gynecology 5 , EN andophalmology 9 , aneshesiologiss show more signs o aigue, emoional ex haus-ion and depersonalizaion.

Faigue is a physical, emoional and psychological sae influenced by acors con-sidered unconrollable by physicians, since hey deal no only wih paiens bu also wih groups o individuals: hospial employees, adminisraive saff and paiens’amilies. ese inerpersonal relaionships ineviably lead o weariness due o heheerogeneous behavior o he many people involved. Faigue can also be defined asa sympom o acue or chronic disease10.

ABLE 1. Faigue and is causes in medical saff

Faigue

In-Hospial Causes

Group relaionship

echnologic resources

Lack o appropriae ools (medicines ec.)

Lack o raining

Job insabili y

Excess workload boh in hours and qualiy

Ex-Hospial Causes

Family insabiliy

Friends’ influences

Dissaisacion wih one’s home

e consan search or success ha is currenly promoed causes grea anxiey odocors, who quesion wha success really means: good income, large workload,academic or social saus or good paien-physician rappor. In ac, successul physi-cians are hose who have good echnical and non-echnical skills, including he abil-iy o manage heir eam wih respec and responsibiliy in order o creae a healhy workplace environmen. is resuls in beter inerpersonal relaions, diminishedoccupaional sress and, consequenly, reduced risk o aigue.

Objecive evaluaions o qualiaive and quaniaive acors show ha even smalleffors when perormed or exended periods can become hard work. is is wha




occurs in aneshesiology, where shis are sressul or he exensive workload andmay or may no be worsened by he severiy o paiens’ illnesses.

e physician’s oulook on office hours is imporan as well. Less experienced physi-cians, wih less experise in handling crises, end o see shis as more sressul due o

heir grea concern abou non-maleficence. Shi-relaed aigue and emoional sressare hereore bigger in hese docors han in experienced ones, independenly o heamoun o working hours.

Scienific discoveries and innovaions have undoubedly expanded our knowledgeo biological sciences. Conceps such as human genome11 , cloning12 , roboic sur-gery 13,14 and many ohers have made echnology an essenial ool in he medicalproession. Aneshesiologiss can and should use echnology o heir advanage inclinical pracice, bu here is no subsiue or solid medical knowledge, since sce-narios wih limied echnological resources, medicines and ools are no uncom-mon and resul in occupaional sress, oen riggering aigue and indifference. Adversiies may be inspiraional or creaive proessionals wih high sel -eseemand good problem-solving skills, bu in he long run, lack o resources may lead oaigue and depression, wih unoreseeable consequences.

Tere are hree recognized orms o aigue15:

a. ransiional: caused by sleep deprivaion or prolonged periods o susainedateniveness.

b. Cumulaive: caused by moderae sleep deprivaion or exra hours o alernessover many consecuive days.

c. Circadian: proessional perormance is diminished during he nigh, which isspecifically dependen on he circadian cycle.

Faigue, in all is orms, is inversely proporional o saey in all means o ranspor-aion and in chemical and nuclear indusries16-19 and here are various disasrousexamples o he consequences o human errors. In 1920, a sleep psychologis calledSiles described aigue as an imbalance beween desrucion and renovaion 20 , a

ransien bu harmul resul o bad habis. According o a quesionnaire-based survey o 647 aneshesiologiss, 49% o hemadmited o having made medical misakes atribuable o aigue; 63% o whomhypohesized ha such errors may have been he resul o work overload leading oauly pre-anesheic evaluaions in 14% o he cases21.

In order o perorm high-r isk procedures, proessionals mus be in heir absolue bes physica l and menal condiion. However, he debae concerni ng medicalaigue canno be limied o such high-risk siuaions, since low-risk procedures

perormed by aigued proessionals may evenually pose high risk as well. Boh body and mi nd mus be well and in harmony in order o assure he bes pos-sible proessional perormance. Approximaely 20% o land ranspor accidens




changed dramaically, and he highes raes are currenly among people who perormmanual labor, showing he influence o economic orces in deermining suicide37.

Sudens ha choose medical educaion aer experiencing a disease hemselvesor in amily members are under higher risk o developing burnou syndrome when

compared o sudens who make heir choice based on alruism, inellecual curi-osiy, proessional auonomy and ineres in human relaions38. e complexiy andlengh o he educaion process, combined wih financial pressure, resul in moremedical sudens showing signs o exhausion han rainees in any oher areas oknowledge39-42.

Sudying medicine is a risky and expensive business, and many sudens need o work on he side o pay or universiy ees, which resuls in signs o exhausion earlyin heir proessional lives. ere is generally a combinaion o personal predisposi-ion, ha suraces a universiy, and sressor acors ha develop hroughou an individual’s proessional lie, which may culminae in severe consequences. (Figure 1)

FIGURE 1. Te Burnou pahway

As illusraed above in he burnou pahway, rom is beginning up unil he possibiliyo aal oucomes, here are several criical seps, and early recogniion o he problemallows early inervenion. e incidence o suicidal ideaion during medical school varies rom 10.7 o 31.4%39-44 , wih higher suicide risk among women45 and an upwardrend in incidence over he years o medical lie41 , bu in general sudens are awareand in conrol o hese houghs. Sudens usually do no seek help or ear o judg-men rom amily, sociey or universiy. During medical school, amily influence acsas a proecive acor, bu as graduaion and residency progress, physicians become

immersed in he hospial environmen and show increasing suicidal endencies, as wellas diminished insigh abou heir houghs and eelings. Furhermore, financial andpersonal expecaions regarding he end o raining and ear o being deemed unfi or a




specialis diploma cause physicians o avoid seeking help a his ime. Also noeworhyis he ease in obaining and using medicaions, which may lead docors o explore heirknowledge o effecs, dosage and roues o adminisraion in order o plan a painlessdeah. e drugs mos requenly used by suicidal physicians were barbiuraes unil1995; since hen, hey have been superseded by opioids, especially among aneshesi-

ologiss46. Anoher imporan acor is ha one in every 15 aneshesiologiss suffersrom drug or alcohol abuse, especially residens and deparmen officers47,48.

A 40-year char review by orre e al revealed ha all causes o deah occur wihlower incidence in he medical populaion excep or suicide. e risk o suicide is70% higher han he general populaion among men and 250-400%37 higher han hegeneral populaion among women49.

Suscepible physicians should be recognized and evaluaed, since he origin o hephenomenon is muliacorial. Since all sudies in his field are rerospecive, hereare sill numerous gaps in knowledge abou i. e presence o risk acors prior ouniversiy, such as menal illness, psychosocial issues and personaliy rais mayshape he profile o he suscepible physician (figure 2)50,51. Mood swings and depres-sion relaed o alcohol and drug abuse are issues ha warran consideraion.

Figure 2. Suicide in he medical populaion and predisposing acors

Psychosocial acors such as occupaional sress and exisenial conflics can leaddocors o quesion heir career choice, resuling in grea anxiey, which requiressuppor boh in he amily and in he workplace environmens. Women are more

suscepible o he work-versus-amily conflic, since hey oen need o delegae hecare o children and he household in he name o heir proession. When his iscombined wih growing proessional demands and shrinking salaries, he siuaion




may become unsusainable, leading o he abandonmen o he proession in avor oamily well-being.

Aneshesiologiss are a higher risk o deah because hey work under uncommoncircumsances, such as exposure o anesheic gas wase, ionizing radiaion, exra-

neous bodily fluids, prescripion drugs, sress, nigh shis, long working hours andsleep deprivaion. Alexander e al52 analyzed daa rom more han 80000 deahs in anatemp o compare risks ha aneshesiologiss are exposed o wih hose o oher med-ical specialies. ere was no saisically significan difference in he raes o cancerand cardiovascular disease, bu here was a significanly higher rae o suicide [relaiverisk () = 1,45, confidence inerval (CI) 95% = 1,07 – 1,97], drug abuse ( 2,79,CI 95% 1,87 – 4,15), cerebrovascular disease ( 1,39, CI 95% 1,08 – 1,79) and deahrom oher causes ( 1,53, CI 95% 1,05 – 2,22) among aneshesiologiss.

e abiliy o solve problems ha arise in his personal and proessional lie dependson he physician’s personaliy – some personaliy rais augmen he risk o suicide,such as obsessive-compulsiveness, sel-blaming, inroversion, anxiey and vulner-abiliy 53. Proessionals who consider hemselves sel-sufficien and convey a sel-confiden image o he world bu are aware o heir conflics and sill do no seek orhelp are he mos vulnerable o suicide.

Sress as a par o aneshesiology

In everyday sociey, people perorm various asks and proessions which oen expose

hem o occupaional hazards. e Naional Insiue or Occupaional Saey andHealh (NIOSH) is he U.S. ederal agency responsible or research and recom-mendaions or he prevenion o work-relaed illnesses or injuries. is organizaionconsiders ha characerisics o he work-worker relaionship are he main cause ooccupaional sress – i.e., when he abiliy, resources and needs o he worker are nocompaible wih he work he perorms54. e NIOSH proposed a model o how heacors leading o sress culminae in occupaional injuries and illnesses. (Figure 3)

Figure 3. NIOSH occupaional sress model




Some proessions are, by he specific naure o he aciviy, more relaed o risks ooccupaional sress and risk o deah:

- Spors: divers, pararoopers, boxers, wreslers, bullfighers, climbers.

- Personal and indusrial saey: guards, policemen.

-ransporaion saff: drivers, pilos, echnicians in aeronauics.

- Healhcare: docors, nurses, especially when working in operaing rooms,emergency rooms and inensive care.

- Adminisraive: managers, accounans, execuives, sock exchange brokers.

- Indusry: producion line and consrucion workers.

- Various: activ ities requiring connement such as workers at sea and military.

A person’s proessional choice depends on several acors, he mos imporan being

he affiniy wih he chosen proession, combined wih abiliy, skill and ideniy operorm i. is choice is closely relaed o individual personaliy rais and way o working – some people ideniy wih high expecaion, high pressure proessions;such individuals will perorm worse and evenually even show signs o depression iplaced in lower inensiy roles. e allocaion o employees according o personaliyrais is essenial or companies, since perormance levels can drop i an employee isunhappy and demoivaed in his role.

e secreion o corisol, caecholamines and oher endogenous subsances ollows

he circadian cycle, in he same way ha proessional aciviy varies hroughouhe day. ere are imes o day when, normally, hormone and caecholamine levels would be reduced, bu occupaional sress and he ateniveness required o perormcerain asks lead o urher caecholamine discharge, in order o balance he nauralcycle. is effec can also be achieved hrough he use o exogenous simulans.

Sress is a necessary evil a cerain imes o an aciviy, in order o achieve he bespossible perormance, bu i he inensiy or duraion o sress is excessive, heaffeced physician may suffer rom reduced alerness and show signs o aigue, which impacs negaively on his echnical and non-echnical skills. e momens

o greaes sress or aneshesiologiss are variable, bu research shows ha 5% oaneshesiologiss are in condiions o consan sress55,56. e sressed docor is nonecessarily a bad docor, bu he may lose conrol in crisis siuaions55.

Any proessional aciviy is subjec o a cerain level o sress, regardless o individualcharacerisics, bu in some proessions, even small daily aciviies enail levels o sressso high hey canno be compared o oher proessions. Proessional sress levels arecorrelaed o he degree o responsibiliy associaed wih he proession57-62 , and doc-ors perorming surgical procedures are he mos suscepible ones. Alhough all asks

mus be perormed responsibly, when here are lives a sake, be ha o he proessionalor o he person receiving he service, he consequences o any acion are undoubedlymore severe, and his mus be aken ino accoun in he sudy o aigue. (Figure 4)




Figure 4. Occupaional sress in he mos suscepible proessions

Awareness o he exisence o higher degrees o occupaional sress depending on heproession mus lead o prevenive measures agains hese consequences. is can beachieved hrough enhancing and updaing inormaion o proessionals regardinghe risks hey are exposed o, hrough beter ime organizaion and disribuion andhrough opimized eamwork in order o render he aciviy more efficien and lessliable o misakes. (Figure 5)

Figure 5. Sress and miigaing acors

Aircra pilos are submited o occupaional risks similar o hose o docors: highdemands in raining, decision-making, ateniveness levels and efficiency. e per-ormance o boh proessions poses significan occupaional risks and hey mus

hereore be waged accordingly (able 2). Human resources and maerials are neces-sary o suppor hese proessionals in he ace o work-relaed sress, and i is crucialo build a suiable workplace environmen.




able 2. Aneshesiologiss x Pilos

Issue Analysis

Who saves more lives, physicians

or pilos?63 (60)

Focus on boh physicians’ and pilos’ missions in ordero evaluae which proession has more lives under heir

responsibiliy.75% responded ha physicians save more lives.

Should pilos (61) and physicianshave similar wages? 64

ere is awareness ha boh proessions are relaed orisks, responsibili ies and money. Medicine ends o be beter compensaed.

Pilos die, docors don’ 65 (62)

e use o checkliss in medicine, as exemplified by heones employed by pilos, is suggesed in order o reducehe incidence o human errors.

Who has he beter job, pilos ordocors? 66(63)

For saey reasons, he use o checkliss is mandaory

or pilos; i should also be ha way in cerain areas omedicine.

Pilos use checkliss, why don’physicians use hem?67 (64)

raining mus be assessed individually and conrolevaluaions mus be underaken in order o guaraneesandard o care in boh proessions.

Wha can docors learn rompilos? 68 (65)

I is argued ha pilos’ wages are no compaible wihhe associaed risks and responsibiliies.

Who’s more proessional, pilos

or docors? 69 (66)

Proessional ineres in amelioraing saey and qualiy

o processes mus be compared beween pilos andphysicians.

Shifs and sress

Hospial care is a coninuous service ha can be compared wih oher aciviies harequire consan atenion, 24 hours a day, such as power and uel suppliers, miliarysaff, policemen, firefighers, communicaions proessionals, ransporaion saff,ec. Perorming hese aciviies requires physiological changes rom proessionals –ligh is he mos poen synchronizer o he cenral nervous sysem (CNS), i reaches

he reina and is ransduced hrough he spinohalamic pahway o he suprachi-asmaic nucleus o he hypohalamus, which governs he circadian cycle70,71. isallows he CNS o differeniae day rom nigh in order o modulae hormone secre-ion, digesion, immunologic uncions72,73,50,51 , mood, wakeulness and proessionalperormance. Hospial-based healhcare proessionals mus be able o perorm a anyime o day, which means medical eams mus work nigh shis or which hey areno physiologically prepared, since heir CNS is programmed o reduce wakeulnessand perormance levels a nigh.

Due o he same reasons, car accidens occur mos requenly a nigh. A sudy o12535 accidens has shown ha he majoriy o hem included young drivers, aigue(15%) and early morning hours, w ih no relaion o alcohol use74,75.




Nigh shis cause physicians some anxiey relaed o possible hreas and dangers onheir way o work (able 3) and, especially, he need o provide medical care a anyime o day. ese concerns rigger physiological changes such as decreased cardiacsympaheic modulaion during he nigh, high levels o anxiey, depression andatenion defici76. is was shown by a ollow-up sudy o hree medical inerns or

hree monhs as hey worked 10 shis per monh o 33,5 hours, each shi ollowed by wo days’ res.

ere is currenly concern over sress levels among aneshesiology residens, sincehe sress hey experience may be greaer han ha experienced by heir supervisors,possibly due o he heavy workload associaed wih worries abou he progression oheir pracical and heoreical knowledge. esidency program supervisors are alsoheavily affeced by sress; heir leadership skills are esed daily in eaching, programmanagemen and clinical care aciviies5. Burnou syndrome consiss o aigue,

impaired perormance, emoional exhausion and depersonalizaion, and is simi-larly requen among residens and supervisors77,78. Because hey are younger andin raining, residens are presumed capable o oleraing heavier weekly workload, which, combined wih alcohol inake and exhausion, conribues o he develop-men o burnou syndrome among aneshesiology rainees79-81.

Physicians are very sensiive o heir workplace environmen, which means is psy-chosocial characerisics exer grea influence over physician perormance (Figure6). ese proessionals end o mirror heir lives, sel-eseem and saisacion in heir

work, hereore inadequae managemen o work environmen may resul in dissais-acion and possibly isolaion o employees.

Figure 6. Te workplace environmen and is influence on burnou syndrome




Undoubedly, a hospial is no an ideal workplace, since here are ongoing hreaso he healh o proessionals (able 3), such as: conac wih erminally ill paiens,accidens, suffering, deah, unsuccessul reamens, responsibiliy o make deci-sions ha will define heir paiens’ qualiy o lie. All hese acors significanlyimpac physicians’ lives; some are able o naurally miigae hese effecs on heir

psychè, while ohers search or exraneous means o compensaion o olerae or be-er assimilae hese adversiies, he mos common o which are smoking, alcohol anddrug inake82,83.

able 3. Nosocomial hreas o docor’s healh.

HREAS

Biological Vir us, bacteria, uids.

Mechanical Bruises, cus, shocks.

Chemical Vapors, gas, allergens.

Physical Sounds, l ighs, emperaure, x rays, laser, elecr iciy, bad posure.

Personal Drug abuse, aigue, sress.

ere are psychological condiions associaed wih a higher risk or burnou syn-drome developmen among docors, such as unrealisically high proessional expec-aions, youh, being single and proessionals wih low sel-eseem or who end o vicimize hemselves over heir colleagues. igid hierarchies, high pressure andexcessive demands a he workplace are negaive acors ha can make he workenvironmen anoher risk acor or burnou.

Docors should have beter working condiions, as work saisacion affecs paien-physician rappor and healh care qualiy. Faigue and qualiy o lie affec proes-sionals’ atenion and can be direcly relaed o medical malpracice. Shanael e alcoordinaed a sudy wih 7905 surgeons, 15% o whom acknowledged having com-mited significan malpracice; 70% o hose atribued he error o a single acor,

such as lack o ime or proper decision-making, sress, burnou, lack o concenra-ion or aigue84 , hereby confirming ha proessional well-being mus consider individual and organizaional eaures.

A hospial provides more han jus healh care ser vices o he populaion, i is a place where uorials, eaching and learning aciv iies are developed during he enire day.Faigue and sleep deprivaion exer negaive impac on sudens’ learning skills85-89. Aer a srenuous workload physicians’ capaciy o memorize and learn is compro-mised90-92 so inormaion will no be properly absorbed, creaing a difficul siuaion

where he eacher believes ha all his words will be used in he reamen o paiens bu sudens have no acually absorbed he inormaion. Classes and clinical dis-cussion schedules can also affec learning skills, as human body is geneically pro-




grammed o sleep rom 3 o 7 a.m. and rom 1 o 4 p.m.,93, 94 while i shows higherlevels o vigilance rom 9 o 11 a.m. and rom 9 o 11 p.m. Physician’s aciviies may be affeced by aigue, sleep disorders and changes in he circadian cycle and he onlyreamen or aigue is o sleep.95

Ouside he medical scope, he American Auomobile Associaion (AAA) publishedin 2010 a repor in which 27% o inerviewed drivers admited o having driven whilehey were somnolen, wih difficuly o keep heir eyes open, in he previous monh;41% o hose ell asleep a some poin; 10% o all he inerviewed admited o havingslep while driving a leas once during he previous year. 96

e influence o exhausion in driving capaciy is similar o he influence o he high-es legally allowed blood concenraion o alcohol.97 Faigue and sleep deprivaioncan, hereore, affec driving skills by leading o lower levels o atenion, vigilanceand percepion. In he case o healh proessionals, consecuive overnigh shis delayhe capaciy o analyze moniors98 and here is a risky poin where i does no materhow experienced he proessional is, physical and menal aigue will overcome heabiliy o susain vigilance and he physician will lose conrol o he siuaion .

Criical siuaions experienced by aneshesiologiss in he operaing room can becompared o he siuaions experienced by pilos, considering human, economicaland financial aspecs. 52,63-69

Errors, morals, ehics and he physician.

e pracice o medicine is difficul and complex; he word error in his milieu cre-aes proound impac wih significan consequences. Medical malpracice is an ac oimprudence, malpracice or negligence ha causes severe or poenially severe con-sequences or he paien. I mus be careully analyzed by proessionals wih knowl-edge and experise o be considered wrong, a medical malpracice.99 Complicaions,prevenable adverse evens aer medical reamen or surgical procedure whose risks were previously know n, are no he same hing as medical error.100-102

Jus as success, errors are he resul o a sequence o evens and any acor ha influ-

ences he process will affec he resul. When i comes o medical error, he paien’ssiuaion is he only concern, and physicians’ physical and menal circumsances hamay affec heir judgmen are no aken ino accoun. In medicine no every error will lead o aal or severe consequences, however, in some specialies such as anes-hesiology and surgery errors are no allowed.

ohn’s repor, daed rom 1999, is used as a reerence or medical errors. In hispublicaion, approximaely 100.000 paiens died rom complicaions ha couldhave been avoided.103 Sudies repored ha aigue and sleep were he main causes o

medical errors among residens.

103 -108

For he pracice o aneshesiology, physicians should be in heir bes physical, men-al and emoional condiions in order o successully inegrae and apply all heir




knowledge and pracical skills. Faigue, burnou, sleep deprivaion and indifferenceo he paien make proessionals more prone o errors. esidens and expers areaware ha he number o overnigh shis, workload and hospial working condiionscan be decisive acors in aneshesiologiss’ perormance qualiy during criical siu-aions. So i is necessary o analyze he reasons why aneshesiologiss accep such

heavy workload (insiuional requiremen, lack o organizaion, financial or per-sonal reasons). In some insiuions, overnigh shis are a way o increase employeeincome, so physicians overload heir agenda a he expense o qualiy o medical careand lie. Oher docors choose o work harder and have more overnigh shis no orfinancial reasons, bu because o personaliy rais and liesyle, in his case exces-sive work is jus a par o heir realiy. Lack o insiuional organizaion o opimizehospial’s available resources conribues o greaer emoional disress a work.

us, aneshesiologiss should no work under inadequae physical, menal or organi-

zaional condiions, since proessionals mus have commimen and provide he besevidence-based reamen o he paien. Human lie is considered an asse – AlredSauvy in his book eniled “e cos and value o human lie”110 (Coû e valeur de la viehumaine) repored lie-relaed crieria considering social, religious, racial, poliical,economical and proessional eaures. Excessive workload and grea responsibiliiescan be negoiaed in order o improve amily lie111, 112 and paien’s qualiy o care.

Conclusions

Human lives are saved every day hanks o developmens in biomedical sciences. Aneshesiologiss should always sr ive o expand heir knowledge and o compre-hend everyhing ha happens o he paien. Sudies in physics, chemisry andcompuer science, as well as leadership and hospial managemen knowledge, areimporan or he medical field. ese sciences have been changing conceps andproocols o beter guide clinicians. Usually docors know more abou heir paienshan abou hemselves, since hey do no recognize occupaional risks and do noperceive he laen aigue caused by heir duies and obligaions. I is necessary oinervene and change he behavior o physicians and oher healhcare saff in order

o achieve beter qualiy o lie or hese proessionals and beter qualiy and saeyo care or heir paiens.

Reerences

1. Freudenberger HJ: e saff burn-ou syndrome in alernaive insiuions, Psychohera-py: eory, esearch, and Pracice.1975; 12:73– 82.

2. Freudenberger HJ: Burn-ou: Occupaional hazard o he child care worker. Child CareQ 1977; 6:90–9.

3. Maslach C, Schaueli WB, Leier MP: Job burnou. Annu ev Psychol 2001; 52:397– 422.

4. Felon JS: Burnou as a clinical eniy: Is imporance in healh care workers. Occup Med(Lond) 1998; 48:237–50.




5. Gabbe SG, Melville J, Mandel L, e al: Burnou in chairs o obserics and gynecology:Diagnosis, reamen and prevenion. Am J Obse Gynecol 2002; 186:601–12.

6. Golub JS, Johns MM 3rd, Weiss PS, e al: Burnou in academic acul y o oolaryngology-head and neck surger y. Laryngoscope 2008; 118:1951– 6.

7. Barger L, Cade B, Ayas N. Extended Work Shis and the Risk of Motor Vehicle Crashes

among Inerns. N Engl J Med 2005; 352:125-34.8. De Oliveira GS Jr, Ahmad S, Sock MC,e al. High incidence o burnou in academic

chairpersons o aneshesiology: should we be aking beter care o our leaders? Aneshe-siolog y. 2011;114:181-93.

9. Cruz OA, Pole CJ, omas SM: Burnou in chairs o academic deparmens o ophhal-mology. Ophhalmology 2007; 114:2350 –5.

10. eam E. ichardson A. Faigue: aconcep analysis. In J Nurs Sud. 1996;33:519-29.

11. Searle , Hopkins PM. Pharmacogenomic variabiliy and anaeshesia. Br J Anaesh.

2009;103:14-25.12. Wilmut I, Schnieke AE, McWhir J, Kind AJ, Campbell KH . “Viable ospring derived

rom eal and adul mammalian cells”. Naure. 1997;385 : 810–3.

13. woh, Y. S., Hou, J., Jonckheere, EA, e al. A robo wih improved absolue posiioningaccuracy or C guided sereoacic brain surgery. IEEE rans. Biomed. Engng.1988, 35,153–161.

14. McConnell, PI; Schneeberger, EW; Michler, E . “Hisory and developmen o roboiccardiac surgery”. 2003.Problems in General Surgery 20: 20–30.

15. Fligh crew member duy and res requiremens. FAA NPM Docke No. FAA-2009-

1093; Noice No. 10-11, Federal egiser 16 Sep 2010 Aviaion Medicine AdvisoryService-NBAA 2010.

16. National Transportation Safety Board: Grounding of US Tankship Exxon Valdez onBligh Reef, Prince William Sound Near Valdez, AK, March 24, 1989. Washington, DC,Naional ransporaion Saey Board, 1990.

17. Moss H, Sills DL: e ree Mile Island Nuclear Acciden: Lessons and Implicaions.New York, New York Academy o Sciences, 1981, pp 341.

18. epor on he Acciden a he Chernobyl Nuclear Power Saion. Washingon,DC, USGovernmen Prining Office, 1987.

19. epor o he Presidenial Commission on he Space Shutle Challenger Acciden. Wash-ingon, DC, US Governmen Prining Office, 1986.

20. Siles P. ypes o aigue. Am J Public Healh (N Y). 1920; 10: 653–56.

21. Gaba DM, Howard S, Jump B .Producion pressure in he work environmen. Calior-nia aneshesiologiss’ atiudes and experiences. Aneshesiology. 1994;81:488-500.

22. Akersed : Consensus saemen: Faigue and accidens in ranspor operaions. J Sleepes 2000; 9:395.

23. Dawson D, eid : Faigue, alcohol and perormance impairmen . Naure 1997; 388:235

24. Denisco R, Drummond JN, Gravensein JS. e effec o aigue on he perormance oa simulaed anesheic monioring ask. J Clin Moni 1987; 3:22–4.




25. Friedman C, Bigger J, orneld DS. e inern and sleep loss. N Engl J Med 1971;285:201–3.

26. Smih-Coggins , osekind M, Buccino , Dinges DF, e al. oaing shiworkschedules: Can we enhance physician adapaion o nigh shis? Acad Emerg Med 1997;4: 951–61.

27. Smih-Coggins , osekind M, Hurd S, e al. elaionship o day versus nigh sleep ophysician perormance and mood. Ann Emerg Med 1994;24:928–34.

28. Craig A, Condon : Speed-accuracy rade-off and ime o day. Aca Psychol 1985;58:115–22.

29. Schmid and Lee, 1999. Schmid , Lee . Moor Conrol and Learning. A BehavioralEmphasis (3rd. ed.). Champaign, IL: Human ineics, 1999.

30. Nagengas A J., Braun DA,Wolper1 D. isk sensiiviy in a moor ask wih speed-accu-racy rade-off .J Neurophysiol. 2011; 105: 2668–74.

31. osenberg J, Maximov II, eske M, e al. “Early o Bed, Early o ise”: Diffusion ensorImaging Idenifies Chronoy pe-Specificiy. Neuroimage. 2013 Aug 31: S1053-8119.

32. Juda M, Veer C, Roenneberg T. Chronotype modulates sleep duration, sleep qualit y,and social je lag in shi-workers.J Biol hyhms. 2013 ;28:141-51.

33. Shanael D, Balch CM, Dyrbye L, e al. Suicidal ideaion among American surgeons. Arch Surg 2011;146:54– 62.

34. Schernhammer ES, Coldiz GA. Suicide raes among physicians: a quaniaive and gen-der assessmen (mea-analysis). Am J Psychiar y 2004;161:2295–302 .

35. Goeber D, ompson D, akeshia J, e al. Depressive sympoms in Suicide o Dr.

Horace Wells, o Harord, Connecicu, U.S”. Providence Medical and Surgical Journal1848.12 : 305–6.

36. achur SP, Poter LB, Powell E, osenberg ML. Suicide: Epidemiology,Prevenion,and reamen. Adolesc Med 1995;6:171-82.

37. Hampon . Expers address risk o physician suicide. JAMA. 2005;294:1189–91.

38. Pagnin D, De Queiroz V, De Oliveira Filho MA, et al.Burnout and career choice motiva -ion in medical sudens. Med each. 2013;35:388-94.

39. hokher S, han MM. Suicidal ideaion in Pakisani college sudens. Crisis

2005;26:125–7.40. Alexandrino-Silva C, Pereira ML, Busamane C, e al. Suicidal ideaion among sudens

enrolled in healhcare raining programs: a cross-secional sudy. ev Bras Psiquiar2009;31:338–44.

41. Schwenk L, Davis L, Wimsat LA. Depression, sigma, and suicidal ideaion in medicalsudens. JAMA 2010;304:1181–90.

42. Curran A, Gawley E, Casey P, Gill M, e al. Depression, suicidaliy and alcohol abuse. IrMed J. 2009;102:249-52.

43. Tyssen R, Vaglum P, Grønvold NT, Ekeberg O. Suicidal ideation among medical students

and young physicians: a naionwide and prospecive sudy o prevalence and predicors. J Affec Disord 2001;64:69–79.




44. Okasha A, Loai F, Sadek A. Prevalence o suicidal eelings in a sample o nonconsulingmedical sudens. Aca Psychiar Scand 1981;63:409–15.

45. Linderman S, Laara E, Hakko H, e al. A sysemaic review on gender specific moraliyin medical docors. Br J Psychiary 1996; 168:274 - 9.

46. Hawon , Clemens A, Simk in S, e al. Docors who kill hemselves: a sudy o he

mehods used or suicide. Q JM : Monhly Journal o he Associaion o Physicians 2000,93:351-7.

47. omas I; Carer JA. Occupaional hazards o anaeshesia. Educ. Anaesh Cri CarePain2006; 6:182-7.

48. Berry CB,Crone IB, Plas M. Subsance misuse among anaesheissin he Unied ng-dom and Ireland. Anaeshesia 2000;55:946-52.

49. orre DM, Wang NY, Meoni LA, e al. Suicide compared o oher causes o moral iy inphysicians. Suicide Lie rea Behav. 2005 ;35:146-53.

50. DeSole DE, Singer P, Aronson S. Suicide and role srain among physicians. In J Soc Psy-chiary. 1969;15:294–301.

51. Doyle JP, Frank E, Salzman LE, McMahon PM, e al.Domesic violence and sexualabuse in women physicians:associaed medical, psychiaric, and proessional difficulies. J Women’s Healh Gend Based Med. 1999;8:955–965.

52. Alexander BH, Checkoway H, Nagahama SI, Domino B. Cause-specific moraliy riskso aneshesiologiss. Aneshesiology. 2000; 93:922-30.

53. Sansone R, Sansone LA. Physician Suicide: A Fleeing Momen o Despair Psychiar y2009;6:18–22.

54. DHHS (NIOSH) Sress... A Work Bookle . 1999.99-101.55. e Associaion o Anaesheiss o Grea Briain and Ireland, 9 Bedord Square, London

WC1B 3R, U . Sress in Anaesheiss. Sepember 1997

56. Hawon , Clemens A, Sakarovich C e al. Suicide in docors: a sudy o risk accordingo gender, senioriy and specialy in medical praciioners in England and Wales, 1979-1995. J Epidemiol Communiy Healh 2001;55:296–300.

57. Garbarino S, Cuomo G, Chiorri C, e al. Associaion o work-relaed sress wih menalhealh problems in a special police orce uni. BMJ Open. 2013;3.:1-27.

58. Cooper CL, Marshall J: Occupaional sources o sress: a review o he lieraure relaingo coronary hear disease and menal ill healh. J Occup Psychol 1976, 49:11-28.

59. Bourbonnais R, Malenfant R, Vezina M, Jauvin N, Brisson I. Les caracteristiques du tra- vai l e la sane des agens en service de deenion. ev ue Epidemiolog ique Sane Publique2005, 53:127-42.

60. Dewa CS, McDaid D, Etner SL.An inernaional perspecive on worker menal healhproblems: who bears he burden and how are coss addressed? Can J Psychiary 2007,52:346-56.

61. Cullen F, Link BG, Wole N, Frank J. e social dimensions o correcional officer

sress. Jusice Quarerly 1985, 2:505-533.62. Maslach C, Schaueli WB, Leier MP: Job burnou. Annual evue o Psychology 2001,

52:397-422.




80. Chan AO, Huak CY. Influence o work environmen on emoional healh in a healh careseting. Occup Med 2004;54:207–12

81. Balch CM, Shanael D, Dyrbye L, Sloan JA, ussell , Bechamps GJ, Freischlag JA. Surgeon disress as calibraed by hours worked and nighs on cal l. J Am Coll Surg2010;211:609–19

82. De Oliveira GS, Chang , Fizgerald PC,e al. e Prevalence o Burnou and Depres-sion and eir Associaion wih Adherence o Saey and Pracice Sandards: A Survey oUnied Saes Aneshesiologyrainees. Anesh Analg 2013;117:182-93.

83. Oreskovich M, aups L, Balch CM, e al.Prevalence o alcohol use disorders among American surgeons. Arch Surg. 2012;147:168-74.

84. Shanael D, Balch CM, Bechamps G, e al. Burnou and medical errors among Ameri-can surgeons. Ann Surg. 2010;251:995-1000.

85. Graves L, Pack A, Abel . Sleep and memory: a molecular perspecive. rends Neurosci.2001;24:237–43.

86. Maque P. e role o sleep in learning and memory. Science. 2001;294:1048–52.

87. Sickgold . Sleep-dependen memory consolidaion. Naure. 2005;437:1272–8.

88. Ellenbogen JM, Hulber JC, Sickgold , e al. Inerering wih heories o sleep and mem-ory: sleep, declaraive memory, and associaive inererence. Curr Biol. 2006;16:1290–4.

89. Walker MP, Sickgold . Sleep, memory, and plasiciy. Annu ev Psychol. 2006;57:139–66.

90. arni A, anne D, ubensein BS, e al. Dependence on EM sleep o overnigh im-provemen o a percepual skill. Science. 1994;265:679–82.

91. Stickgold R, James L, Hobson JA. Visual discrimination learning requires sleep aerraining. Na Neurosci. 2000;3:1237–8.

92. Ferrara M, Iaria G, De GL, e al. e role o sleep in he consolidaion o roue learning inhumans: a behavioural sudy. Brain es Bull. 2006;71:4–9.

93. Van Dongen HP, Dinges DF: Circadian rhythms in fatigue, alertness, and perfor-mance, Principles and Pracice o Sleep Medicine, 3rd ediion. Edied by ryger MH,oh , Demen WC. Philadelphia, Saunders, 2000, pp 391–9.

94. Czeisler CA, halsa SB: e human circadian iming sysem and sleepwakeregulaion, Principles and Pracice o Sleep Medicine, 3rd ediion. Edied by ryger MH,

oh , Demen WC. Philadelphia, Saunders, 2000, pp 353–75.95. Caldwell, J.A. Faigue in he Aviaion Environmen: An Overview o he Causes

and Effecs As Well As ecommended Counermeasures.Avia Space and Environ Med1997, 68:932-8.

96. American Auomobile Associaion Foundaion or raffic Saey, 2010. Asleep a he wheel: he prevalence and impac o drowsy driving,htp://www.aaaoundaion.org/pd/2010DrowsyDrivingepor.pd.

97. Powell, N.B, Schechman, B., iley .W, e al,. e road o danger: he compara-ive risks o driving while sleepy. e Laryngoscope 2001, 111:887-93.

98. Weinger MB, Ou JC, Vora S, et al. Further evaluation of the eects of nighime work on mood, ask paterns, and workload during aneshesia care. Aneshesiology2001;95:A1196.




99. Wu AW, Folkman S, McPhee SJ, e al. Do house officers learn rom heir misakes? JAMA. 1991;265:2089 –94.

100. Brennan A, Leape LL, Laird NM, e al. Incidence o adverse evens and negligence inhospialized paiens. esuls o he Harvard Medical Pracice Sudy I. N Engl J Med.1991;324:370 –376.

101. Baker GR, Norton PG, Flinto V, et al. e Canadian Adverse Events Study: the incidenceo adverse evens among hospial paiens in Canada. CM AJ. 2004;170:1678 –1686.

102. Leape LL, Brennan A, La ird N, e al . he naure o adverse evens in hospial-ized paiens. esuls o he Harvard Medical Pracice Sudy II. N Engl J Med.1991;324:377–384.

103. ohn L, Corrigan J, Donaldson MS. Insiue o Medicine (US); Commitee on Qual-iy o Healh Care in America. o err is human: building a saer healh sysem. Washing-on (DC): Naional Academy Press; 1999.

104. Landrigan CP, ohschild JM, Cronin JW, aushal , Burdick E, az J, e al. Effec oreducing inerns’ work hours on serious medical errors in inensive care unis. N Engl JMed. 2004;351:1838–48.

105. Barger L, Ayas N, Cade BE, Cronin J W, osner B, Speizer FE, e al. Impac o exend-ed-duraion shis on medical errors, adverse evens, and atenional ai lures. PLoS Med.2006;3:e487.

106. Lockley SW, Barger L, Ayas N, ohschild JM, Czeisler CA, Landrigan CP, e al.Effecs o healh care provider work hours and sleep deprivaion on saey and peror-mance. J Comm J Qual Paien Sa. 2007;33(11 Suppl):7–18.

107. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates ofmedicaion errors among depressed and burn ou residens: prospecive cohor sudy.BMJ. 2008;336:488–91.

108. Sargen MC, Soile W, Soile MO, ubash H, Barrack L.Qualiy o lie during orho-paedic raining and academic pracice: par 2: spouses and significan ohers. J Bone Join Surg Am. 2012; 3;94:e145(1-6).

109. Hakim C. Women, careers, and work-lie Preerences. Briish Journal o Guidance &Counselling, 2006:34,279-94.

110. Sauvy, Alred: Coso y valor de la vida humana.: Emecé Ediores, Buenos Aires,

Argenina 1980.111. Murha Y. Perspecives o Being Spouse, Paren, Surgeon. J Orhop rauma. 2013 Jul 22.

[Epub ahead o prin]

112. Wang Y, Liu L, Wang J, Wang L. Work-amily conflic and burnou among Chinese doc-ors: he mediaing role o psychological capial. J Occup Healh. 2012;54:232-40.



1.3 - Facors involved in he developmen o chemical dependency in aneshesia personnel | 57

Factors involved in the development of chemical dependencyin anesthesia personnel

Roger Addison Moore Professional Well-being Commitee of WFSA

Associae Professor of A neshesiology, Universiy of Pennsylvania and Chair Emerius , Deparmen of Aneshesiology, Deborah Hear and Lung Cener

Te problem

For a variey o reasons, discussions concerning he possible use and abuse opharmaceuicals by aneshesiologiss and oher medical proessionals have beengenerally mued and resrained. Unorunaely he public is becoming aware o hisproblem hrough independen news sources over which he proession has litle or no

conrol1, 2

. Obviously no proession wishes o draw negaive atenion o isel, espe-cially in he view o he public or regulaory bodies. On he oher hand, i a problemdoes exis, an inenional lack o atenion may deea he developmen o producivemehods or inervening and reamen sraegies. Tereore, as a firs sep, denialmus be pu aside and he quesion direcly answered, do aneshesia praciionershave a problem? Decades o medical lieraure seem provide a definiive answer ohis quesion.

An imporan sudy published in 19743 , surveyed he causes o deah or 211 anes-hesiologiss who were members o he American Sociey o Aneshesiologiss living

in he Unied Saes and Canada. Tis sur vey was simply par o an ongoing series osudies o a similar naure evaluaing any aberraions in he causes o deah amonganeshesiologiss 4, 5 . No surprisingly, each survey had similar findings. Moraliyor aneshesiologiss, compared o a cohor o he general public, showed an overallreduced deah rae in all caegories, including cardiovascular disease, accidens andmalignancies. However, when suicides were evaluaed, aneshesiologiss showed analarming hree-old higher deah rae han he normal populaion cohor. Deahs by drug overdoses were no separaed rom suicides. A more recen sudy 6 , appear-ing in Aneshesiology, compared he moraliy o aneshesiologiss wih a cohor oinerniss beween 1979 and 1995. Te resuls showed significanly higher levels omoraliy or aneshesiologiss in 4 differen areas: 1) cerebral vascular accidens, 2)human immunodeficiency viral inecions and viral hepaiis or male aneshesiolo-giss; 3) suicide and 4) a 2 ½ higher deah rae relaed o drugs. In regard o deahsdue o drugs, aneshesiologiss were a he greaes risk during he five years afermedical school, bu he rae o drug deahs in aneshesiologiss coninued o exceedinerniss hroughou heir careers. Te conclusions o he sudy were: “Subsanceabuse and suicide represen significan occupaional hazards for aneshesiologiss” 6 .

Aside rom he personal ragedy rom he loss o lie, his sudy also poins ou heimmense proessional and economic oll produced by hese deahs. Some 1,583 pro-essional lie years were los due o suicide and 2,108 proessional lie years were los




geneic variaions. e effec o anesheic agens on individual paiens is in parmodulaed hrough geneic conrol. ere are known differences in aneshesia sensi-iviy among mammals based on differences in geneic makeup. In paricular a number o mice and ra sudies have been perormed showing ha variaions o a singlegene produce significan differences in anesheic and hemodynamic sensiiviy o

propool30, 31. Differences in anesheic sensiiviy have also been seen wih inra- venous32 and inrahecal enanyl33 , as well as inravenous remienanil34. oughconradicory inormaion exiss, i would seem ha paiens wih red hair may havea recessive variaion in he gene known as he melanocorin-1 recepor gene hacould be relaed o aneshesia resisance and inraoperaive awareness35-37 , houghno all sudies suppor his observaion38. e key message is ha he role o genom-ics in predicing a paien’s response o a myriad o agens prior o giving hese agensmay well be on he horizon. In ac, as ar back as 200339 an ediorial abou he useo genomics in aneshesia poined ou he direcion aneshesiology was headed. eauhors saed:

“Perioperaive Genomics seeks o apply uncional genomic approaches o revealhe biological reasons why similar paiens can have significanly differen clinicaloucomes aer surgery. For he perioperaive physician, hese findings may soonranslae ino prospecive risk assessmen incorporaing genomic profiling o mark-ers imporan in inflammaory, hromboic, vascular, and neurologic responses operioperaive sress, wih implicaions ranging rom individualized addiional pre-operaive esing and physiological opimizaion, o perioperaive decision-making,

opions o monioring approaches, and criical care resource uilizaion”39 - How-ever, he auhors also poined ou he risks and ehical concerns associaed wih hisnew ronier.

Seeing he imporance o genomics in he presen and uure delivery o aneshesiacare, i should come as no surprise ha geneics has an equally imporan role o playin preselecing aneshesia personnel a greaer risk or developing subsance abuseand dependency. A consensus seems o be developing ha geneics may accoun orover 50% o an individual’s predisposiion oward he developmen o addicion o

alcohol40-43

, while i may also play a significan role in addicion o boh nicoine44, 45

and oher drugs46, 47.

Genomics o Addicion based on win and Family Sudies

he irs indicaion o a possible geneic link or addicion came rom com-paraive case-conrolled populaion sudies, and he i ndings rom paernal a ndraernal win sudies. he purpose o hese sudies was o deermine he con-cordance o alcoholism in one win wih he occurrence rae o alcoholism inhe oher. I alcoholism was linked o geneic acors, he monozygoic win ses

migh be expeced o have a higher concordance rae han he dizygoic wins .he posiive indings in his regard direced he consideraion ha here was hepossibiliy o genes having a role in subsance abuse 40, 48-50. However, disagree-




men coninued o exis in rega rd o he relaive imporance o naure (geneics) verses nuru re (environmen) i n he developmen o addicion 51. A presen heconclusion is ha addicion sems rom an inerplay o boh acors and ha hemore sable he environmen, he less eec geneic predisposiion has owardhe developmen o addicion. he primary limiaion in making deiniive

saemens abou he imporance o genes and environmen is ha here are amuliude o variables ha conound he picure ha are direcly relaable ohe individual’s environmen, and o ha individual’s physical and psychosocialenvironmens. Anoher mehod used or assessing he possible role or genes inaddicion was he use o amily sudies. In hese evaluaions amil ies ideniied wih a number o addiced members rom muliple generaions have compa ri-sons made beween he addicion rae in he newes generaion and esimaionso geneic sharing o he same genome beween generaions52, 53. Once againenvironmenal acors compound he diiculy or separaing ou purely geneicacors, bu in spie o ha diiculy a posiive relaionship was ound poiningo a srong geneic link or addicion.

Animal sudies also poi n o gene ic involvemen in predisposing oward addic-ion. Muan mice wih a single poin muaion making he aceylcholine recep-ors exhibi increased sensiiviy o nicoine, produced an elevaed responsive-ness o even low doses o nicoine and a endency oward dependence54 . hissudy provided evidence ha or hose individuals geneically predisposed oabusing a subsance, even low level exposure could induce an addicion/depen-

dence paern. I is known ha once a dr ug is abused, changes in he brain’s phys-iology and biochemisry occur55. he geneic predisposiion may be responsibleor inducing hese changes a an earlier ime in lie and wih less drug ex posure, which could ex pla in why some indiv iduals ca n abuse a drug wihou becomingaddiced, whi le ohers become addiced almos immediaely. However, manyoher acors are also a play, serving o eiher augmen he chances o addicionor proec agains addicion. More recen work on geneic variaions in rodens isalso beginning o uncover he reasons or dierences in responsiveness o anes-heic agens30, 31.

Genomics o Alcohol Addicion

he inding o a geneic link o addicion based on win and amily sudies ledo a major sep orward in deermining geneic predisposiion o addicion - hesearch or he gene or genes causing addic ion. Gene sequencing mehods havegrealy evolved and improved over he pas decade, allowing research ino hegeneics o addic ion o become more ocused and illu mina ing. However, inspie o hese improved mehods or invesigaion, we are sill a a nescien sage

o discovery in his ield. Wih improvemens in echnology and he abiliy osequence he enire genome, here also occurs he increased di iculy in a nalyz-ing he huge amouns o daa generaed. Perhaps some o he cleares evidence



62 | Occupaional Well-being i n A neshesiologiss

or a direc geneic link o subsance abuse comes rom research on he geneicso alcoholism56, 57.

Approaches or sudying he geneic link o alcohol addicion have aken a numbero differen direcions. One approach based on he observed concurrence o addic-

ion wihin amilies is o perorm geneic analysis on amily members wih a highsubsance abuse rae and amilies ha seem o be ree o alcoholism. Perormance oDNA analysis based on porions o he genome hough o be involved wih addic-ion poin o geneic variaions ha migh increase he risk o addicion. As migh be expeced his needle in he haysack approach is challenging bu has led o heidenificaion o several variaions in he genome ha are more oen ound in people wih addicions.

A sim ilar approach has been a ken on an individual basis where a single gene has

been evaluaed compa raively or groups o people wih and wihou addicion,irrespecive o amily concur rency raes. As migh be expeced he di icul y inhis approach has been he need o predeermine wha genes o evaluae whichare suspeced o be relaed o addic ion. he value o hese sudies seems o be greaes or genes involved in alcohol meabol ism, which wil l be discussed below. Finally, more wide spread evaluaions o he en ire genome are beingperormed hough all 3 billion nucleoides ha make up he human genomeare no esed. aher, large sec ions o he genome are sequenced58, 59 allowingor a more speciic ideniicaion o geneic variaions, called single nucleoide

polymorphisms, ha predispose he developmen o addic ion. Based on hesemehods a many geneic sies have been locaed which seem o play a role in hedevelopmen o addicion56, 57. For alcoholism alone muliple gene sies are involved,(See able 2) boh in a direc manner and indirecly hrough neurophysiologicrais60 . In realiy here may be as many as 100 or more genes ha can in luencehe risk o addicion and i is he suble inerplay o hese geneic variaions incombinaion wih environmenal and oher acors ha ulimaely deerminean individuals’ predisposiion o addic ion. hereore here is no absolue hahaving a cerain geneic variaion will lead o addicion, only ha ha geneic

subgroup migh be a greaer risk o addicion under cerain c ircumsances. hisis paricularly imporan o poin ou when a genomic evaluaion o every anes-hesiologis is possible. Havi ng a geneic predisposiion o addic ion is no hesame as having he disease o addicion.

able 2 – Some o he many genes involved in alcohol addicion. e complex ineracion omany geneic rais in combinaion wih oher acors seems o be he primary deerminanleading o one individual becoming addiced compared o anoher. e genes mos sronglyimplicaed in developing or proecing rom alcoholism are hose involved in alcohol

meabolism - alcohol dehydrogenase and aldehyde dehydrogenase. o a lesser exen genesencoding or he neuroransmiter gamma-aminobuyric acid (GABA) and is receporssubunis are linked o alcoholism.




Some alleles linked o alcoholism

Alcohol meabolism genes – some are proecive

ADH1B

ADH1B

ADH1A

ADH4

ADH1C

ADH5

ADH6

ADH17

ALDH2

Proein Encoding GenesGABR2

GABG1

GABR1

GABG3

GAB1

GAB2

GAB3(Adaped rom: Edenberg HJ; Genes conribuing o he developmen o Alcoholism - An Overview; Alcohol esearch: Curren ev iews; 2012; 201; 336-338)

Genes in Alcohol Meabolism

As indicaed in able 2, here is a very close relaionship beween geneic varia-ions in alcohol meabolism sequences and alcoholism. e wo primary enzymesinvolved in alcohol meabolism are alcohol dehydrogenase (ADH) and aldehydedehydrogenase (ALDH). e meabolism o alcohol is shown in Figure 1.

Figure 1 – Simplified schemaic o ehanol meabolism. Ehanol is convered o anacealdehyde, uilizing he enzyme alcohol dehydrogenase (ADH) in conjuncion wihhe co-enzyme, nicoinamide adenine dinucleoide (NAD+). e acealdehyde is urheroxidized o aceic acid wih he help o he enzyme acealdehyde dehydrogenase (ALDH).




e firs sep is he conversion o he alcohol molecule o an acealdehyde hroughuilizaion o alcohol dehydrogenase (ADH) and coenzyme nicoinamide adeninedinucleoide (NAD+). Furher meabolism o he acealdehyde occurs wih is conversion o aceic acid ui lizing he gene conrolled enzyme NAD+. e genes play amajor role in his meabolic sequence and have a proound impac on proecing an

individual rom alcoholism. e majoriy o people have an allele called ADH1B which causes a slow conversion o alcohol o acealdehyde bu some populaiongroups, such as Asians, as well as many individuals, have a varian allele called ADH1B*2 which increases he conversion rae, leading o a rapid increase in aceal-dehyde. is varian allele is very common in people wih Eas Asian ancesry and inhe people o he Middle Eas61-63.

e ADH1B*2 allele has also been ound o occur in a much smaller percen opeople rom Arican and European ancesries, bu as wih he Asian populaions,

he individuals having he geneic variaion showed a highly significan proeciveeffec agains he developmen o alcoholism64. e presence o he allele was noonly associaed wih a lower amoun o alcohol consumed, defined as he maximumnumber o drinks consumed in a 24-hour period, bu also an overall decrease in herisk o developing alcohol dependence.

Mos people uilize a ype o ALDH called ALDH2 o meabolize he acealdehydeo aceic acid in a rapid and efficien manner. However, in cerain populaions suchas Asians, a varian allele o he normal acealdehyde dehydrogenase (ALDH2) gene,

called ALDH2*2 is produced which is only 8% as efficien as ALDH2 in converingacealdehyde o aceic acid. In ac some 50-70% o he Japanese populaion has hisgeneic variaion bu i is also ound in European and Arican populaions, houghmuch less commonly 63, 65. O ineres in one sudy o alcoholic Chinese men only12% had he ALDH2*2 allele, while 48% o non-alcoholic Chinese men had he vari-an and proecive allele66.

Acealdehyde is oxic o humans so ha or individuals wih he ADH1B*2 and ALDH2*2 alleles, he effec o drinking alcohol is o produce high serum levels oacealdehyde which in urn produces he “flush syndrome,” where he ace becomesflushed, and he unpleasan sympoms o nausea, vomiing, palpiaions, and head-aches occur63. ese sympoms serve o proec he individual rom alcoholism sincehey negaively reinorce he use o alcohol. In ac a similar effec is produced wihhe ani-alcoholism drug, Anabuse, which produces a rapid elevaion o acealde-hyde on consumpion o alcohol. O ineres, hese geneic predisposiions proec-ing agains alcoholism can be overcome by social influences or individuals wih asingle ALDH2*2 allele in heir genome62. However, when he individual has wo ALDH2*2 alleles, he chances o becoming alcoholic are virually zero, due he

severe adverse sysemic effecs o he un-meabolized acealdehyde.ough ADH1B*2 and ALDH2*2 alleles are he primary geneic varians ha have been ound o effec alcoholism in a proecive manner, oher varians are a lso el o




possibly play a lesser role. Mos o hese geneic variaions occur in he genes closedassociaed wih he ADH and ALDH genes and are hough o primarily uncion byalering he acive expression o hese genes, raher han by having an independendirec effec. Some o he genes relaed o having such aciviy are ADH4, ADH1C, ADH5, ADH6, and ADH7. Ineresingly, unlike he ADH1B*2 and ALDH2*2

alleles, hese geneic variaions are linked o a predisposiion or he developmen oalcohol dependence67-69.

Genes Effecing Alcoholism hrough Proein Encoding

ough some genes affecing he meabolism o alcohol have a major effec on herisk o developing alcoholism, oher geneic variaions encoding or subunis ohe neuro-recepors ha respond o he neuroransmiter, γ-aminobuyric acid(GABA), have also been implicaed in having a role in he risk or alcoholism and

oher addicions70-74

. e lis o he GABA gene varians ha have been associaed wih addicions are lised in able 2. Par o he difficuly in deermining wheher ageneic variaion is proecive or places an individual a increased risk or addicionis conounded by he observaion ha he GABA recepors may undergo changes inhe addiced paien – boh molecularly and in physiological response.

Oher neuroransmiter sysems have also been implicaed in addicion, includingdopamine, seroonin, and aceylcholine, bu he involvemens are complex and noclear a his ime. For insance i is known ha dopamine, serving as a neurorans-miter wihin he limbic sysem, is acive in reinorcing addicive behaviors due ohe effec on he pleasure ceners o he brain. Nicoine seeking behavior in mice isaugmened when a subuni o he limbic nicoinic aceylcholine recepor is presen bu he drug seeking behavior is absen when a geneic varian causes he absenceo ha subuni on he dopaminergic neuron. In humans a variaion in a cholinergicmuscarinic recepor is involved in memory and cogniion, can also increase he risko alcoholism, as well as oher drug dependencies and psychiaric disorders75-79.

Genomics o Opiae and Oher Drug Addicions

ough he evidence o a geneic link o addicion is very srong or alcohol, here ismouning evidence ha oher subsance addicions also have a srong geneic predis-posiion. For opioids, as wih alcohol, win sudies has been perormed o provideindirec evidence or a geneic link o narcoic addicion. e premise o one sudy 80 was based on he observaion ha some o he side effecs o narcoics are unpleas-an. Paiens who were geneically similar, such as wins, migh be expeced o havesimilar concordance in heir side effecs. In addiion individuals who perceived heeffec o an opioid as a negaive experience migh well be proeced agains he devel-opmen o an addicion, in a manner similar o he avoidance o alcohol or hose

having he ADH1B*2 and ALDH2*2 alleles. e sudy findings were somewhacloudy in ha no only did significan heriabiliy exis or he side effecs o respira-ory depression (30%), nausea (59%), and drug dislike (36%), hey also ound ha




amilia l acors played a role in he side effecs o sedaion (29%) prurius (38%), anddrug liking (26%). e overall conclusions o he auhors80 and he edior81 were hageneics did affec he response o individuals o opioids bu ha environmen anddemographics acors also played a key role. Geneic acors could accoun or asmuch as 50% o he observed opiae mediaed nausea and his adverse effec migh

well be proecive agains he developmen o an opioid addicion. Ohers sudiesalso suppor a geneic role in he predisposiion or he developmen o opiae drugaddicion82, 83. e acual genes involved in opioid responses are show in able 3 ,hough he correlaion o hese gene varians wih a predisposiion o developing aopioid addicion are no as srong as he geneic link ound wih alcoholism.

able 3 – Some o he genes hough o play a role in opioid addicion. Muliple acorsincluding environmenal and demographics inerac wih he geneic acors in a complex anda presen obscure manner o produce he undesirable predilecion or narcoic addicion.

Genes Possibly Involved In Opiae Responses

OPRM1 – Sronges Associaion - MU Recepor Modulaion

UG2B7

ABCB1 – P-Glycoproein Gene

HR3B

COM

POMC

OPRK1 – Also Associaed Wih Alcohol Addicion – Kappa Modulaion

e OPM1 gene encodes he G proein-coupled mu opioid recepor which in urnis the primary target for all the opiates. Variations in this gene are thought to beresponsible, a leas in par, or observed individual variaions in opiae dependenceand responsiveness83. e imporance o OPM1 polymorphism in regard o hesynergisic relaionship o propool used wih he narcoic remienanil or aneshe-sia was explored in a group o paiens undergoing sedaion or endoscopy 84.

e imporan findings were ha paiens wih a single nucleoide polymorphism(A118G) in he mu 1 recepor gene (OPM1) were no able o show a synergisicresponse o remienanil when i was added o a propool inusion. In addiion o heimporance o he mu recepor modulaion in opioid’s effecs, he geneic modula-ion o he kappa opioid recepor may also play an imporan par in he geneics oopiae responsiveness and addicion. e kappa opioid recepors are ound in hedopaminergic neuronal limbic sysem, which serve as he pleasure reinorcemenceners o he brain. As indicaed previously, his sysem may be involved in he riskor alcohol addicion also. However, he imporance o his sysem and he kappa

recepor is no obvious a his ime and requires urher sudy o elucidae is impor-ance. In addiion addicion o cocaine and propool may well be linked o geneic variaions affecing his sysem.




General Geneic Overview

As scienific evidence coninues o accumulae, he imporance o geneics inpredisposing any individual o subsance abuse canno be minimized. Obviously,non-geneic acors disor some o hese sudies, bu overall, geneics is increasinglyconsidered o play a significan role. e whole sudy o geneic acors in addicionis sill in is inancy, bu research is poining o a defined geneic predisposiion ormany individuals. In ac as much as 50% o an individual’s predisposiion o becom-ing addiced o a subsance is predicaed upon geneic acors. However, i mus besressed rom he onse ha geneic predisposiion is no a direc causaive acor ordeveloping addicion. Simply pu, geneics by isel is only an imporan modifierha can eiher increase or decrease he chances o an individual becoming addiced.Geneics is no an absolue in regard o wheher cerain genes will compleely proecone or cause one o urn o drugs. In spie o his uncerainy, as more inorma-

ion on he imporance o geneics in predisposing o addicion accumulaes, here will be increasing calls ha all medical personnel be checked prior o accepancein proessional schools o “redirec” he choice o specialy or hose predisposed oaddicion o lower risk proessions.

Figure 2 – ere are common geneic acors, as well as specific geneic acors (SGF) hainfluence addicion o each subsance. Along wih he geneic acors here is subsanialmodificaion o he geneic influences by environmenal and demographic acors.

(Adaped rom: Edwards AC, Svikis DS, Pickens W, Dick DM; Geneic Influences on Addicion; Primary Psychiary; 2009; 16:40-46)

Also, wih our rudimenary undersanding o he geneics o addicion begins o solid-iy, one model ha seems o make sense is shown in Figure 2 , which is adaped roma paper by Edwards85. is schemaic crudely indicaes our presen undersanding




concerning how genes play a role in he developmen o addicion. ere are commonmajor geneic acors which predispose o all sors o addicive behaviors and he geneiccodes ha provide his generalized predisposiion seem o exis near he alleles haalso predispose an individual o be a risk aker. In addiion secondary geneic variables work in concer wih he main geneic varian o predispose oward specific addicions,

such hings as alcohol, opioids, and nicoine. e specific geneic acors (SGF) eiheraffec he meabolism o he arge subsance o affec how he subsance ineracs wihhe end-recepor. Finally, i mus be emphasized ha aside rom geneic predisposi-ion, oher acors are imporan in leading any paricular person ino drug abuse andaddicion. Geneic acors may be 50% o he causaive predisposiion, bu he oher50% is direcly atribuable o he abiliy o cope and endure he many sresses oundin ha individual’s environmen. In he case o he pracicing aneshesiologis, hesesressors are common o he proessional workplace – he modern operaing room.

Proessional sress acors – he vicious cycle

ere is a vicious cycle encounered in rouine aneshesia pracice ha ends o eardown coping mechanisms and increase he chances ha an aneshesiologis mighurn o misuse o a subsance in order o cope wih he sresses. e cycle ypicallysars wih physical aigue, which seems an inegral par o modern aneshesia prac-ice. Faigue leads o medical errors, which in urn, hrough sel-recriminaion and/or a malpracice sui, leads o sress and increased emoional aigue. (see Figure 3) Any one o hese acors can lead o an aneshesiologis looking or a way o relieve

sress. Wih he availabiliy o drugs, one avenue ha is unorunaely seleced all oooen is drug abuse, which in urn leads o a spiral o addicion. e role o each ohese acors will be discussed individually.

Figure 3 – Faigue leads o he increased risk o making a medical error. Medical errorslead o a high sress sae and can resul in medical malpracice law suis, which alsoproduces high sress. Sress causes emoional aigue and predisposes o he making o moreerrors. Wihou proper suppor and coping mechanisms in place o break his cycle, hedysuncional reacion o he aneshesiologis may be subsance abuse, burnou, or suicide.




Faigue

Faigue or he aneshesiologis can be physical, menal or emoional in origin. I isno inrequenly ha all hree play a major role causing burnou syndrome. oughhe vicious cycle o aigue, medical error, malpracice and sress can be enered aany poin, he mos common origin ino his cycle is aigue. In he pas decade herole o aigue in causing human error during he provision o healhcare has becomeincreasingly recognized. In he Unied Saes concern ha overworked medicalresidens migh cause serious paien injury and even deah was responsible or he Accrediaion Council on Graduae Medical Educaion puting ino place sringenlimiaions on residen work hours in 2003. Since 2003 he sandards or residenduy hours have been refined and key elemens as o July 2011 are shown in able 486.

ough regulaory curailmens o work hours or residen raining are being pu inoplace, he same is no occurring or experienced aneshesiologiss. e lack o work

rules or he pracicing aneshesiologis becomes o even greaer concern when viewedin he conex o he larger numbers o older aneshesiologiss ha coninue o acivelypracice. An excellen review o aigue in aneshesia poins ou he risk o aigue in hespecialy o aneshesiology is based on no only a lack o sleep bu also a disrupion ohe circadian rhyhm when shi work changes beween day and nigh87.

able 4 – Elemens in he Accrediaion Council on Graduae Medical Educaionresricions on medical residen duy hours. Addiional rules provide modificaions o heserules based on year o residency. Effecive: July 1, 2011

ACGME sandards or residen work rules

1) max imum hours o work a week – 80 hours averaged over 4 weeks

2) moonlighing work – couns oward he 80 hour maximum

3) a leas one duy ree day a week

4) maximum duy period should no exceed 16 hours or firs year

5) maximum duy period is 24 hours or second year and above

6) minimum o 8 hours ree o duy beween duy periods

7) in house call no more requen han every hird nigh(Adaped rom: htp://www.acgme.org/acgmeweb/abid/271/GraduaeMedicalEducaion/DuyHours.aspx)

Faigue and a Lack o Sleep

Documenaion o he adverse effec ha a lack o sleep has on perormance is wide-spread in boh he medical88-90 and indusrial lieraure91, 92. e primary concernssurrounding aigue’s effec on perormance is i presens impairmen o vigilanceand reacion ime, which are boh cenral o he provision o sae aneshesia care93, 94.

ough sae aneshesia demands coninuous alerness and atenion wih he abiliyo rapidly reac i problems arise, aigue undermines no only he reacion ime bualso he abiliy o mainain an atiude o alerness95,96.




ough he operaing room environmen is usually quie and he paiens are usuallysable, his works agains he aigued aneshesiologis by allowing he developmeno a alse sense o securiy and a lowering o alerness. When a problem arises, aigueinervenes in slow he recogniion ha a problem exiss and slow he responsesneeded o correc he problem. When sleep deprived aneshesiologiss were com-

pared o resed aneshesiologis during a paien care simulaor over 4 hours, here were sriking reducions in psychomoor perormance, mood and level o alernessin he sleep deprived subjecs97.

One sudy compared neurobehavioral perormance in groups o residens aer hav-ing a hard workload nigh o being on-call, aer a ligh workload nigh on call, andaer alcohol ingesion98. e no surprising findings were ha a heavy nigh on callproduced he same impairmen in perormance as having a 0.05% blood alcohol level.Similarly, ohers have ound he same blood alcohol level o 0.05% was equivalen o

17 hours wihou sleep or simple perormance measuremens o hand-eye racking.I sleep deprivaion was exended o 24 hours, he impairmen was equivalen o a blood alcohol level o 0.1%99. While careers o aneshesiologiss have been signifi-canly compromised rom he discovery o a blood alcohol level equivalen o hoseound in hese sudies, no similar concern has ye been aken in regard o proecinga paen rom care provided by a praciioner who has been working coninuously orover 24 hours.

For he older aneshesiologis , he challenge o sleep deprivaion and aigue on heirclinical perormance may be compounded. One sudy o aneshesiologiss over 65 years old concerning he incidence o malpracice law suis would indicae he olderaneshesiologis is a paricularly greaer risk o being sued100. e causaive acors were no elucidaed bu here was a suggesion ha some o he same perormancederimens ha occur wih aigue may also play a role during he aging process.Compounding hese naurally occurring effecs wih he addiional derimen oaigue migh be a cause o increased concern or he pracicing elderly aneshesiolo-gis. In ac sel-recognized sress rom being required o paricipae in nigh call wasa primary acor or many elderly aneshesiologiss deciding o reire101,102.

Faigue and he Circadian Rhyhm

Faigue is no only caused by a lack o sleep bu also by a disrupion o he normal cir-cadian awake/sleep cycle. Since mos aneshesiologiss ake call a nigh, disrupiono he normal circadian rhyhm is nearly assured. e circadian rhyhm is an inernalcycle modulaed by he hypohalamic suprachiasmaic nucleus which is in urn direclyaffeced by secreions o melaonin rom he pineal gland. Melaonin secreion is sim-ulaed by ligh and suppressed by darkness which is how he synchronizaion beweenhe circadian rhyhm and he day/nigh cycle occurs. e circadian sysem keeps he

body’s biochemical, physiological, and behavioral processes on an approximaely 24hour cycle. Such parameers as body emperaure and blood pressure change during a24 hour period based on he circadian cycle. In individuals wih a normal wake-sleep




cycle he circadian rhyhm allows he individual o anicipae hormonally and physi-ologically regular environmenal changes. However, changing he iming o he sleep wake cycle in he ace o an esablished circadian rhyhm, which occurs or aneshe-siologiss when hey periodically perorm nigh call duies, can be derimenal o he body’s normal uncion and he abiliy o provide he bes paien care. e reason ha

disrupion o he circadian cycle is imporan or concerns abou an aneshesiologisaigue, is ha when he cycle is usually a is lowes beween 2 and 4 AM, alerness andperormance are also a heir lowes103. Sleepiness which is also governed by he circa-dian rhyhm is a is peak a nigh rom 1 – 7 am and in he early aernoon. e cyclemay be he cause or observed diminuion in he abiliy o emergency room physicianso rapidly and effecively inubae paiens during he nigh compared o he day 104,105.Similarly, he placemen o epidural caheers by aneshesia personnel resuled in moredural puncures a nigh aer midnigh han during he day 106. ereore, physicianschanging rom a day shi o a nigh shi encouner a orm o “je lag” ha can havesignifican adverse effecs on heir psychophysiological perormance wih paricularemphasis or aneshesiologiss’ alerness and vigilance.

In regard o subsance abuse by aneshesiologiss, he circadian cycle seems o havesignifican involvemen wih he iming o drug seeking behavior. During cerainporions o he circadian cycle, alcohol and drug use increases. No only is alcoholconsumpion modulaed by he ime o day based on he circadian rhyhm107 , he use oalcohol has been observed o increase in individuals whose circadian rhyhm has beendisruped by roaional shi work or ime-zone changing ravel108,109. A he same ime

ha alcohol and oher drug use is modulaed by he circadian cycle, drugs also havea direc effec on he normal circadian by suppressing plasma coricoserone levelshrough he inerrupion o he uncion o he hypohalamic piuiary axis. e effeco alcohol and drugs on his axis is hough o be mediaed hrough so called “clockgenes” which regulae he circadian cycle110,111. e “clock genes” may also be criical orconrolling he propensiy o consume alcohol o relieve sress112, 113. Similarly, opioidsand cocaine also have direc effecs on sress relie 114-117. ereore, he normal sressresponses, which are exaggeraed during cerain imes o he circadian cycle or whenhe cycle is disruped, are relieved in par by he use o alcohol and drugs. e reduc-ion in sress associaed wih subsance abuse serves as a posiive reinorcemen whichurher simulaes drug seeking behavior and urher disrups he normal circadianrhyhm. For he aigued aneshesiologis already having a disruped circadian cycledue o changing day/nigh shis and who encouners addiional sressors while providing aneshesia care, urning o subsance abuse can be he maladapive mechanismor sress relie.

Faigue and Medical Errors

e associaion beween aigue in aneshesiologiss and he chance o ha anes-hesiologis making an error in judgmen or pracice is firmly esablished wih asmany as 50% o surveyed aneshesiologiss admiting ha hey were responsible or




making a medical error when aigued118-121. e recogniion o he high risk o mak-ing an error while aigued has led naional aneshesia socieies across he globe omake specific recommendaions or ways o reduce aneshesia provider aigue andresulan paien harm ha sems rom ha aigue. e Unied Saes122 , Ausra-lia and New Zealand20 , Canada18 , as well as Grea Briain and Ireland123 have been

leaders boh in recognizing he problem and in atemping o deal wih i. However,since he implemenaion o mechanisms o avoid praciioner aigue usually occursa a local level, penerance o he recommendaions has been variable. Concernabou he poenial harm o paiens led he Aneshesia Paien Saey Foundaion odevoe an enire Newsleter o differen aspecs o his problem124.

O paricular concern is aigue in residency raining programs, since even wihreduced work hour rules, sleep deprivaion is common in many inernships and resi-dencies125. No only is here a loss o cogniive uncion wih he loss o sleep or a

single 24 hour period bu here is also a cumulaive effec wih longer erm parialsleep deprivaion126-128. O major concern or aneshesiologiss is ha one o hemos imporan impairmens accompanying aigue rom sleep loss was vigilance. A loss o vigilance in aneshesia ranslaes ino medical errors and poenial paienharm. In one sudy o 380 inernal medical residens, here was a direc associa-ion ound beween he sel-recogniion ha aigue exised and he making o majormedical errors89. In addiion he same sudy ound ha a residen’s sel-recogniiono emoional disress was an independen acor associaed wih he occurrence o amajor medical error. Emoional disress is common when a residen makes a medical

error129 and hereore an inernal vicious cycle is produced whereby an error made because o aigue leads o disress which in urn increases he chances ha anohererror will be made. e end resul is a high sress level, depression and burnou - allo which can lead o drug addicion or suicide or relie o he resulan sress.

Faigue and Burnou

e concep o burnou which was originally used o describe drug users who had basically reached he botom o heir addicion, has been expanded o include work-

ing individuals who have adversely responded o chronic job relaed emoional andinerpersonal sresses130,131. e hree primary dimensions which define burnou areexhausion, cynicism, and proessional ineffeciveness. e key elemen leading o burnou and he one which is considered mos imporan is a sae o exhausion, which occurs a a physical, emoional and menal level132. I is he combinaion o work load and emoional demands on he job ha serve as he major sressors leadingo burnou131. ese same sressors have also been linked o various orms o drugabuse and addicion. O significance, younger adul populaions below 30 years oage seem o be a a higher risk or burnou compared o he more elderly workers131.

ereore, i is no surprising o find a high rae o burnou and suicidal ideaion inhe highly sressed medical suden populaion133. Among aneshesia praciioners,i is he inerns, residen, and newly graduaed aneshesiologiss ha are mos likely




o become burned ou and urn o drugs as a coping mechanism. is finding wassubsaniaed by a survey compleed by 1508 Unied Saes aneshesia rainees134.41% o he aneshesia rainees were ound o be a high risk o burnou. In addiionhe acors ha seemed o be mosly closely correlaed wih burnou risk were beingemale, working over 70 hours a week, and drinking more han 5 alcoholic drinks a

week. O grea concern or paien saey was he finding ha 33% w ih high burn-ou scores also admited o muliple errors in giving medicaion as opposed o hoserainees wih low burnou scores ha had only a 0.7% medicaion error rae134. erisk o a medical error by our surgical colleagues is also increased when hey are in anexhaused, burned ou sae135. As previously indicaed, making a medical error byisel causes significan sress and aigue which hen can predispose o urher medi-cal errors being made. A comparison o rainees ha uilized he “bes pracices,” when giv ing aneshesia based on quesions concerning i hey ollowed aneshesiasandards o care, showed a significan inverse correlaion beween he aneshesiarainees wih high burnou scores and heir “bes pracice” scores. (see Figure 4)

Figure 4 – Aneshesia rainees who had he highes burnou scores also had he lowesscores indicaing ha hey ollowed bes pracice sandards.

(Figure aken rom: De Oliveira GS, Chang , Fizgerald PC, e al; e prevalence o burnou anddepression and heir associaion wih adherence o saey and pracice sandards: A survey o UniedSaes Aneshesiology rainees; Anesh Analg ; 2013; 117:182-193.)

In spie o some proecion rom burnou wih age, all physicians seem o be a risko burnou136 wih an esimaed 35% o all pracicing physicians showing signs o burnou137. One group o senior aneshesiologiss seems o be a special risk or burn-ou and ha is academic chairpersons. A survey o 93 academic chairs, only 32%

repored a high job saisacion raing while 28% me he crieria or high burnouand anoher 31% were moderaely burned ou138. O ineres 28% also indicaed hahey were planning on sepping down as chair wihin he ollowing year or wo. Such




findings indicae a crisis in aneshesiology leadership. e healh o he proessiondepends on finding way o help all aneshesiologiss cope wih increasingly difficul working condiions. Cerainly alernaive, consrucive approaches or emoionallycoping wih job sresses mus be ound o preven our colleagues rom aking hemaladjused approaches o subsance abuse and suicide139.

Medical Errors

When a new physician akes he Hippocraic Oah i quie clear ha a primar y con-cern when caring or a paien is o do no harm. e Oah saes: “By Apollo he phy-sician … I will keep his Oah. I will ollow ha sysem o regimen which, accordingo my abiliy and judgmen, I consider or he benefi o my paiens, and absain rom whaever is deleerious and mischievous.”

As physicians, he concep o doing no harm has evolved ino a sel-imposed level o

perecionism ha does no olerae misakes or errors. O course “o err is human”and by aking on he manle o error ree perecionism, a physician has adopeda philosophy which is bound o ail. Sriv ing or perecionism is a noble goal andone ha he public expecs. Achieving perecionism is virually impossible in spieo he public’s expecaion. Provision o aneshesia care by is very naure is basedon a combinaion o ar and science. e huge clinical variabiliy in one paien’sresponse o a drug or inervenion canno always be prediced and here is a ime inevery aneshesiologis’s career ha an incorrec predicion will be made and paienharm will resul. For he physician who only wans he bes or his paien, makingsuch an error is one o he greaes sressors he will encouner in lie. e sress iscompounded i he aneshesiologis realizes ha he error was his aul due o aigueor due o having overlooked an obvious piece o inormaion. When his occurshe physician mus ace he realiy ha he is no perec, which undermines his sel-image o immuniy rom error, and can be devasaing o his sel-confidence. In ache physician who is he mos sel-criical and has he highes personal sandardsmay be a paricularly high risk rom he consequences o making an error140.

e loss o sel-image may desroy he very basis upon which he physician pracices

and even lead o he physician abandoning clinical care. ereore i is no surpris-ing that this situation has been labeled “e Second Victim” syndrome141. eprimary vicim is he paien bu significan suffering also occurs or he physician.In atemping o cope wih his own suffering and guil he physician may well urno alcohol or oher subsances, and evenually even o suicide. In ac drug abuseand alcoholism under circumsances o increased sress or depression ollowing heoccurrence o a medical error may well be he nuclear cause o he increased suiciderae or all physicians bu also aneshesiologiss specifically 142.

e physician ha akes he roue o subsance abuse and suicide will oen do so ihere is no oher avenue ha is seen open o help cope wih he medical error. Hav-ing empaheic and undersanding colleagues who can discuss he error in a non-




accusaory and proessional manner goes a long way in helping he physician com-miting an error be able o deal wih he misake. e inervenion wih colleaguesis especially helpul i discussions are cenered on ways o learn rom heir error andhow o preven similar errors in he uure140.

By aking posiive seps oward atacking he error, he inward urning o sel-accu-saion and recriminaion can be mued. However, in spie o recommendaions oran immediae debriefing ollowing an inraoperaive caasrophe143 , here is litlescienific evidence supporing a requiremen or such inervenion144,145. e lacko firm evidence o he long erm benefi o a debriefing should no preven suchcounseling since i does allow vening o anxiey, anger and concerns ha could bepoenially crippling146 .

As imporan as having open discussions wih one’s colleagues is having a ace o acealk wih he harmed paien or he paien’s amily. Perhaps a alk wih he paien oramily is one o he mos emoionally difficul imes a physician may have o endure.Physicians oen eel ha exposing heir misake will no only lessen heir saurein he eyes o he paien bu will increase heir risk o a malpracice sui. Quie heconrary and couner-inuiively, a malpracice sui is ar more likely when he physi-cian avoids he paien and amily, since he will be viewed as aloo and uncaring. Inaddiion by openly admiting error, boh o himsel and o he paien, he physicianachieves a caharsis o guil ha is oherwise difficul o atain. Wihou he abso-luion o open discussion and he inward accepance o having made an error, he

sensiive and reflecive physicians may find dysuncional ways o dealing w ih heirguil, such as subsance abuse and suicide141.

e emoional consequences o a physician making a medical error are unexpecedlylong lasing and deep. Evidence o he link beween making a medical error and hedevelopmen o emoional and proessional repercussions or aneshesiologiss wasrepored in a sur vey o he atiudes o 300 anesheiss in England, aer experienc-ing an inraoperaive deah147. From he 251 aneshesiologiss ha replied some 92%had experienced an inraoperaive deah. ough he majoriy o hese deahs wereexpeced and no prevenable, many o he aneshesiologiss sill el high sress lev-els. In spie o he sress, hey immediaely coninued o provide aneshesia care ooher paiens. e coninuaion o clinical services was in spie o over 10% o hemeeling ha heir proessional abiliies had been compromised by he experience. Inaddiion some 35% indicaed a eeling o personal responsibiliy or he deah.

e survey revealed ha while 71 % o he aneshesiologiss hough ha i would be pruden o or a praciioner o delay he provision o care o oher paiens or 24hours aer an inra-operaive deah, ha in realiy less han 25% acually ollowedhis pracice. e conclusion o he sudy was ha he loss o a paien inra-opera-

ively, wheher expeced or no, was a highly sressul even or many aneshesiolo-giss and consideraion should be given o he provision o psychological suppor andhe disconinuaion o urher operaions or hose psychologically raumaized147.




Anoher sur vey o 1600 Briish and Irish aneshesiologiss148 ound similar resuls.40% o he aneshesiologiss whom had an inraoperaive caasrophe had a senseo personal responsibiliy, which was compounded i an error in judgmen was elo have conribued o he caasrophe. 24% el ha i ook hem days o recover bu o major concern, some 7 % had eelings o guil or years and 1% even consid-

ered leaving he specialy o aneshesiology. A more recen survey o he impac operioperaive caasrophes on aneshesiologiss in he Unied Saes provides urherevidence o he long erm and proound emoional impac ha an unoward evencan produce149. 1200 randomly seleced members o he American Sociey o Anes-hesiologiss were sen a survey wih a 56% compleion rae. O he responders 84%had been involved in a leas one caasrophic inra-operaive even, usually an unan-icipaed deah or serious injury. More han 70% relived he even wih he eelingso guil and anxiey. (see Figure 5)

Figure 5 - e adjused percenage o aneshesiologiss showing he emoional impac o aninra-operaive caasrophe.

(Figure aken rom: Gazoni FM, Amao PE, Malik ZM Durieux ME; e Impac o PerioperaiveCaasrophes on Aneshesiologiss: esuls o a Naional Survey; Anesh Anal; 2012; 114:596-603)

o a lesser exen he sress o having an adverse experience led o depression, sleepless-ness and a ear o he possibly o being sued. O grea concern is ha over 10% o herespondens considered changing careers and 5% urned o subsance abuse o helphem cope. e conclusions are dramaic; he occurrence o a major adverse inra-operaive even akes a devasaing oll on he aneshesiologis. However, no only ishere an immediae impac rom experiencing an inra-operaive caasrophe, bu heemoional aermah or many aneshesiologiss is long lasing149, 150. Emoional “recov-ery” was mos requenly saed o be one week, hough some 12% declared ha hey were no a all emoionally affeced. (see Figure 6) On he oher end o he scale, 19%

o he respondens indicaed ha hey never ully recovered. Pu ino perspecive oneou o 5 aneshesiologiss experiencing an adverse inraoperaive episode coninuedo carry he sress and guil associaed wih ha caasrophe or an exended period




o ime. When addiional sressors are added o heir already exising sress, wihouadequae coping mechanisms, subsance abuse migh be viewed as sel-medicaion ordealing wih he emoional upheaval. ecogniion o his proound problem by he Associaion o Anaesheiss o Grea Briain and Ireland lead o an imporan mono-graph being developed concerning how major caasrophes in aneshesia pracice

should be deal wih aer hey have occurred151. ecommendaions concerning how bes o deal wih a major adverse inraoperaive even are deailed aking ino consider-aion he major impac ha such an even has on an aneshesiologis’s emoional sae.

Figure 6 – e ime i ook o achieve emoional recovery aer having experienced an inra-operaive caasrophe.

(Figure aken rom: Gazoni FM, Amao PE, Malik ZM Durieux ME; e Impac o PerioperaiveCaasrophes on Aneshesiologiss: esuls o a Naional Survey; Anesh Anal; 2012; 114:596-603)

I is eviden rom he Gazoni sudy 149 ha 5% o he aneshesiologiss urned o sub-sance abuse as a way o cope wih a medical disaser. Based upon hese dramaicfindings some recommendaions were suggesed o help he aneshesiologis cope

ollowing an inra-operaive disaser152

. Firs a serious evaluaion mus be perormed by aneshesiology groups and healh care organizaions concerning how o handle apraciioner’s operaive schedule immediaely aer ha praciioner experiences aninra-operaive caasrophe. Due he emoional upheaval and disracion produced by such an even, having he aneshesiologis ake a break rom coninuing o providecare or oher paiens migh help preven a “hird vicim” arising rom hese unor-unae circumsances. e “hird” vicim being he nex paien he cared or by hedisraced and sressed aneshesiologis. Secondly, aneshesia groups and healhcare organizaions need o be proacive in seting up an acue suppor sysem or he

aneshesiologis ha has an inra-operaive disaser and provide menal healh reer-ral o preven ha praciioner rom urning o dysuncional mechanisms in ordero cope wih he accompanying emoional upheaval. irdly, as par o an ongoing




wellness program, he aneshesia deparmen and healh care organizaion need ohave in place on-going monioring o each praciioner’s menal sae, since psycho-logical impairmen and subsance abuse are wo significan long lasing resuls o anadverse even. Par o his long erm monioring program should be he offering oeducaional programs direced a mehods or coping wih he sress o an adverse

inra-operaive even. Finally, a ormal evaluaion o he efficacy and impac on hepraciioner o criical inciden reviews and ull disclosure recommendaions should be carried ou. A presen here is anecdoal evidence ha such aciviies may behelpul bu scienific subsaniaion is presenly lacking152.

Because o he exraordinary long erm impac o a medical error or inra-operaivecaasrophe on he ypical aneshesiologis, i migh be expeced ha here could behesiaion in reporing such an even. One sudy ound ha here were atiudinaland emoional barriers o reporing an adverse even, i he even was caused by he

praciioner153

. When presened wih a scenario o a paien having an anaphylacicreacion due o an error by he aneshesiologis, as opposed o he same scenario when no error was made, a greaer number o aneshesiologis hough ha here would be greaer barriers in reporing he error o induced anaphylaxis han one haoccurred w ihou culpabiliy.

e keys barriers o reporing were “liigaion, geting ino rouble, disciplinaryacion, being blamed, unsupporive colleagues and no waning he case discussedin meeings”153. e increased reicence or reporing an inra-operaive caasrophe,

especially when an error is made, can cause he soliary and isolaed aneshesiologiso become even more inrovered and guil ridden. Wihou coping mechanisms inplace a dysuncional response may be he resul. In spie o calls or aneshesiologisso engage in ull disclosure and o be par o he eam ha provides direc medicalerror disclosure o he paien and amily, such a sysem is rarely in place154. In acevidence would indicae ha even when an incompeen physician is recognized in apracice, oher physicians are relucan o repor heir concerns o he auhoriies155.

Because every aneshesiologis will a one ime in heir career have o ace a paien orhe paien’s amily and admi ha an error in judgmen or skil l occurred, i would seemha acive raining or dealing wih his siuaion should be incorporaed ino everyresidency raining program. In addiion in order o preven subsance abuse or suicideas a way o cope wih overwhelming guil and anxiey, par o every raining programshould include educaion on how o deal wih medical errors. Each insiuion shouldhave a suppor sysem in place o help he praciioner pas hese difficul imes.

Malpracice Liigaion

One unorunae and emoionally draining oucome or a physician involved wih

a medical error leading o paien harm is a malpracice lawsui 156 . No only arephysicians involved in a medical error oen overcome wih guil rom having apaien under heir care experience an adverse oucome, bu he sresses o dealing




wih a malpracice lawsui can become overwhelming. A ypical response seen inover 95% o physicians receiving noificaion o a pending malpracice lawsui issevere emoional disress ha inensifies as he malpracice sui progresses157. Inac he iniial sense o anger, shock and dread is equivalen o any major severenegaive li e even, such as he loss o a spouse or loss o a job158.

e sress is amplified by secondary psychological responses, such as insomnia,depression, eelings o sel-doub, ideaion o inadequacy, inensificaion o physi-cal sy mpoms rom exising il lnesses, he developmen o new illnesses, and ur n-ing o alcohol or oher subsances or ension reducion. Wihou a psychologicallysupporive coping sysem in place which uilizes amily, riends, and he physi-cian’s aneshesia deparmen colleagues, i is undersandable how he sresses omalpracice liigaion migh well end in addicion and/or suicide159.

Unorunaely, aneshesiologiss seem o be paricularly a risk or hese adversepsychological oucomes, mos likely due o heir personaliy makeup. In ac anes-hesiologiss involved in medical malpracice liigaion have been singled ou as being a higher risk or suicide han oher medica l specialies, wih some 2.2% inone sudy having commited or having atemped o commi suicide160. O iner-es when compared o oher physicians, aneshesiologiss are no sued on a morerequen basis161. In ac he findings would indicae ha on an annual basis acrossspecialies, while 7.4% o all physicians had a malpracice sui and 1.6% had omake an indemniy paymen due o he sui, aneshesiologiss acually had ewer

suis and less requen paymens. In addiion aneshesiologiss also ell belowmos oher specialies in he median amoun paid ou in malpracice awards wihhe median paymen or aneshesiologis being slighly less han $100,000 and hemean paymen being slighly less han $300,000161. ereore, he higher risk osuicide and subsance abuse canno be atribued o a higher rae o lawsuis orhigher awards.

One special subgroup o aneshesiologiss a risk or malpracice liigaion is heelderly aneshesiologis. In a survey o aneshesiologiss o various ages anes-

hesiologis over 60 years o age generally had shorer work weeks han heir younger counerpars , alhough 5% o hem coninued o work 70 o 79 hour weeks. here was no saisica lly signi ican di erence in hou rs worked amongmen and women. In addiion he older aneshesiologiss seemed o providecare o less complex cases101. hereore, wih ewer and less complex cases, onemigh expec ha liigaion would decrease or he older aneshesiologis. heindi ngs are he opposie, as shown by a sudy rom Canada100 , where a correla-ion exised beween aneshesiologis over he age o 65 years o age and heoccur rence o law suis. Boh he risk o a malpracice lawsui and he higher

severiy o injury o he paien were he indings or care provided by an olderaneshesiologis. In spie o hese indings, mos malpracice suis agains anes-hesiologiss a re groundless162,163.




Figure 7 – e legal lawsui raio evaluaed each year rom 1993 o 2002 oraneshesiologiss in hree age ranges. e aneshesiologiss over 65 years o age had a higherclaims raio hen heir younger counerpars.

(Figure aken rom: essler MJ, Shrier I, Seele J; Associaion beween Aneshesiologis Age andLiigaion; Aneshesiology; 2012; 116:574-9)

For older aneshesiologiss (see Figure 7) he increased number o legal claimsmay poin o more errors being made. rying o dissec ou he roo causes or hisincreased liigaion is no sraigh orward. Faigue rom old age and cogniive dys-uncion migh be roo causes bu unil his is urher deermined, a rush o “reire”older aneshesiologiss is premaure164. However, i mus be recognized ha heolder aneshesiologiss are also a risk o suicide and subsance abuse when acingmalpracice liigaion; and like heir younger counerpars, hey need suppor sys-

ems in place o help hem cope wih he more requenly encounered sresses o amalpracice sui.

Availabiliy acors and ease in divering

When evaluaing he drugs o choice or aneshesiologiss becoming addiced, (seeable 1), i is eviden ha drugs readily obainable in common aneshesia praciceare seleced ar more requenly han illegal sree drugs. In addiion as drug usageschange wih changing aneshesia pracices, he new drugs ha are inroduced also become he incorporaed ino he lis o abused drugs. A case in poin is propool which has increasingly become a drug abused by aneshesia personnel165-167. For along ime i has been suspeced ha a key acor relaed o he abuse o drugs by anes-hesiologiss is heir easy accessibiliy in he normal daily pracice o aneshesia168,169.ereore, i would no be unexpeced ha he drugs ound being he cause or addic-ion were ones commonly ound used by aneshesiologis in heir daily pracices. Insome aneshesia residency programs decades ago personal use o anesheic agen was encouraged as a way o beter undersand “wha he paien experienced”. Obvi-ously, wih presen knowledge o he severe addicive effecs o even one usage o

modern anesheic agens, such pracices are unaccepable.ere are essenially wo mehods or helping o ensure drug availabiliy does no become a acor in he addicion o aneshesia personnel: 1) rigid conrol o drug dis-




pensing and reurn or; 2) random drug esing o all aneshesia personnel. Neiherare oolproo bu each may have cerain advanages. In regard o conrol over drugdispensing and reurn, here are now auomaed sysems170 , such as Pyxis Med-saion,ha dispense a drug only aer a praciioner has enered an individualize password inohe sysem. I also requires a second praciioner o ener heir individual password o

subsaniae he winessing o unused drug disposal a he end o a case. A review o apraciioners drug usage compared agains he aneshesia records will urn up any dis-crepancies ha would need o be invesigaed and explained171 An alernaive mehodis each ime an addicive subsance is used i mus be signed ou by a specific responsible praciioner and all unused rug reurned o he pharmacy or periodic random drugesing. Once again comparisons beween he aneshesia record documened drug useand he amoun o drug dispensed would indicae discrepancies ha could poin oaneshesia personnel a risk or subsance abuse172-176. However, wih any sysem o hisnaure, he driven addic can effecively hid drug diversion. One o he mos insidious ways o divering drugs or personal use is by subsiuing a non-anesheic soluion,such as saline, or he drug being divered. e paien hereore does no receive hedocumened drug and mus suffer he consequences, which migh include awarenessunder aneshesia, or pos-operaive pain177. Less raumaic or he paien is simplyindicaing more drug is being used or a paricular paien han acually given bu heserelaively larger drug usage paterns can be picked up over ime wih he audis178.

e oher approach proposed or decreasing subsance abuse among aneshesiapersonnel is random drug esing. In spie o many indusries now rouinely usingrandom drug esing or employees whom migh harm he public i under he influ-ence o drugs, a similar idea o random drug esing o high risk medical personnelhas no been embraced179. Due o significan concerns abou subsance abuse in younger aneshesiologis, par icularly residens in raining, some insiuions have begun insiuing random urine esing or drugs, as an early warning signal and asa deerren180,181. e effeciveness o random drug esing as a deerren has beenproven or individuals under sur veillance or pas drug abuse - mainly because ohe severe adverse consequences o having a posiive urine es 182,183. Similarly, he

insiuion o random drug esing in residency programs a he MassachusetsGeneral Hospial180 and he Cleveland Clinic181 were based upon a belie ha resi-dens educaed abou he career desroying effec o a posiive es, would acivelyavoid any orm o subsance abuse. e resuls o he Massachusets General Hos-pial experience were a change in he rae o subsance abuse beore he sudy rom1-2% o a 0% posiive rae. In spie o he exisence o mehodological issues in hissudy, he conclusion was ha he $50,000 cos o a ully implemened program was minimal compared o he cos o he los l ie or producive proessional yearso a single residen deerred rom sampling drugs and becoming addiced. is

evaluaion is paricularly relevan paced in conex o he increased concern haonce addiced, especially o narcoics, an aneshesiologis should be redirecedaway rom he pracice o aneshesiology 184 .




No mater wha he evenual mechanism ound o have greaes success in deerringaneshesia personnel rom abusing he drugs hey use o provide paien care, here isno quesion ha a leas or some praciioners ha have become addiced, one acorin heir addicion was heir easy access o drugs and he lack o accounabiliy hahe drugs were being used or heir inended purpose.

Personal Psychological Facors

ough geneics and many oher acors play imporan roles in he developmen osubsance abuse, as well as suicidal endencies in any individual aneshesia provider, pre-exising personaliy rais also play a significan role. ough he relaive conribuionso geneics as opposed o environmenal and demographic acors in he developmen odrug addicion have been explored previously, he same argumens can be made beweenhe imporance o geneics or environmen on he developmen o personaliy rais.

In he final analysis, hey boh play significan roles. When individuals wih subsanceabuse are evaluaed, over 50% are ound o have personaliy disorders185. e ac hapeople wih personaliy disorders have such a high incidence o drug abuse has led someo hypohesize ha he drug abuse is simply a orm o sel-medicaion – reinorced byimprovemens in he inernal psychopahological sae186. Depression is requenly oundas a co-morbidiy o physicians a risk or drug abuse and suicide bu he difficuly in eval-uaing his is dissecing ou wheher he depression caused he addicion or was he resulo he addicion187 , 188. However, as in geneic amily sudies o addiion, depression issignificanly higher when here is a amily hisory o depression189,190. In addiion physi-

cians in general end o have behaviors making hem more vulnerable o depression159

.(see able 5) e lack o sleep leading o aigue has already been explored in regard ooverall healh, bu poor nuriion, due o grabbing meals whenever possible, lack o imeor rouine exercise, use o caffeine on a requen basis, as well as social isolaion due o adesire o be le alone o recuperae when off duy, all conspire o produce burnou and heuse o subsances as a orm o sel-medicaion.

able 5 – Behaviors lised increase he likelihood o a physician urning o drugs o relievesress and burnou. Mos o hese behaviors are a direc resul o physician’s desire o pu he

paien beore hemselves.Couner producive physician behaviors

Lack o sleep

Lack o nuriious ood

Lack o physical exercise

Lack o riendly posiive social ineracions

Dependence on simulaors such as caffeine

Ignoring own healh concerns or an exended period

Addiionally, personal psychological rais may also influence a physician o urn o sub-sance abuse. Physicians oen hide behind a syndrome o perecionism or “Godliness,”




considered a possible predisposing cause or addicion. In addiion exposure o inha-laional agens exhaled by he paien migh acivae oherwise dorman addiciveneuronal pahways. ere is a whole area o addicion medicine, called epigeneics,ha is exploring he concep ha exposure o drugs may acively affec he geneicexpression o alleles which in urn increases he predisposiion o addicion.

Epigeneics was originally discussed in 1942199 , as a way various dr ugs migh alergenomic expression wihou acually changing he DNA sequence. I is houghha he drugs ac on genomic expression by wo mechanisms – mehylaion oexising DNA which alers he DNA uncion and modificaion o he proeinssurrounding he DNA which in urn alers genomic expression200,201. I abusedsubsances can change brain chemisry via genomic expression so ha a lack o hedrugs produces a wihdrawal sympomaology, one can undersand he origins oaddicion. When his occurs wih second hand exposure o sub herapeuic levels

o anesheic agens ha mos aneshesiologiss come ino conac wih on a daily basis, one can undersand he concerns ha are raised in regard o he healh a ndsaey o he aneshesia workorce.

Drug seeking behavior in he ace o wihdrawal sympoms is simply an atemp ore-esablish “normal” brain chemisry which has been alered rom previous drugexposure. For he aneshesiologis who has unwitingly been exposed repeaed ohe second hand drugs and jus does no “eel righ” rom wihdrawal sympomsha canno be oherwise idenified, one can undersand ha even a single exposureo he subsances ha re-esablish “normalcy” could rigger addicive behavior. Apresen he occurrence o addicive predisposiion rom sub herapeuic second handexposure o anesheic agens remains hypoheical bu plausible.

Summary

Subsance abuse, addicion, burnou, and suicide are occupaional hazards o anes-hesia praciioners. ough hese problems have been recognized or decades, ewcounries have aken consrucive acion o inervene and preven he resuling dev-asaing loss o lie, loss o proessional work hours, and personal emoional rauma.

e cause or he deadly downward spiral is muliacorial . Geneics is increasingly being recognized as a criical acor in he developmen o addicion. Findings rom boh amily and populaion sudies sugges ha he conribuion o geneics migh be as high as 50% or he predisposiion oward he developmen o subsance depen-dency. Geneics also have an imporan role in proecing agains addicion due o var ying geneically conrol led acions on eiher he meabolism o abuse subsancesor by aleraion in he manner he subsances inerac wih neuronal recepors.However, having a geneic predisposiion does no senence a person o becomingan addic. Many demographic, environmenal and individual acors can modiy

boh he predilecion, as well as he proecive effecs o geneics. esearch inohese complex ineracion o geneics on subsance abuse in acively progressing andshould be beter defined in coming years.




Aside rom gene variaions, causes specific o aneshesia personnel ha can leado subsance abuse include he many unique sressors encounered in he modernoperaing room. Also causaive o sress is he expecaion o perecion ha is a cen-ral par o aneshesia medical raining. e long hours o work wih he atendanemoional physical and menal aigue serve o reduce an aneshesiologis’s samina

and coping abiliy.

Faigue is a srong independen acor ha increases he likelihood o a medical error being made, which adds high sress and increases he aigue acor even more. Also,caasrophic occurrences in he operaing room, wheher due o medical error or no,have devasaing and long erm effecs on he aneshesia praciioner. I a malprac-ice sui occurs, aneshesiologiss seem o be disproporionally affeced wih resul-an higher drug seeking behavior and suicide. Par o hese responses may in par beascribed o personaliy rais oen ound in aneshesiologiss such as perecionism,

isolaionism, and independence. Par o hese responses may also be due o he lacko insiuional and deparmenal suppor sysems, so ha drugs are viewed as heonly oule or overwhelming sress.

Finally, one as ye unproven cause or subsance abuse among aneshesia providers,oher han easily availabiliy o he drugs, is second hand exposure o exhaled drugsrom he paien. Fenanyl, propool and all he inhalaional agens are exhaled bypaiens in small amouns, as hey recover rom he effecs o aneshesia. oughhe concenraions o he drugs are sub herapeuic, i has been proposed ha hese

second hand drugs secondarily inhaled by he aneshesia praciioner may induceneuronal pahways ha can predispose o addicive behaviors and perhaps even wihdrawal sympomaology. ough plausible, his explanaion or subsanceabuse by aneshesia personnel is as ye unounded.

e problem o aigue, subsance abuse and suicide among aneshesia personnel isfinally geting atenion world-wide. e World Federaion o Socieies o Aneshe-siologiss is aking an acive role in poining ou ha his problem is no isolaed ospecific naions bu raher is world-wide. Only hrough hones recogniion o heproblem can seps be developed o inervene and preven is occurrence.

Reerences

1. Zengerle, J; Going Under; Te New epublic , December 31, 2008; pp. 21-25.

2. McDougall C; e Junk ie in he O.. Par 3; Men’s Healh , November 2006, pp. 187-193.

3. Bruce D, Eide K, Smih N, e al; A Prospecive Survey o Aneshesiologis Moral iy,1967-1971; Aneshesiology; 1974; 41:71-74.

4. Lew EA; Moraliy Experience Among Aneshesiologiss 1954-1976; Aneshesiology;

1979; 51:195-199.5. Bruce D, Eide K, Linde HW, Eckenhoff JE; Causes o Deah Among Aneshesiologiss:

A 20 Year Survey; Aneshesiology; 1968: 29:565-569.




6. Alexander B, Checkoway H, Nagahama S, Domino ; Cause Specific Moraliy isks o Aneshesiologiss; Aneshesiology; 2000; 93:922-930.

7. Collins GB, McCalliser MS, Jensen M, Gooden A: Chemical Dependency reamenoucomes o residens in aneshesiology: esuls o a survey; Anesh Analg ; 2005;101:1457-1462.

8. Bryson EO, Silversein JH; Addicion and Subsance Abuse in Aneshesiology; Aneshe-siology; 2008;109: 905–917.

9. Talbo GD, Gallegos KV, Wilson PO, Porter TL; e Medical Association of Georgia’sImpaired Physicians Program eview o he firs 1,000 Physicians: Analysis o Specialy;

JAMA; 1987; 257:2927–2930.

10. Booth JV, Grossman D, Moore J, et al; Substance abuse among physicians: a survey ofacademic aneshesiology programs; Anesh Analg ; 2002; 95:1024–1030.

11. Lindors PM, Mereoja OA, Luukkonen R, Elovainio MJ, Leino J; Suicidaliy amongFinnish Aneshesiologiss; Aca Anaeshesiol Scand; 2009; 53:1027–35.

12. Ohonen P, Alahuha S; Moraliy among Finnish aneshesiologiss rom 1984–2000; Aca Anaeshesiol Scand; 2002; 46:1196–1199.

13. Casey P, Dunn G, elly BD, e al; e prevalence o suicidal ideaion in he general po-pulaion: resuls rom he Oucome o Depression Inernaional Nework (ODIN) sudy.Soc Psychiary Psychiar Epidemiol; 2008; 43:299–304.

14. Juel K, Husum B, Viby-Mogensen J, Viskum S; Mortality among anesthesiologists inDenmark, 1973–95; Aca Anaeshesiol Scand; 2002; 46:1203–5.

15. Svardsudd , Wedel H, Gordh Jr; Moraliy raes among Swedish physicians: a

populaion-based naionwide sudy wih special reerence o aneshesiologiss; Aca Anaeshesiol Scand; 2002; 46:1187–95.

16. Shiwani MH; Healh o Docors: A Cause o Concern; J Pakisan Med Soc; 2009; 59:194-5.

17. Beaujouan L, Czernichow S, Pourria JL, Bonne F; Prevalence and risk acors or subs-ance abuse and dependence among anaesheiss: a naional survey; Ann Fr Anesh ea;2005; 24:471-479.

18. Canadian Medical Associaion; Guide o Physician Healh and Well-being. Facs, adviceand resources or Canadian docors; Te Canadian Medical Associaion; 2003; 1-36.

19. Grea Briain/Ireland Hawon , Clemens A, Sakarovich C, Simkin S, Deeks JJ. Sui-cide in docors: a sudy o risk according o gender, senioriy and specialy in medicalpraciioners in England and Wales, 1979–1995. J Epidemiol Communiy Healh; 2001;55:296–300.

20. Ausralian and New Zealand College o Anaesheiss; Saemen on Faigue and he Anaesheis; PS43; 2007; pp1-4; ABN 82 055 042 852

21. Moore R, Gupa P, Neo, GFD; Occupaional Faigue: Impac on Aneshesiologis’sHealh and he Saey o Surgical Paiens; ev Bras Anesesiol; 2013; 63:1-3’

22. Peckman C; htp://ww w.medscape.com/inernalmedicine: May 15, 2013

23. Neo GD; epor o he Proessional Well-being Work Pary o WFSA (PWWP): i isime o reflec on, and do somehing abou he aneshesiologis’s occupaional healh;WFSA Newsleter ; April 2011.




24. Yang , iehl J, Eseve E e al; Pharmacologic and uncional characerizaion omalignan hyperhermia in he 163C y1 knock-in mouse; Aneshesiology; 2006;105:1164–75.

25. Gillard E, Osu , Fujii J, e al; A subsiuion o cyseine or arginine 614 in he ryano-dine recepor is poenially causaive o human malignan hyperhermia; Genomics; 199;

11:751–5.26. Rueert H, ieme V, Wallenborn J, et al; Do variations in the 5-HT3A and 5HT3B

seroonin recepor genes (H3A, H3B) influence he occurrence o posoperaivenausea and vomiting (PONV)?; Anesh Analg ; 2009; 109:1442–1444.

27. Safford-Smih M, Podgoreanu M, Swaminahan M, e al, - PEGASUS Invesigaors; As-sociaion o geneic polymorphisms wih risk o renal injury aer coronary bypass grasurgery; Am J Kidney Dis; 2005; 45:519-530.

28. Welsby IJ, Podgorea nu MV, Phil lips-Bute B, e al - PEGASUS Invesigaors; Geneicbasis or bleeding afer cardiac surgery – A preliminary repor; J Tromb Haemos; 2005;

3:1206-1213.29. Grocot HP, Whie WD, Morris W, - PEGASUS Invesigaors; Geneic polymorphisms

and he risk o sroke aer cardiac surgery; Sroke; 2005; 369:1854-8.

30. Sadnicka A, Conney SJ, Moreno C; Mechanism o differenial cardiovascular respon-se o propool in Dahl sal-sensiive, Brown Norway, and chromosome 13-subsiuedconsomic ra srains: ole o large conducance Ca2+ and volage-acivaed poassiumchannels; J Pharmacol Exp Ter ; 2009; 330:727–35.

31. Sonner JM, Gong D, Eger EI 2nd; Naurally occurring variabiliy in anesheic poencyamong inbred mouse srains; Anesh Analg ; 2000; 91:720–6.

32. Landau , ern C, Columb MO, e al. Geneic variabiliy o he mu-opioid receporinfluences inrahecal enanyl analgesia requiremens in laboring women; Pain; 2008;139:5–14.

33. Fukuda , Hayashida M, Ide S, e al; Associaion beween OPM1 gene polymor-phisms and enanyl sensiiviy in paiens undergoing painul cosmeic surgery; Pain;2009;147:194–201.

34. osek E, Jensen B, Lonsdor B, e al; Geneic variaion in he seroonin ransporergene (5-HTLP, rs25531) influences he analgesic response o he shor acing opioid

emienanil in humans; Mol Pain; 2009; 5:37.35. Mogil JS, Wilson SG, Chesler EJ, e al; e Melanocorin-1 recepor gene mediaes

emale-specific mechanisms o analgesia in mice and humans; Proc Nal Acad Sci; 2003;100:4867-72.

36. Liem EB, Lin CM, Suleman MI, e al; Anesheic equiremen is Increased in edheads; Aneshesiology; 2004; 101:279-83.

37. Xing Y, Sonner JM, Eger EI, Cascio M, Sessler DI; Mice with a Melanocortin 1 ReceptorMuaion Have a Slighly Greaer Minimum Alveolar Concenraion han Conrol Mice;

Aneshesiology; 2004; 101:544-6.

38. Douas AG, Orhan-Sungur M, omasu , e al; Bispecral index dynamics duringpropool hypnosis is similar in red-haired and dark-haired subjecs; Anesh Anal; 2013,116:319-326.




39. Donahue BS, Balser JR; Perioperative Genomics: Venturing into Uncharted Seas (Edito-rial); Aneshesiology; 2003; 99:7-8.

40. Heah AC, Bucholz , Madden PA, e al; Geneic and environmenal conribuions oalcohol dependence risk in a naional win sample: Consisency o findings in women andmen; Psychological Medicine; 1997; 27:1381–1396.

41. McGue M; e behavioral geneics o alcoholism; Curren Direcions in PsychologicalScience; 1999; 8:109–115.

42. Prescot CA, endler S; Influence o ascerainmen sraegy on finding sex differencesin geneic esimaes o win sudies o alcoholism; Am J Med Gene ; 2000; 96:754-761.

43. Hansell N, Agrawal A, Whifield JB e al; Long-erm sabiliy and heriabiliy o e-lephone inerview measures o alcohol consumpion and dependence; win es HumGene.; 2008; 11:287-305.

44. Vink JM, Willemsen G, Boomsma DI; Hereditabilit y of smoking initiation and depen-dence; Behav. Gene .; 2005:397-409.

45. Broms U, Madden PA, Heah AC, e al; e nicoine dependence syndrome scale in Fin-nish smokers; Drug Alcohol Depend; 2007; 89:42-51.

46. endler S, Prescot CA; Cannabis use, abuse and dependence in a populaion-basedsample o emale wins; Am J Phychiary; 1998; 155:1016-1022.

47. suang M, Lyons MJ, Meyer JM, e al; Co-occurrence o abuse o differen drugs in men:he role o drug specific shared vulnerabiliies; Arch Gen Psychiary; 1998; 55: 967-972.

48. endler S, Jacobson C, Prescot CA, Neale MC; Specificiy o geneic and environ-menal risk acors or use and abuse/dependence o cannabis, cocaine, hallucinogens,

sedaives, simulans, and opiaes in male wins; Am J Psychiary; 2003; 160:687-695.49. endler S, Prescot CA, Myers J, Neale MC; e srucure o geneic and environmen-

al risk acors or common psychiaric and subsance use disorders in men and women; Arch Gen Psychiary; 2003; 60:929-937.

50. Malone SM, Iacono WG, McGue M; Drinks o he aher: Faher’s maximum number odrinks consumed predics exernalizing disorders, subsance use, and subsance use di-sorders in preadolescen and adolescen offspring; Alcoholism: Clinical and Experimenalesearch; 2002; 26:1823–1832.

51. Donovan JE, Molina BS; Childhood risk acors or early onse drinking; Journal o Su-

dies on Alcohol and Drugs; 2011; 72, 741-751.52. Edenberg HJ, Foroud .:e geneics o alcoholism: Ideniying specific genes hrough

amily sudies; Addicion Biology; 2006; 11:386–396.

53. Holmans, P; Saisical mehods or pahway analysis o genome-wide daa or associa-ion wih complex geneic rais; Advances in Geneics; 2010; 72:141–179.

54. apper A, Mcinney SL, Nashmi , e al; Nicoine acivaion o α4* recepors: suffi-cien or reward, olerance, and sensiizaion; Science; 2004; 306:1029–1032.

55. Mohn A, Yao WD, Caron MG; Geneic and genomic approaches o reward and addic-

ion; Neuropharmacology; 2004; 47:101–110.56. Hiroi N, Agasuma S; Geneic suscepibiliy o subsance dependence; Mol Psychiary;

2005; 10:336–344.




57. reek MJ, Nielsen DA, LaForge S; Genes associaed wih addicion: alcoholism, opiae,and cocaine addicion; Neuromolecular Med; 2004;5:85–108.

58. Sranger BE, Sahl E.A, aj ; Progress and promise o genome-wide associaion sudiesor human complex rai geneics; Geneics; 2011; 187:367–383.

59. Manolio A; Genome wide associaion sudies and assessmen o he risk o disease;

NEJM ; 2010; 363:166–176, 2010.60. Edenberg HJ; Genes conribuing o he developmen o Alcoholism - An Overview;

Alcohol esearch: Curren eviews; 2013; 201; 336-338.

61. Li D, Zhao H, Gelerner J; Srong associaion o he alcohol dehydrogenase 1B gene(ADH1B) wih alcohol dependence and alcohol-induced medical diseases; Biological

Psychiary; 2011, 70:504 –512.

62. Higuchi S, Masushia S, Imazeki H, e al; Aldehyde dehydrogenase genoypes in Japane-se alcoholics; Lance ; 1994; 343:741–742.

63. Shen C, Fan JH, Edenberg HJ, e al; Polymorphism o ADH and ALDH genes among ourehnic groups in China and effecs upon he risk or alcoholism. Alcoholism: Clinical and Experimenal esearch; 1997; 21:1272–1277.

64. Bieru LJ, Goae AM, Breslau N, e al; ADH1B is associaed wih alcohol dependenceand alcohol consumpion in populaions o European and Arican ancesry; Molecular

Psychiary; 2012; 17:445–450.

65. Edenberg HJ; e geneics o alcohol meabolism: ole o alcohol dehydrogenase andaldehyde dehydrogenase varians; Alcohol esearch & Healh; 2007; 30:5–13.

66. omasson H, Edenberg HJ, Crabb DW, e al; Alcohol and aldehyde dehydrogenase geno-

ypes and alcoholism in Chinese men; American Journal o Human Geneics; 1991; 48:677–681.67. Luo X, Kranzler HR, Zuo L, et al; ADH4 gene variaion is associaed wih alcohol de-

pendence and drug dependence in European Americans: esuls rom HWD ess andcase-conrol associaion sudies; Neuropsychopharmacology; 2006; 31:1085–1095.

68. Macgregor S, Lind PA, Bucholz , e al; Associaions o ADH and ALDH2 gene va-riaion wih sel repor alcohol reacions, consumpion and dependence: An inegraedanalysis; Human Molecular Geneics; 2009; 18:580–593.

69. Edenberg HJ, Xuei X, Chen HJ, et al; Association of alcohol dehydrogenase genes with alcoholdependence: A comprehensive analysis; Human Molecular Geneics; 2006; 15:1539–1549.

70. Agrawal A, Edenberg HJ, Foroud , e al; Associaion o GABR2 wih drug dependence in hecollaboraive sudy o he geneics o alcoholism sample; Behavior Geneics; 2006; 36:640–650.

71. Enoch MA; e role o GABA(A) recepors in he developmen o alcoholism; Pharmaco-logy, Biochemisry, and Behavior ; 2008; 90:95–104.

72. Lappalainen J, rupisky E, emizov M, e al; Associaion beween alcoholism andgamma-amino buyric acid alpha2 recepor subype in a ussian populaion; Alcoholism:Clinical and Experimenal esearch ; 2005; 29:493–498.

73. Dixon CI, osahl W, Sephens DN; argeed deleion o he GABR2 gene encoding

alpha2-subunis o GABA(A) recepors aciliaes perormance o a condiioned emoionalresponse, and abolishes anxiolyic effecs o benzodiazepines and barbiuraes; Pharmacology,

Biochemisry, and Behavior ; 2008; 90:1–8.




74. Boehm SL, 2nd , Ponomarev I, Jennings, AW, e al; Gamma-Aminobuyric acid A receporsubuni muan mice: New perspecives on alcohol acions; Biochemical Pharmacology ;2004; 68:1581–1602.

75. Wang JC, Hinrichs AL, Sock H, e al; Evidence o common and specific geneic effecs: As-sociaion o he muscarinic aceylcholine recepor M2 (CHM2) gene wih alcohol depen-

dence and major depressive syndrome; Human Molecular Geneics; 2004; 13:1903–1911.76. Luo X, Kranzler H.R, Zuo L, et al; CHRM2 gene predisposes to alcohol dependence,

drug dependence and affecive disorders: esuls rom an exended case-conrol srucu-red associaion sudy; Human Molecular Geneics; 2005; 14:2421–2434.

77. Bowirra A, and Oscar-Berman M; elaionship beween dopaminergic neuroransmis-sion, alcoholism, and reward deficiency syndrome; American Journal o Medical Geneics .

Par B, Neuropsychiaric Geneics; 2005; 132B:29–37.

78. Gelerner J, and ranzler H; D2 dopamine recepor gene (DD2) allele and haployperequencies in alcohol dependen and conrol subjecs: No associaion wih phenoype or

severiy o phenoype. Neuropsycho pharmacology; 1999; 20:640–649. 79. Le Foll B, Gallo A, Le Sra Y, e al; Geneics o dopamine recepors and drug addicion:

A comprehensive review; Behavioural Pharmacology; 2009; 20:1–17.

80. Angs MS, Lazzeroni LC, Phillips NG, e al; Aversive and einorcing Opioid Effecs – Apharmacogenomics win Sudy; Aneshe siology; 2012; 117:22-37.

81. Fillingim B; Geneic Conribuions o Opioid Side Effecs; Aneshesiolog y; 2012;117:6-7.

82. Ho M, Goldman D, Heinz A, e al; Breaking barriers in he genomics and pharmacoki-

neics o drug addicion; Clin Pharmacol Ter ; 2010; 88:779-791.83. Yuferov V, Levran O, Proudnikov D, et al; Search for genetic markers and functional

var ians involved in he developmen o opiae and cocaine addicion, and reamen; Ann N Y Acad Sci; 2010; 1187:184-207.

84. Borrat X, Troconiz IF, Valencia JF, et al; Modeling the Inuence of the A118G Polymor-phism in he OPM1 gene and he Noxious Simulaion on he Synergisic elaion beween Propool and emienanil; Aneshesiology; 2013; 118:1395-1407.

85. Edwards AC, Svikis DS, Pickens W, Dick DM; Geneic Influences on Addicion; Prima-ry Psychiary; 2009; 16:40-46.

86. ACGME. Accrediaion council or graduae medical educaion. [inerne]. Disponí- vel em: htp://www.acgme.org/acgmeweb/abid/271/GraduaeMedicalEduca ion/DuyHours.aspx.

87. Howard S, osekind M, az, JD and Berry AJ; Faigue in Aneshesia; Aneshesiology;2002; 97:1281-1294.

88. Parker JB; e effecs o aigue on physician perormance: An underesimaed cause ophysician impairmen and increased paien risk; Can J Anaesh; 1987; 34:489–95.

89. Wes CP, an AD, Habermann M, e al; Associaion o esiden Faigue and Disress wih Perceived Medical Errors; JAMA; 2009; 296:1294-1300.

90. Landrigan CP, ohschi ld JM, Cronin JW, e al; Effec o reducing inerns’ work hours onserious medical errors in inensive care unis; N Engl J Med; 2004; 351:1838-1848.




91. Dinges DF; An overview o sleepiness and accidens; J Sleep es; 1995;4:4–14.

92. Akersed ; Consensus saemen: Faigue and accidens in ranspor Operaions; JSleep es; 2000; 9:395.

93. Denisco R, Drummond JN, Gravensein JS; e effec o aigue on he perormance oa simulaed anesheic monioring ask; J Clin Moni ; 1987; 3:22–4.

94. Weinger MB, Englund CE; Ergonomic and human acors affecing anesheic vigilanceand monioring perormance in he operaing room environmen; Aneshesiology; 1990;73:995–1021.

95. Pilcher JJ, Huffcut AI; Effecs o sleep deprivaion on perormance: A mea-analysis;Sleep; 1996; 19:318 –26.

96. Doran SM, Van Dongen HP, Dinges DF: Sustained aention performance during sleepdeprivaion: Evidence o sae insabiliy. Arch Ial Biol 2001; 139:253–67.

97. Howard SK, Gaba DM, Smith BE, et al; Simulation Study of Rested Verses Sleep-deprived

Aneshesiologiss; Aneshesiology; 98:1345-1355.98. Arned JD, Owens J, Crouch M, e al; Neurobehavioral Perormance o esidens Aer

Heavy Nigh Call vs Aer Alcohol Ingesion; JAMA; 2005; 294:1025-1033.

99. Dawson D, eid ; Faigue, alcohol and perormance impairmen (scienific correspon-dence); Naure; 1997; 388:235.

100. essler MJ, Shrier I, Seele J; Associaion beween Aneshesiologis Age and Liiga-ion; Aneshesiology; 2012; 116:574-579.

101. ravis W, Mihevc N, Orkin F, Zeilin GL; Age and anesheic pracice: A regionalperspecive; J Clin Anesh; 1999; 11:175–86.

102. az JD: Issues o concern or he aging aneshesiologis; Anesh Analg; 2001; 92:1487–92.

103. Van Dongen HP, Dinges DF; Circadian rhythms in fatigue, alertness, and performance,Principles and Pracice o Sleep Medicine, 3rd ediion; Edied by ryger MH, oh ,Demen WC. Philadelphia, Saunders, 20 00, pp 391–9.

104. Smih-Coggins , osekind M, Buccino , Dinges DF, Moser P; oaing shi-work schedules: Can we enhance physician adapaion o nigh shis? Acad Emerg Med;1997; 4:951–61.

105. Smih-Coggins , osekind M, Hurd S, Buccino ; elaionship o day versus nigh

sleep o physician perormance and mood; Ann Emerg Med; 1994; 24:928–34.106. Aya AG, Mangin , ober C, Ferrer JM, Eledjam JJ; Increased risk o uninenional du-

ral puncure in nigh-ime obseric epidural aneshesia; Can J Anaesh; 1999; 46:665–9.

107. Spanagel , osenwasser AM, Schumann G, Sarkar D; Alcohol consumpion and he body’s biological clock. Alcoholism: Clinical and Experimenal esearch; 2005; 29:1550–1557.

108. osenwasser AM, Clark JW, Fixaris MC, e al; Effecs o repeaed ligh-dark phase shison volunary ehanol and waer inake in male and emale Fischer and Lewis ras; Alco-hol; 2010; 44:229–237.

109. rinkoff AM, Sorr CL; Work schedule characerisics and subsance use in nurses;

American Journal o Indusrial Medicine; 1988; 34:266–271.110. Dong L, Bilbao A, Lauch M, e al; Effecs o he circadian rhyhm gene period 1 (per1)




on psychosocial sress-induced alcohol drinking; American Journal o Psychiary; 2011;168:1090–1098.

111. Logan W, O’ Connell S, Levit D, e al; e involvemen o clock gene Per2 in media-ing sress-induced alcohol drinking behavior in eal-alcohol exposed mice. Alcoholism;Clinical and Experimenal esearch; 2011; 35:107.

112. Comasco E, Nordquis N, Gökürk C, e al; e clock gene PE2 and sleep problems: Associaion wih alcohol consumpion among Swedish adolescens; Upsala Journal o Medical Sciences; 2010; 115:41–48.

113. Zghoul , Abarca C, Sanchis-Segura C, e al; Ehanol sel-adminisraion and reinsa-emen o ehanol-seeking behavior in Per1(Brdm1) muan mice; Psychopharmacology(Berl); 2007; 190:13–19.

114. Zhou Y, Spangler , Maggos CE, e al; Hypohalamic-piuiary-adrenal aciviy andpro-opiomelanocorin mNA levels in he hypohalamus and piuiary o he ra are di-fferenially modulaed by acue inermiten morphine wih or wihou waer resricion

sress; Journal o Endocrinology; 1999; 163:261–267.115. Jarjour S, Bai L, Gianoulakis C; Effec o acue ehanol adminisraion on he release

o opioid pepides rom he midbrain including he venral egmenal area. Alcoholism:Clinical and Experimenal esearch; 2009; 33:1033–1043.

116. asmussen DD, Bold BM, Wilkinson CW, Miton D; Chronic daily ehanol and wihdrawal: 3. Forebrain pro-opiomelanocorin gene expression and implicaions ordependence, relapse, and deprivaion effec. Alcoholism: Clinical and Experimenal e-search; 2002; 26:535–546.

117. Sweep CG, Van Ree JM, Wiegant VM; Characterization of beta-endorphin-immunore-aciviy in limbic brain srucures o ras sel-adminisering heroin or cocaine; Neuro-

pepide s; 1988; 12:229–236.

118. Gander PH, Merry A, Millar MM, Weller J; Hours o work and aigue relaed error: Asurvey o New Zealand anaesheiss; Anaesh Inensive Care; 2000; 28:178–83.

119. Gaba DM, Howard S, Jump B; Producion pressure in he work environmen: Calior-nia aneshesiologiss’ atiudes and experiences; Aneshesiology;1994; 81:488–500.

120. Gravensein JS, Cooper JB, Orkin F; Work and res cycles in aneshesia Pracice; Anes-hesiology; 1990; 72:737–42.

121. Morris GP, Morris W: Anaeshesia and aigue: An analysis o he firs 10 years ohe Ausralian Inciden Monioring Sudy 1987–1997; Anaesh Inensive Care; 2000;28:300–4.

122. Holzman S; Whie Paper - e Wellness Ini iaive ask Force on Physician Wellness: American Sociey o Aneshesiologiss; Commitee on Occupaional Healh, 2009.

123. e Associaion o Anaesheiss o Grea Briain and Ireland, Faigue and Anaeshe-iss; 2004:1-25.

124. Faigue and he Pracice o Aneshesiology; APSF Newsleter – e Official Journal ohe Aneshesia Paien Saey Foundaion; 2005; 20:1-22.

125. Veasey S, Rosen R, Barzansky B et al; Sleep Loss and Fatig ue in Residency Training; JAMA; 2002; 288:1116-1123.




126. Carskadon M, Demen WC; Cumulaive effecs o sleep resricion on dayime sleepi-ness; Psychophysiology; 1981; 18:107-113.

127. Blagrove M, Alexander C, Horne JA; he eecs o chronic sleep reducion on heperormance o cogniive asks sensiive o sleep deprivaion; Appl Cogn Psycho;1994; 9:21-40.

128. Dinges DSF, Pack F, Williams , e al; Cumulaive sleepiness, mood disurbance, andpsychomoor vigilance perormance decremens during a week o sleep resriced o 4-5hours per nigh; Sleep; 1997; 20:267-277.

129. Wes CP, Huschka MM, Novony, e al; Associaion o perceived medical errors wihresiden disress and empahy; JAMA; 2006; 296:1071-1078.

130. Maslach C, Schaueli WB, Leier MP; Job Burnou; Annu. ev. Psychol; 2001; 52:397–422.

131. Campbell C, ohmann S; A psychomeric assessmen o he Maslach Burnou In- venory (General Sur vey) in a cusomer-ser vice environmen; Managemen Dynamics; 2005; 14:16-28.

132. Schaueli WB, Greenglass E; Inroducion o special issues on burnou and healh; Psychology and Healh; 2001; 16:501-510.

133. Dyrbye LN, omas M, Massie FS, e al; Burnou and suicidal ideaion among U.S.medical sudens; Ann Inern Med; 2008;149:334 – 41.

134. De Oliveira GS, Chang , Fizgerald PC, e al; e prevalence o burnou and depressionand heir associaion wih adherence o saey and pracice sandards: A survey o Uni-ed Saes Aneshesiology rainees; Anesh Anal; 2013; 117:182-193.

135. Shanael D, Balch C, Bechamps G, e al; Burnou and medical errors among American

surgeons; Ann Surg ; 2010; 251:1001–2.136. Hyman SA, Michaels D, Berry JM, e al; isk o burnou in perioperaive clinicians;

Aneshesiology; 2011; 114:194-204.

137. Cassella CW; Burnou and he relaive value o dopamine; Aneshesiology; 2011;114:213-217.

138. De Oliveira GS Jr, Ahmad S, Sock MC, e al; High incidence o burnou in academicchairs o aneshesiology: Should we be aking beter care o our leaders? Aneshesiology;2011; 114:181–93.

139. Shanael ; Burnou in aneshesiology - A call o acion; Aneshesiology; 2011; 114:1-2.

140. Vincent, C; Understand ing and Respondi ng to Adverse Events; NEJM ; 2006; 348:1051-1056.

141. Wu AW; Medical Error: e Second Victim; BMJ ; 2000; 32:726-727.

142. Schernhammer E; aking eir Own Lives – e High ae o Physician Suicide; NEJM ; 2005; 352:2473-2476.

143. Cooper J, Cullen D, Eichhorn J, Philip J, Holzman ; Adminisraive guidelines or res-ponse o an adverse aneshesia even. e isk Managemen Commitee o he HarvardMedical School’s Deparmen o Anaeshesia; J Clin Anesh; 1993; 5:79-84.

144. Deahl M; Psychological debriefing: conroversy and challenge; Aus NZ J Psych; 2000;34:929-39.




145. Van Emmerik A, Kamphuis J, Hulsbosch A, Emmelkamp P; Single session debriengaer psychological rauma: a mea-analysis; Lance ; 2002; 360:766-71.

146. Smih I, Jones M; Surgeons’ atiudes o inraoperaive deah: quesionnaire survey; Bri Med J ; 2001; 322:896-738.

147. Whie S, Akerele O; Anaesheiss’ atiudes o inraoperaive deah; Eur J Anaesh;

2005; 22:938-41.148. Wee M. Caasrophes in anaesheic Pracice - Survey AAGBI members in 2005. Anae s-

hesia News; 2006; 224:2-3.

149. Gazoni FM, Amao PE, Malik ZM Durieux ME; e Impac o Perioperaive Caasropheson Aneshesiologiss: esuls o a Naional Survey; Anesh Anal; 2012; 114:596-603.

150. Gazoni FM, Durieux ME, Wells L; Lie aer deah: he aermah o perioperaive caas-rophes; Anesh Analg ; 2008; 107:591–600.

151. Caasrophes in Anaeshesia Pracice – dealing wih he Aermah; Te Associaion o

Anaesheiss o Grea Briain and Ireland; 2005; pages 1-30.152. Marin W, oy C; Cause or Pause Aer a Perioperaive Caasrophe: One, wo, or

ree Victims?; Anesh Anal; 2012; 114:485-487.

153. Gaylene C. Heard GC, Sanderson PM, omas D; Barriers o Adverse Even and Erroreporing in Aneshesia; Anesh Anal; 2012; 114:604-614.

154. Souer J, Gallagher H; e Disclosure o Unanicipaed Oucomes o Care and Medi-cal Errors: Wha does his mean o Aneshesiologiss?; Anesh Anal; 2012; 114:615-621.

155. Desoches CM, ao S, Fromson JA e al; Physicians’ percepions, preparedness orreporing, and experiences relaed o impaired and incompeen colleagues; JAMA;

2010; 304:187-193.156. Jones JW, Barge BN, Seffy BD, e al; Sress and medical malpracice: Organizaional risk

assessmen and inervenion; J Appl Psychol; 1988; 73:727–35.

157. Charles S; Coping wih a medical malpracice sui; Wes J Med; 2001; 174: 55-8.

158. Charles SC, Wilber J, ennedy EC; Physicians’ sel-repors o reacions o malpraci-ce liigaion; Am J Psychiary; 1984; 141:563-565.

159. Holzman S: e Wellness Iniiaive: Evoluion, Curren Challenges and Fuure Vision: Task Force on Physician Wellness Commiee on Occupational Health of the

American Sociey o Aneshesiologiss; 2009.160. Birmingham P., Ward, : A High-isk Suicide Group: e Aneshesiologis involved in

Liigaion (leter); Am. J. Psychiary; 1985; 42:1225-1228.

161. Jena AB, Seabury S, Lakdawal la D, Chandra A; Malpracice isk According o PhysicianSpecialy; NEJM ; 2011; 365:629-636.

162. Edbril SD, Lagasse S; elaionship beween malpracice liigaion and human errors; Aneshesiology; 1999; 91:848–55.

163. Liang BA, Cullen DJ; .e Legal Sysem and Paien Saey: Charing a Divergen Cour-se (ediorial); Aneshesiology; 1999; 91:609–11.

164. Warner MA; More han jus aking he eys Away (edioral); Aneshesiology: 2012;116:501-503.




165. Earley PH, Finver ; Addicion o propool: A sudy o 22 reamen cases; J Addic Med;2013; 7:169-176.

166. Bonne U, Scherbaum N; Craving dominaes propool addiion o an affeced physician ; J Psychoacive drugs; 2012; 44:186-190.

167. Wischmeyer PE, Johnson B, Wilson JE, e al; A survey o propool abuse in academic

aneshesia programs; Anesh Analg; 20 07; 105:1066–71.168. Farley WJ, albot GD; Aneshesiology and addicion (ediorial); Anesh Analg; 1983;

62:465–466.

169. Kintz P, Villain M, Dumestre V, Cirimele V; Evidence of addiction by anesthesiologistsas documened by hair analysis; Forensic Sci In ; 2005; 153:81–84.

170. Epsein H, Grach DM, Grunwald A; Developmen o a Scheduled Drug DiversionSurveillance Sysem Based on an Analysis o Aypical Drug ransacions; Anesh Analg ;2007; 105:1053–1060.

171. Bryson EO, Silversein JH; Addicion and Subsance abuse in Aneshesiology; Aneshe-siology; 2008; 109:905-917.

172. Silversein JH, Silva DA, Iberi J; Opioid addicion in aneshesiology. Aneshesiology;1993; 79:354–375.

173. Adler G, Pots FE III, irby ; Narcoics conrol in aneshesia raining; JAMA;1985; 253:3133–3136.

174. Moleski J, Easley S, Barash PG; Conrol and accounabiliy o conrolled subsanceadminisraion in he operaing room; Anesh Analg ; 1985; 64:989–995.

175. Shaer AL, Lisman S, osenberg MB; Developmen o a comprehensive operaing

room pharmacy; J Clin Anesh; 1991; 3:156–166.176. Schmid K, Schlesinger MD; A reliable accouning sysem or conrolled subsances in

he operaing room; Aneshe siology; 1993; 78:184–190.

177. Berge H, Dillon , Sikkink M, aylor , Lanier WL; Diversion o drugs wihinhealh care aciliies, a muliple-vicim crime: paterns o diversion, scope, consequen-ces, deecion, and prevenion; Mayo Clin Proc; 2012; 87:674–682.

178. Epstein RH, Gratch DM, McNulty S, Grunwald Z; Validation of a System to Detect Sche-duled Drug Diversion by Aneshesia Care Providers; Anesh Anal; 2011; 113:160-164.

179. Scot M, Fisher S; e evolving legal conex or drug esing programs; Aneshesiology;1990; 73:1022-1027.

180. Fizsimons MG, Baker H, Lowensein E, Zapol WM; andom drug esing o reducehe incidence o addicion in aneshesia residens: preliminary resuls rom one pro-gram; Anesh Analg; 2008; 107:630–5.

181. ezlaff J, Collins GB, Brown DL, Pollock G, Popa D; A sraegy o preven subsanceabuse in an academic aneshesiology deparmen; J Clin Anesh; 2010; 22:143–150.

182. Jacobs WS, Repeo M, Vinson S, Pomm R , Gold M. Random urine testing as an inter- venion or drug addicion; Psychiaric Ann; 2004; 34:781–4.

183. Shore JH. e Oregon experience wih impaired physicians on probaion. An eigh-yearollow-up; JAMA; 1987; 257:2931–4.




184. Collins GB, McAlliser MS, Jensen M; Chemical Dependency reamen Oucomes oesidens in Aneshesiology: esuls o a survey; Anesh Anal; 2005; 101:1457-1462.

185. Nace EP, Davis CW, Gaspari JP; Axis II comorbidiy in subsance abusers; Am J Psychia-ry; 1991; 148:118–120.

186. Markou A, osen , oob GF; Neurobiological similariies in depression and drug

dependence: a sel-medicaion hypohesis; Neuropsychopharmacology; 1998; 18:135–174.187. Hawon , Clemens A, Simkin S, Malmberg A; Docors who kill hemselves: a sudy o

he mehods used or suicide; Q J Med; 2000; 93:351-7.

188. Schernhammer E, Coldiz G; Suicide aes Among Physicians: A Quaniaive and Gen-der Assessmen (Mea-Analysis); Am J Psychiary; 2004; 161:2295–302.

189. Luo X, Kranzler HR, Zuo L, et al; CHR M2 gene predisposes to alcohol dependence,drug dependence and affecive disorders: resuls rom an exended case-conrol srucu-red associaion sudy; Hum Mol Gene; 2005; 14:2421–2434.

190. Short S: Psychiaric illness in physician;. Can Med Assoc J ; 1979; 121: 283-288.191. Peers M, ing J; Perecionism in docors; BMJ ; 2012; 344:10.

192. McCracken CB; Inellecualizaion o Drug Abuse; JAMA; 2010; 303:1894-1895.

193. Gold MS, Byars JA, Fros-Pineda . Occupaional exposure and addicions or phy-sicians: case sudies and heoreical implicaions; Psychiar Clin Norh Am; 2004;27:745–753.

194. Sekine Y, Minabe Y, Ouchi Y, e al; Associaion o dopamine ransporer loss in he orbi-oronal and dorsolaeral preronal corices wih mehampheamine-relaed psychia-ric sympoms ; Am J Psychiary; 2003; 160:1699–1701.

195. Malison , Bes SE, Wallace EA, e al; Euphorigenic doses o cocaine reduce [123I] bea-CI SPEC measures o dopamine ransporer avai labiliy in human cocaineaddics; Psychopharmacology; 1995; 122:358–362.

196. Heinz A, agan P, Jones DW, e al; educed cenral seroonin ransporers in alcoho-lism; Am J Psychiary; 1998; 155:1544–1549.

197. McAuliffe PF, Gold MS, Bajpai L, e al; Second-hand exposure o aerosolized inrave-nous anesheics propool and enanyl may cause sensiizaion and subsequen opiaeaddicion among aneshesiologiss and surgeons. Med Hypoheses; 2006; 66:874–82.

198. Gold MS, Melker J, Dennis DM, e al; Fenanyl abuse and dependence: urher eviden-ce or second hand exposure hypohesis. J Addic Dis; 2006; 25:15–21.

199. Waddingon EC; e epigenoype. Endeavour ; 1942; 1:18–20.

200. ornberg, D; Chromain srucure: A repeaing uni o hisones and DNA; Scien-ce;1974; 184:868–871.

201. Hsieh J, Gage FH; Chromain remodeling in neural developmen and plasiciy; CurrenOpinion in Cell Biology; 2005; 17:664–671.



1.4 - Burnou syndrome in anaeshesiologiss - e acual realiy | 97

Burnou Syndrome In Anaeshesiologiss - Te Acual Realiy

Prayush Gupa Proe ssional Well-being Commitee o W FSA

Florian Nuevo Proe ssional Well-being Commitee o W FSA

Aneshesiologiss’ Well-Being

e inricae relaionship beween work lie balances can eiher manies isel posi-ively in an individual, resuling in posiive job engagemen and pleasure filled lie.Or a he oher end o he specrum, his can negaively impac he person’s socialand psychological being resuling in sress and burnou. Wih presen ineres in“Weingology”, ha is, he science o sudying well-being, we hope o undersandmore his inricae relaionship beween work and lie.

In his chaper, we would like o review he personal well-being o aneshesiologiss,ocusing on burn-ou syndrome. Aneshesiologiss are expeced o render paiens“sress-ree” as hey undergo any diagnosic or herapeuic procedure. Ironically ,as he aneshesiologis carries ou his daily work, he is placed under undue sress because o he inheren risks in ever y anesheic and surgical procedure, aggravaed by producion pressure and /or lack o resources a work environmen.

e increased applicaion o economic and business adminisraion principles ohealh care in he lae 20h and early 21s cenuries ineviably led o he inroduciono managemen pracices o improve he efficiency o anesheiss1. e pressure oa growing economic compeiiveness and he need o do more wih a reduced work-orce are associaed wih he emergence o more difficul cases. is ransormaionhas impaced he occupaional well-being o aneshesiologiss2.

Aneshesiology is a medical specialy ha has been singled ou as having made majoradvances in paien care saey over he pas ew decades. Boh morbidiy and moral-iy raes have undergone significan improvemens due o innovaions in pharmacol-ogy, monioring and clinical approaches. Ye paien harm secondar y o errors made by aneshesia praciioners coninues o exis in spie o he many oher advances.One key cause or praciioner error ha is well documened in he medical lieraureis he praciioner’s level o aigue3.

rough his chaper, we aim o creae awareness abou Burnou Syndrome amonghe medical raerniy and especially discuss is prevalence among anaeshesiolo-giss in differen pars o he world, as we know i oday. Available lieraure has beenreviewed and he magnanimiy o his problem, is causaive acors, is effecs on

he work and lie o anaeshesiologiss globally and heir various coping mechanismshave been discussed. Mos o he available research has ocussed on he negaiveaspecs o sress and burnou a work.




In his chaper, we would like o srike a balance and encourage a shi o ocus oruure anaeshesia research on he posiive rais o job involvemen/engagemenand pleasures a work. We have ried o raise various concerns in he work o ananaeshesiologis, and how bes i can be deal wih.

In Nicomachean Ehics, writen in 350 BC, Arisole saes his amous EudaimonicTeory o Happiness4. He says ha happiness (also being well and doing well) ishe only hing ha humans desire or is own sake, unlike riches, honor, healh orriendship. He observed ha men sough riches, or honor, or healh no only or heirown sake bu also in order o be happy. He believed ha virue brings atainmen(ulfil lmen), and ulfillmen brings happiness.

Ariso le a lso believed in he imporance o cer ain goods and oru ne in shapi ng well-being. In addiion o vir ue (mora l and inellecual excellence) and physi-ological well-being (e.g., healh), which he considered “inernal goods” (i.e.,hey exis in he sel ), he successul pursu i o happiness also required “exernalgoods” as riends, wealh, poliical power, and securiy – i.e., wha Arisole calls“exernal prosperiy.” Exernal prosperiy and physiological well-being dependo some exen on good orune, which means ha one’s happiness can be under-mined, a leas o some exen, by ill orune5. Wih his hisorical background,can we i nd some parallelism by which aneshesiologiss can ind personal well- being while a work?

A new erm “Weingology” has been proposed wih an aim o promoe well-beinga work. We hope ha scienific research and uure clinical sudies will help creaeawareness and ineres in his opic, helping i o develop ino an independen spe-cialiy, or be an imporan par o every medical curriculum.

Wha is Burnou Syndrome

Burnou is a psychological erm ha reers o long-erm exhausion and diminishedineres in work. I is work specific, occurs in individuals who did no have anypreexising psychopahology and commonly ound in care giving proessions. e

erm burnou in psychology was coined by Herber Freudenberger in his 1974 aricle“Saff burnou” , presumably based on he 1960 novel “ A Burn-Ou Case” by GrahamGreene, which describes a proagonis suffering rom burnou quis his job and wih-draws ino he Arican jungle6.

Several definiions and heories abound o describe Burnou and is associaedsympoms ha are collecively called “e Burnou Syndrome”. I has been hard odescribe Burnou Syndrome, since i is more o a subjecive eeling and raher di-ficul o objeciy. Simply pu, Burnou Syndrome is a sae o being, in which he

individual is unable o cope up wih he demands o his work environmen, eels de-energised and loses ineres in his work oucome. How close one can ge o burnoudepends on he individual’s capaciy o handle sress.




e mos widely acceped work or quaniaive assessmen o Burnou is he MaslachBurnou Invenory (MBI) developed by Maslach and Jackson in 19817. ey havedefined burnou syndrome as having hree dimensions o emoional exhausion,depersonalisaion and a eeling o lack o personal accomplishmen8. Emoional Exhausion (EE) is he cenral componen o he syndrome, and or mos pracical

purposes, he erm Burnou is synonymous wih he experience o exhausion.

Depersonalizaion (DP) is an atemp o pu disance beween onesel and servicerecipiens by acively ignoring he qualiies ha make hem unique and engag-ing people. I is characerised by a negaive and unaffeced atiude owards heirpaiens. Feeling o lack o Personal Accomplishmen (PA) arises when one’s effi-ciency is compromised by lack o adequae resources o cope. A high level o burnouis defined by a high level o EE, high level o DP and low level o PA.

In he 10h revision o he Inernaional Classificaion o Diseases (ICD 10) he erm‘burnou’ has been described under Z.73.0 as ‘Burnou-sae o vial exhausion’ 9.Occurrence o burnou syndrome in diverse occupaions, e.g. in social workers, advi-sors, eachers, nurses, laboraory workers, speech herapiss, docors and deniss,police and prison officers, sewardesses, managers, and even in housewives, sudensand unemployed people has also been described10. In mos o hese occupaions hecombinaion o caring, advising, healing or proecing, coupled wih he demands oshowing ha one cares is o cenral imporance.

Occupaional psychosocial and psychomenal sress acors or burnou eio-paho-

genesis have been discussed, namely pressure o ime, overime and shiwork, lacko auonomy as well as mobbing, economic pressures, and muliple asks such as job,amily and leisure aciviies. In addiion, he imporance o personal compeence, par-icularly in he so-called eriary secor, is coninually increasing (e.g. communicabil-iy, being able o work in a eam, rusraion olerance, service orienaion, flexibiliy).

e climae in medicine is also changing: producion pressure lead o less docor-paien conac ime, an increase in paperwork, a rend owards managed care,reduced governmen spending, diminished physician resources and increased

medical school uiion11

. A he same ime, paiens have become more srenuous anddemanding, have higher expecaions, and no longer have he same respec as heyused o have or docors. All hese acors no only conribue o lower job saisac-ion bu can also cause a decline in auonomy and conrol in docors.

Undeniably, high job saisacion can be a poenial buffer agains he developmen o burnou. When docors’ ‘invesmen’ in heir work– which may include ime, effor,empahy, or atenion – are reciprocaed by paiens showing graiude and appreciaionaer a consulaion, or when paiens recover aer reamen, he invesmens and ou-

comes are balanced, and equiy exiss. Lack o reciprocaion conribues o imbalance. According o he job-srain model10 , which has been esablished or many years inoccupaional medicine as a sress - srain concep, a high level o srain can resul




rom he accumulaion o psycho-menal/psycho-social sress and a lower level osress olerance, which in his conex is o be regarded as “negaive sress”. When“negaive sress” becomes chronic and is no deal wih adequaely i leads o adverseeffecs on he healh. No only do psychological and social acors play a role, bu soalso do biological and biochemical acors. Above all, hormonal and endocrinologi-

cal changes, paricularly a permanen increase in he corisol level and disurbancesin he hypohalamic - piuiary -adrenal conrol sysem are also being evaluaed.

Risks o Burnou among Docors

e risk o burnou is influenced no only by he exen o he sress acors anddeficis in personal resources, bu above all by “social suppor” sysems and “coping”sraegies. Primary personaliy srucure ha leads o burnou includes: idealism,perecionism, imidiy, insecuriy, emoional insabiliy, inabiliy o relax .

Negaive acors which influence he individual sress olerance are: inadequae orlacking sraegies o deal wih sress, disappoined expecaions/ negaive experi-ences, inadequae suppor due o a lack o social relaionships/parnerships, lack opaien graiude or medical care provided, risks o liigaion.

A sudy by eeve e al12 disinguishes wo ypes o aneshesia rainees as judgedsuccessul and unsuccessul on he basis o he assessmens by seniors and havecompared heir personal profile. e successul rainees demonsrae greaer deach-men, menal quickness, drive and deerminaion, sabiliy, high sandards, sel-

sufficiency, openness and sel-conrol. ese personal resources may buffer againssress percepion.

Social suppor11 is believed o be a buffer agains sressul work lie. However, whenhere is litle ime le o spend wih your amily, he opporuniy or help rom yourspouse or parner is limied. ime away rom work has been idenified as a conribu-or o burnou reducion, as i has been shown ha par ime general praciionershave significanly less signs o burnou compared o heir ull-ime counerpars13.

In addiion, gender differences in his conex are worh urher commen. Female

physicians may be involved wih home and amily organisaion o a greaer exenhan heir male counerpars. Hence, hey may have beter social suppor bu alsohigher workload and less ime or hemselves. Gender however, has no been showno be a srong predicor o burnou14. Maslach8 surveyed 2,247 male and 3,421 emaleparicipans during he implemenaion o he Maslach Burnou Invenory (MBI)model and concluded ha no significan difference was ound.

Docors are he leas likely o admi ha hey are under sress hemselves11. Sel-careis no par o he docor’s proessional raining and is ypically low on heir lis o

prioriies. In ac, many docors don’ even have heir own general praciioner. Earlyrecogniion o heir problems prevens urher deerioraion o heir menal andphysical healh and more specifically he developmen o burnou.




Maniesaions o Burnou Syndrome

Sympoms10 o burnou include concenraion and memory disurbances (a lack oprecision, disorganizaion), a lack o drive and personaliy changes (a lack o ineres,cynicism, aggressiveness). Severe disurbances are anxiey and depression, whichcan culminae in suicide. Also he developmen o addicions (e.g. alcohol, medi-cines) has been associaed wih burnou15,16.

A endency owards subsance abuse – alcohol, drugs and pharmaceuicals, maydevelop as almos 10% o healh proessionals develop a subsance relaed disordera some poin in heir lives. e access o pharmaceuicals, hrill seeking, and sel-reamen o pain increase he risk or addicion17,18.

Depressive eelings are oen he consequence o burnou sympoms wih suicidesomeimes as he final disasrous oucome19. eir access o drugs, in combinaion

wih hese depressive eelings, could explain why his ragedy is more prevalenamong people working in medicine han mos oher proessions. Common somaicsympoms10 are headaches, gasro-inesinal disorders (irriable somach, diarrhoea),or cardio-vascular disurbances such as achycardia, arrhyhmia, and hyperonia.

Social consequences manies as wihdrawal a he workplace, parner/ sexual prob-lems and social isolaion. From he perspecive o sociey, here is an increased risk orepeaed or long periods o absence rom work and early invalidiy. All his pus noonly he individual a risk, bu also compromises on paien saey.

Paricularly depersonalisaion and reduced personal accomplishmen can havedevasaing effecs. e more cynical atiude can resul in a decrease in empaheicconcern owards heir paiens, a psychological wihdrawal rom work, irriabiliyand lack o paience11.

e reduced eeling o compeence ha is associaed wih burnou can resul in adecreased subjecive and objecive perormance evaluaion in docors as well asnurses. Paiens show lower adherence o physician’s advice rom docors wih low job saisacion, who are unhappy, cynical and irriable.

Moreover, physicians wih low job saisacion have been linked o inappropriaemedicine prescribing paterns and o a boundary violaion or unehical physicianconduc, such as sex wih paiens, violaion o paien confidenialiy, or prescrib-ing or sel 11.

Differenial Diagnosis

I may be firs required o separae primary psychiaric disorders, i.e. hose indepen-den o exogenous acors, rom burnou. Furhermore, chronic somaic diseases,

such as chronic inecions (e.g. viral hepaiis), endocrinopahy (e.g. hyroid disor-ders, Addison’s disease), auo-immunopahy, umours or he so called chronic ai-gue syndrome (CFS) mus also be considered.




Workplace relaed measures are:

• creation / preservation of a “healthy working environment”

• time management

• communication style of leadership

• reviving values, motivation and goals• learning orientation- motivation of individuals to learn and increaseheir compeence

• recognition of performance- praise, appreciation, reward programs, money

• training of managers (“key role” of the boss in burnout prevention)

Person-oriened sraegies are:

• Carrying out of “suitability tests” before job training

• Peer Support groups, conducting specic programmes accompanying the worko persons rom risk groups (e.g. Balin groups or eachers and docors)

• Regular occupational − medical/psychological monioring (e.g. esablishmeno a special “job-sress” checkup or he early recogniion o burnou)

Engagemen24 represens a desired goal or any burnou inervenion. I promoes asysem which is likely o enhance employees’ energy, vigor and resilience; promoesheir involvemen and absorpion wih he work asks; and ensures heir dedicaion

and success on he job. A srucured process, C EW (Civiliy, espec, and Engagemen a Work)25 , has been demonsraed o improve civ iliy among coworkers, ulimaely ransormingino improvemens in he cynicism dimension o burnou, job saisacion, organi-zaional commimen, and managemen rus. egular organizaional assessmeno well-being in employees provides evidence on he overall healh and well-beingo he organizaion, as well as indicaors o areas o srengh and areas o possibleproblems ha need o be addressed.

Burnou is more han jus exhausion. ere are five more possible domains o jobsressors han workload isel ha may affec developmen o burnou. In such condi-ions, an organizaional checkup process is one effecive way o showing hese orga-nizaions wha he oher possibiliies are in heir case.

Maslach e al8 have proposed six areas o “individual-job” fi model which include:a susainable workload, eelings o choice and conrol, appropriae recogniion andreward, a supporive work communiy, airness and jusice, and meaningul work.is model ocuses on he degree o mach, or mismach, beween he person and six

domains o his or her job environmen. e greaer he gap, or mismach, beweenhe person and he job, he greaer he likelihood o burnou; conversely, he greaerhe mach (or fi), he greaer he likelihood o engagemen wih work.




Alhough one is emped o believe ha work load may be he primary acor or burnou, i may no be rue in al l cases − oher areas, such as airness, or conrol,or workplace communiy, may urn ou o be he more criical poins! esearchrials and projecs aimed a evaluaion o he ineracions o hese six areas mayconribue richly owards he uure developmen and expansion o Weingology.

Burnou Sudies among Aneshesiologiss

In Romania, a survey 26 on prevalence o Burnou Syndrome was carried ou on Aneshesia Inensive Care (AIC) physicians. eir average working week was 70hours. High levels o burnou by using MBI scale was ound in 29.85% o respon-dens, while moderae levels in 53.03% and low levels in 17.12%. A high level o emo-ional exhausion (EE) was ound in 34.2%, depersonal izaion (DP) 38.4% and a lowlevel o personal accomplishmen (PA) in 37.7% o he docors rom he survey. ey

ound a saisically significan (p 0.027) higher prevalence o EE in emale anaeshe-iss (mean 23.82) compared wih male docors (mean 19.53).

Workload, AIC specific work and daily hassles were ound o be predicive acors ordevelopmen o EE. In addiion, managerial role among AIC personnel was oundo be a srong predicor or DP. e burden o he difficul work mean working wihcriically ill paiens (rauma paien; sepic paien; exposure o conaminaion; burned and brain dead); working under pressure; being acive and aler all he ime;expecing high qualiy resuls in lives saving, keeping up wih he new echnologyand he modern reamens; needing ime or coninuing medical educaion; and being always approachable o paiens, relaives, colleagues.

e atending physicians had longer working hours per week han he residens bu he level o exhausion was no significanly differen. Despie he ac ha heomanian AIC physicians worked more hours per week han oher specialies, heydid no ideniy a relaionship beween his independen variable and burnou.

Exhausion is a resul o physical, menal and emoional aigue. ey lis several causeso exhausion: job demands (severiy o paien problems), poor communicaion wih

people on differen levels o he proessional scale (head physicians, subordinaes, col-leagues, and paiens), unair or unsaisacory rewards, oo much responsibiliy andoo litle suppor, or he need o quickly acquire new skills and knowledge.

All hese findings reinorced he need or: a higher number o omanian A IC physi-cians o decrease he number o working hours, coninuous medical educaion, good AIC resources, and sress managemen educaion. A limiaion o he sudy was haonly 15% o he omanian AIC docors were surveyed, hereore he resuls may no be represenaive or he whole populaion o omanian A IC docors.

A sudy o French medical inensiv iss ound a much higher incidence o burnou27 ascompared o he above menioned sudy o omanian anesheic inensiviss. Usinghe MBI, a high level o burnou was idenified in 46.5% o he respondens, 23.3%




repored a low level o burnou and 30.2% indicaed a moderae level o burnou. Abou 50% o he inensiviss exhibiing a high level o burnou wished o leave heir jobs. However, or people who sayed on he job, burnou lead o lower produciv iyand effeciveness a work. Consequenly, i was associaed wih decreased proes-sional saisacion and reduced commimen o he job or he organizaion. Conflics

wih coworkers (wih anoher inensivis or nurse) were associaed wih he higherlevel o burnou. In conras, good qualiy o he relaionships wih nurses and chienurses was associaed wih a lower degree o burnou.

Prevalence o sress and burnou in anesheiss in Belgium Universiy Nework has been sudied by Nyssen e al 28. By using he Psychological Sae o Sress Measure(PSSM-A) scale29 , hey revealed a moderae level o sress in anaesheiss ha wasno higher han in oher proessional groups (median sress level in anesheiss was50.6, policemen 50.6, office workers 51.3; levels greaer han 60.0 represen severe

sress). Almos 17.9% o he anaesheiss were in he high sress-level group and72.8% and 9.3%, respecively, in he medium- and low-level groups. e hird-yearanesheiss in-raining showed he highes sress scores (his year o raining is par-icularly criical because his is when he rainees sar o work on heir own in heoperaing room, calling or help when problems occur).

e mos requenly repored healh problems (Physical Healh Scale30 o ideniy somenegaive healh consequences) were headache (15%), somach ache (12.5%), inesinalache (7%) and ulcers (6%). e median score or burnou (MBI-Emoional Exhausion

subscale) was 27 (range 10±59), which corresponds o a moderae level according o henormaive scores. 40.4% o he anaesheiss were in he high-level burnou group and44.4% and 15.2%, respecively, in he medium- and low-level groups.

Surprisingly, anaesheiss under 30 years o age showed he highes burnou raes.e lack o empowermen and he lack o suppor/qualiy supervision, by decreasinghe individual’s abiliy o cope wih sressul siuaions, could explain he high scoreor emoional exhausion ound in he young anaesheis group. rough he Work-ing Condiions and Conrol Quesionnaire (WOCCQ)31 hey ound ha he anaes-heiss el a lack o conrol mainly over ime managemen (overime, difficuly ak-ing a break and planning non-clinical asks such as lecures, scienific research, ec.), work planning (difficuly in geting he work schedule in advance, requen changesduring he day), and risks.

ere was a negaive correlaion beween sress and conrol scores. Men indicaed ahigher level o empowermen and conrol over risks. e mos requen problemaicsiuaions (he Problemaic Job Siuaions Quesionnaire, developed by he sameauhors o supplemen WOCCQ) cied were a) relaed o `work organizaion: 35%(e.g. unpredicabiliy o schedules, lack o coordinaion wihin he eam, lengh o

workdays, inappropriae super vision); b) inherenly difficul job siuaions: 25%(e.g. difficul inubaion or recovery); c) inerpersonal relaionship conflics: 17%(e.g. lack o communicaion wihin he eam, wih he surgeon ec.); d) doub and




pressure on responsibiliy: 16% (e.g. ear o human error, inappropriae compeence)and e) lie-career worries: 7%. e problemaic siuaions a work and ways o solve/cope up wih hem have also been deal wih laer in his chaper55.

Ineresingly, anaesheiss el more confiden abou heir uure han did oher

workers. e auhors discuss ha sress levels can be miigaed by having highauhoriy and high saisacion in he job32,33. In he sudy, anaesheiss reporedhigh levels o job saisacion, job challenge, work commimen and empowermen, which in urn may have moderaed he sress levels. ey conclude by proposing hamos o he sressors revealed in heir sudy are hings ha he hospial and depar-men adminisraion can do somehing abou in heir managerial role since he majorperceived demands are on work and ime managemen.

Advice and specialis counsellors can suppor rainees when problems occur. Acci-den and inciden conerences, in which anaesheiss presen he criical siuaionshey encounered, could give he opporuniy o discharge overload and emoionalsress. e simulaor, which is increasingly used or crisis-managemen raining, can be used or improving communicaion and problem-solving sraegies.

In Ausria, Lederer e al34 have ried o evaluae he relaionship beween work-ing place condiions and burnou in 89 anesheiss working in he UniversiyHospials. Working condiions were invesigaed wih he Insrumen or Sress-relaed Job Analysis35 (ISTA, Version 5.1, short form, Vdf Hochschulverlag AG,EH Zurich, Swizerland). In heir sudy, workload was assessed as very high by45 (50.6%) anesheiss, moderaely high by 32 (36.0%) and low by 12 (13.5%)anesheiss. ree (3.4%) anesheiss, wo males and one emale, were diagnosedo have burnou syndrome. All o hem were in he same age group (31−40 years).is age group handles sress no only a workplace (high pressure o perorm-career / promoion / less senioriy) bu also handles sress in privae spheres (e.g.conronaion wih growing children, purchase o propery, and deah o relaives).Middle-aged persons are very suscepible o develop a “grea hirs or lie”, con-neced wih he ear o having missed somehing imporan. Addiionally, weny

five percen (23 o 89) o he respondens were ound o be a risk o developing burnou syndrome.

Anesheiss a risk or burnou had more physical complains, greaer job dissais-acion, saisically significan lack o PA scores, and repored a decreased abiliy oproblem solving. Anesheiss no a risk or developing burnou syndrome showedsignificanly more regulaion possibiliies a heir working place, being able o handlehigher complexiies in work ye having conrol over heir work a he same ime.

According o ISA, i means ha he availabiliy o resources such as one’s own influ-

ence on work pace and work schedule and he abiliy o conac and communicae wih ohers a work seems o be an imporan orm o proecing onesel agains hedevelopmen o burnou syndrome. I also has a srong influence on job saisacion.




Worh noing is heir inerpreaion o DP when hey say ha i iniially serves asa proecive mechanism o avoid emoional aigue bu subsequenly i impairs hephysician/paien relaionship.

ey conclude wih he noion ha work environmen and job condiions conribue

o he developmen o a burnou syndrome o a greaer exen han do personaliysrucure. Hence, prevenion o working place circumsances, e.g. change o basic job condiions, are o greaer imporance in prevening burnou syndrome han are behavioral prevenion, e.g. a more healhy behavior o he individual36.

A urkish survey o 159 anaeshesiology rainees37 was conduced o undersand hereason behind increasing incidence o suicide and burnou among heir rainees (14anaeshesia rainees and residens had commited suicide in he previous 5 years).e survey was based on MBI and Perceived Sress Scale38. I revealed ha sress was very high in he early years o raining.

As he number o aneshesiologiss was well below he need in urkey, nurse anes-heiss and aneshesia echnicians were he main providers o aneshesia in heircounry. egardless o heir raining, hese skil led nurses and echnicians were ableo handle mos o he criical siuaions wihou he help o he residen. Lack o con-rol o rainees in heir own field was causing eelings o inadequacy and low scoresor sense o personal accomplishmen.

Perceived sress was decreased in older ages. Ageing and emale sex were associaed

wih lower emoional exhausion and depersonal izaion scores respecively, and boh were associaed wih higher personal accomplishmen. Ineresingly, havingwo or more children was associaed wih significanly high personal accomplish-men bu low depersonalizaion and emoional exhausion scores.

An Ausralian survey o 422 anaeshesia specialiss was conduced39 o assess helevels o sress and job saisacion among anaeshesiologiss in Ausralia. Highesrepored sress levels were in he ages 41-50 years. Anaesheiss wihin he ages30–60 years were able o prioriise home ⁄ work commimens beter han heir younger or older praciioners. Female anaesheiss repored higher sress levels onhe visual analogue scale and ended o reac o sressul siuaions by raning andraving more han male anaesheiss. For hem, group cohesion was more imporanin reducing sress a work and hey were also able o prioriise home ⁄ work commi-mens beter han he males.

ime consrains (pressure o ge liss going on ime, arriving early or preoperaiveassessmen o day care paiens, working uncerain hours) was he sronges acorconribuing owards sress, he mos common coping response being discussinghe problem wih colleagues and parners, or being irriable. Having experienced

assisans and beter work organizaion was quoed as he mos avoured mehod oreduce sress in he workplace. Mean sress level o 4.1 and job saisacion score o7.1 (scale o 0-10) was recorded by he survey.




Saisying componens o heir specialiy were providing services o high sandard,immediacy o effecs and pracicaliy o work. However, he percepion abou heir job being imporan is geting eroded. e lack o reerrals by surgical colleaguesand being considered as expenses raher han asses by hospial managemen eams were cied by many as areas o disconen. e sudy idenified ha burnou was

no uncommon in he group o Ausralian-based anaesheiss. I appeared ha Ausralian-based special is anaesheiss had indicaors o burnou ha were con-sisen wih oher clinical groups, ye a he lower end o he scale or burnou. Highemoional exhausion, high levels o depersonalisaion and low levels o personalachievemen were seen in 20, 20 and 36% o respondens, respecively.

In India40 , abou 41.7% o he anaesheiss (oal 115 surveyed) el overworkedmos o he imes and 29.6% el overworked someimes. Abou 50% o respondensel hey were sressed ou, hough he average daily working hours ranged rom

5-12 hours. Alhough 47.2% were saisfied wih heir earnings, only 1.7% claimedha hey received excellen remuneraion while 26.1% believed hey received poorremuneraion. Almos 60% anaesheiss had a good relaionship wih surgeonsand nearly hal o he anaesheiss el ha hey did no ge due recogniion orheir services.

Sixy one o he anaesheiss repored spending qualiy ime wih he amily despieheir hecic work schedules. In spie o he sress, overwork and personal sacrifices,an overwhelming number o hem (82.6%) enjoyed heir work. Common ailmens

repored were backache (n=19), acid pepic disease (n=14), hyperension (n=12),diabees mellius (n=8), depression (n=4) and coronary arery disease (n=2).

e auhors conclude by saying ha good inerpersonal relaionships, communicaionskills and high emoional quoien are required or he pracicing anaeshesiologiss ohrive and recommend periodic vacaion wih amily o desress hemselves. A limia-ion o his sudy was ha i was conduced on he paricipans o a conerence a aregional venue, and hence may no be represenaive o he whole populaion.

In Nigeria , 55 anaeshesiologiss were surveyed41 or heir levels o job saisacion

and sress. O he 46 responders, no gender differences exised in job saisacion ordissaisacion bu he older respondens (age range 40–49 years) were more con-ened wih heir job as aneshesiologiss. Overall, 27 (58.7%) o he aneshesiolo-giss were saisfied (grade 3–5 on Liker Scale) wih heir job. While 8.7% were verysaisfied (grade 5), 6.5% were very dissaisfied (grade 1) wih heir job. e hoursspen a work per week or aneshesiologiss below he rank o consulan was 75–88h. In he pas 1 year, 54.3% had gone on vacaion and only 34.8% engaged in one ormo sporing aciv iy.

ime pressure (leading cause), long working hours wih complains o insufficiensleep, and employmen saus (medical officers, residens and senior regisrars whohad uncerain job uure) were he main sressors idenified. O concern was ha




21.4% (6 ou o 28) regisrars would consider oping ou o anaeshesia residencyprogram while 32.6% were ready o seek anoher career i given anoher opporu-niy. Sress was managed mainly by praying or seeking spiriual help. e auhorsconclude by suggesing ha having a definie closing ime would urher enhanceheir job saisacion.

A survey in Finland42 was conduced o measure he degree o sress and burnouamong 550 specialis anaeshesiologiss (328 responded), and consequences o sressamong hem. A modified Occupaional Sress Quesionnaire 43 , M BI and a series ooher quesions were used. e mean age o he group was 47 years. Sixy-eigh percen o he working anaeshesiologiss el sressed. Perceived sress increased wih workload (p = 0.02). e main sel-repored reasons or sress were: work (in 64%),combining work and amily (48%), healh (17%), amily (16%), personal relaion-ships (13) and financial issues (12%) among he respondens.

ime consrains, work overload, organizaion issues and he ear o harming paiens were he main “worries a work ”. On-call sress relaed sympoms included exhaus-ion, irriaion, yawning, sleep disurbances, eeling cold, memory disurbances andheadache. No surprisingly, here was a saisically significan all in hese sympomsaer a wo week vacaion period. Female gender and younger age group had highersress levels. On-call workload significanly affeced he levels o EE and Burnou, wih EE repored by 32% in he lowes and 68% in he highes workload caegories, while burnou by 18% and 45%, respecively.

No saisically significan gender differences in burnou were recorded. Being on-call was he mos requenly repored reason or perceived sleep deprivaion. Alarm-ingly, almos 25% o he respondens (general populaion figure o 10%) had con-emplaed suicide, while 2% had seriously planned i as well. Anaesheiss had highproessional efficacy scores, explained by heir long careers and good proessionalskills, hus lowering he overall burnou indicaor.

e auhors quoe ha in Finland, suicide (17%) and accidens (11%) were over-represened causes o deah among anaesheiss in comparison wih oher physi-

cians and he general populaion! An Anaesheis’s ime schedule sill dependedon he schedules o surgeons or oher disciplines, lowering heir proessional con-rol and efficacy.

e sudy concludes by proposing ha inervenions are needed o shoren he on-call work period, limi nigh shis, and monior consequences o work-relaed sress by developing mehods or is early deecion.

In he Unied Saes o America44 , a naionwide cross secional sur vey o 117 anaes-hesiology chairs was conduced o ideniy poenial sressors or heir deparmens

and he incidence o Burnou. Almos 59% o he chairs were a a risk o developingBurnou Syndrome. e oremos sress provoking issues or hese academic chairs were aculy reenion and deparmen finances.




O he 93 respondens, 34% repored high curren job saisacion, hough i ellsigni icanly over he pas 1 and 5 years in academic chair posiion. W hen heir work lie balance was assessed, 44% ex pressed moderae o high dissaisacion, while only 13% repor ed he same dissaisacion levels wih heir sa lary. heyexpressed moderae level o conrol over heir proessional lives and viewed heir

impac in a avorable manner. O 93 aneshesiology chairs, 26 (28%) me hecrieria or high burnou, wih an addiional 29 (31%) in he moderae o high burnou caegor y. Age, sex, i me as a chai r, i me worked week ly, and perceivedeeciveness did no dier beween chairs in he high-risk compared wih helower-risk caegories.

High-risk chairpersons repored a greaer likelihood o sepping down wihin henex 2 years, demonsraed lower personal efficacy scores, had low curren job sais-acion, and were more affeced by sressors acing he deparmen. Spouse suppor

scores were also significanly lower in high risk burnou group, wih heir spousesailing o undersand he exra hours o work being pu in by hese chairs. Decreasedcurren job saisacion and low spousal/significan oher suppor were idenified asindependen predicors o a high risk o burnou in his sudy.

Sress relaed o budgeary concerns, aculy reenion, and accrediaion/compli-ance issues associaed wih he residency program were among he larges sourceso sress. O special concern here is he ac ha aneshesiology chairs exhibied ahigher rae o burnou compared wih chairs o obserics/gynecology 45 , oolar yn-

gology 46

, and ophhalmology 47

in similar sudies. e degree o depersonalizaionand emoional exhausion was higher in aneshesiology chairs han in chairs o hesedeparmens. e imporance o suiable menorship in handling sress and admin-israive challenges has also been discussed48.

e auhors suppor he convicion ha physicians who culivae heir personaland proessional well-being are less likely o develop burnou or will a leas dimin-ish is impac on heir lives49. e developmen o well-being should be simulaedhroughou one’s career, always being careul o minimize he delayed graificaion

mechanism used so requenly by physicians50

.In Canada , a survey o 945 aneshesiologiss was conduced51 o assess he overall job saisacion among aneshesiologiss. Perceived surgeons’ and paiens’ atiudesowards aneshesiologiss were also analysed. 75% o he respondens raed heir jobsaisacion highly (graded 4 and 5 on Liker scale). 10% o he aneshesiologiss were oally saisfied, whereas 1% o he sample were oally dissaisfied. Averagehours a work per week were 59 ± 12 hr.

Job saisacion among aneshesiologiss was significanly associaed wih inellec-

ual simulaion, good qualiy o paien care and ineracion wih paiens. Compar-ing saff aneshesiologiss and residens, he residens were more saisfied overall.ere were no significan differences in saisacion beween genders or beween




sress, despie he problem no being solved. Main problems idenified were heinheren difficulies in anaeshesia like difficul cases or siuaions, making ehical lydifficul decisions and lack o respec rom oher docors/surgeons.

Various problem solving strategies described were simplifying the work in hand, pri-

oriising i and saring rom he mos obvious and simple ask, seeking suppor romcolleagues, delegaing work and having a good communicaion wih surgeons and saff.Coping sraegies described were acceping difficul siuaions as par o one’s work, rec-ognising one’s own limiaions (individual compeence and o he healhcare sysem),saying “no” o excessive demands and limiing he ask one can ake up saely.

e auhors conclude ha here is ample evidence ha he anaesheiss’ work isdifficul and poenially very sressul. Hence, hey need well-uncioning copingsraegies. Anaesheiss, especially he young consulans o oday (work ime direc-ives limiing heir oal clinical exposure in heir raining years) someimes may nohave he experise necessary or some o he difficul cases ha hey will encouner a work. ey hereore have o develop heir abiliy o cope wih uncerainy and error,a personal qualiy ha belongs o proessionalism56. Young physicians should also behelped o develop ino specialiss who are conen wih heir work. Enjoying workpromoes he well-being o docors and heir paiens57.

A he World Federaion o Socieies o Anaeshesiology (WFSA), Te Proessional Well-being Commitee (PWC) is acively involved in research and developmen omehodologies o promoe well-being a work among anaeshesiologiss across he world.

In he spring o 2010, he PWC conduced an invesigaion2 involving 120 member-socieies o WFSA, using a ques ionnaire, whose objec ive was o ideniy heincidence o occupaional healh problems among he members o a specific socieyand he approaches used by hose socieies o rea he occupaional healh o anes-hesiologiss. esuls showed ha more han 90% o Naional Anaeshesia Socieiesconsidered he Burnou Syndrome as a problem among heir members, bu only 14%had developed some sor o sraegy o ace i.

e PWC o WFSA also organized a special session on “Proessional Well-beingin Anaeshesiologiss” a he World Congress o Aneshesiologiss, 2012 a Buenos Aires, Argenina. opics covered included suicidaliy, chemical dependence, ageingand burnou among anaeshesiologiss. e need or creaing awareness on Burnouand sress in our proession, as well as coming up wih laws/recommendaions/leg-islaions wih help o world organizaions and enorcemen bodies (WFSA, WHO, ASA, cenral-provincial governmens, ec) was discussed.

Conclusion

Burnou Syndrome in Anaeshesiologiss is as coming up as a significan chal-lenge, wih is prevalence considered o be around 20-50 % worldwide. Burnouhas been preerenially seen in occupaions involved wih human care. Anaeshe-




siologiss by proessional condiioning appear o be a vulnerable group. ey eelobligaed o respond o majoriy o paien care requiremens in he perioperaiveperiod, seldom geting credi or he same. e increased work demands in ace ounme graiude rom boh paiens as well as clinical colleagues manies as sressand burnou in he anaeshesiologiss.

Depersonalizaion has been used as an imporan componen o Burnou by Maslachand colleagues in raming he Maslach Burnou Invenory. However, we eel ha a fineline exiss beween being considerae owards our paiens’ saey on one hand, and ingoing overboard and being overly atached wih one’s work owards he paien.

Expecing rewards or graiude aer inimae involvemen comes naurally, and sodoes sress rom unme expecaions. Being rigid, cynical, over sincere, perecionisand emoionally atached wih paiens under our care may acually resul in “Per-sonalizaion” and develop ino Burnou over ime. Hence, o an exen, being sae a work and working w ih a “neural approach owards one and all” is proposed here asone o he means o couner burnou.

Having an unbiased, impersonal response o mos o he aneshesia work, includ-ing preoperaive assessmen, planning, execuion, procedures, pos operaivemanagemen and handling o criical evens, wihou negaively inflicing harmo he paien is proposed. When one’s care is delivered wihou emoions, ego,sel-eseem or pride, resuls may acually urn ou beter or he paien as well ashe reaing clinician.

A limiaion o his “Personalizaion” heor y may be he observaion o high inci-dence o burnou in young aneshesia rainees who may no appear o have ye worked or sufficien ime in anaeshesia o accumulae sress. A combinaion o lowpersonal accomplishmen, criical incidens and lack o adequae social/proessionalsuppor may precipiae burnou aser in such populaion.

Lack o mauriy (personal coping resources) in he young rainees and he hrill odo complex asks independenly may requenly push hem ino high risk siuaions,adding o heir sress levels and ulimaely, Burnou. Hence, we advocae ha i’sime o move away rom “Personalizaion” model o acually one o “Depersonaliza-ion”. Developmen o ools and surveys wih negaive correlaion o high poins in“Personalizaion” as a componen o Burnou raher han Depersonalizaion would be an appropriae sep in his direcion.

Mos o he sudies surprisingly reveal ha he anaeshesiologiss have a high jobsaisacion and are a conened lo. However, lack o conrol over ones work andlack o organizaion a work place accoun or significan sress and burnou amonganaeshesiologiss. ole o communicaion, eamwork/camaraderie wih colleagues

and nursing saff, availabiliy o skilled assisance, and mos imporanly, inerven-ion by managemen people o improve and organise working condiions or heanaeshesiologiss appear o be some recommended measures.




Men appear o have a higher level o empowermen and conrol over risks, while women are seen o have a higher incidence o emoional exhausion , maniesingas higher endencies owards Burnou. I any specialiy, e.g. Anaeshesia ends ohave a majoriy o women enering he specialiy han he number o men, i couldpoenially il he numbers in avour o a higher incidence. Hence, i may be pruden

o direc more resources, social suppor and iniiaives owards rehabiliaing emaleanaesheiss and preven he increased prevalence o Burnou in our specialiy.

Summary

o summarize, a new erm “Weingology” has been coined o promoe imporance ohis subjec in he currenly demanding work environmen. Weingology is all aboumoving away rom a negaive “Burnou Model” owards one o healhy encouraging“Job engagemen”. Sudies which can help us come up wih inervenions o reduce

daily adminisraive work hassles, give us beter conrol over our ime and work, as well as promoe a posiive environmen o job engagemen are urgenly needed. “Per-sonalizaion eory” has been proposed here as a hindrance o work reedom, andha Depersonalizaion may acually be beneficial! Naional policies o preven andhandle he Burnou Syndrome and relaed pahologies in healh care proessionalmus be developed.

Reerences

1. htp://en.wik ipedia.org/wiki/Hisory_o_general_aneshesia. Accessed 21/06/13.

2. Neo GD, Bonne F, Howard S, Gupa P, e al. Proessional Well-being Work Pary o WFSA: I is ime o ink and ake Acion egarding he Occupaional Healh o Anes-hesiologiss. ev Bras Anesesiol (Ediorial) 2011; 61: 4: 389-396.

3. Moore , Gupa P, Neo GD. Occupaional Faigue: Impac on Aneshesiologis’s Healhand he Saey o Surgical Paiens. ev Bras Anesesiol. 2013;63(2):167-169.

4. Nicomachean Ehics. htps://en.wik ipedia.org/wiki/Nicomachean_Ehics. Accessed1/07/13.

5. htp://ww w.bergen.edu/acul y/gcronk/arisolenoes.hml. Accessed 1/07/13.

6. Freudenberger HJ. Saff burnou. JSoc Issues 1974; 30:159-165.7. Maslach C, Jackson SE, Leier MP. 1996. Maslach Burnou Invenory Manual. Palo Alo,

CA: Consul. Psychol. Press. 3rd ed.

8. Maslach C, Schaueli WB, Leier MP. Job Burnou. An nu. ev. Psychol. 2001.52:397–422.

9. htp://apps.who.in/classificaions/icd10/browse/2010/en#/Z70-Z76. Las accessed20/07/2013.

10. Weber A, einhard AJ. Burnou syndrome: a disease o modern socieies? Occup. Med.2000; Vol. 50, No. 7, pp. 512-517.

11. De Valk M, Oostrom C. Burnout in the medical professioncauses, consequences andsoluions. Occupaional Healh a Work. 2007;3(6).




12. Reeve PE, Vickers MD, Horton JN. Selecting anaesthetists: the use of psychological testsand srucured inerviews. J Soc Med 1993; 86:400–403.

13. irwan M, Armsrong D. Invesigaion o burnou in a sample o Briish general praci-ioners. Br J Gen Prac. 1993;45(394):259-260.

14. Walt N VD. Burnout: when there is no more fuel for the re. South Af r J Anaesth Analg,

2013;19(3):135-6.15. McNamee , een I, Cockhill CM. Morbidiy and early reiremen among anaeshe-

iss and oher specialiss. Anaeshesia. 1987;42:133–40. [PubMed: 3826586].

16. Gravensein JS, ory WP, Marks G. Drug abuse by aneshesia personnel. Anesh Analg.1983;62:467–72. [PubMed: 6601467].

17. Gundersen L. Physician burnou. Annuals o Inernal Medicine. 2001;135: 145–148.

18. Weeks AM, Buckland M, Morgan EB, Myles M. Chemical dependence in anaesheicregisrars in Ausralia and New Zealand. Anaesh Inens Care. 1993;21:151–5.

19. Helliwell PJ. Suicide among anaesheiss in raining. Aneshesia. 1983;38:1097.20. Isaksson E, Gude , yssen , Aasland OG. Counselling or burnou in Norwegian

docors: one year cohor sudy. Br Med J. 2008;337(7679):1146-1149.

21. Peerson U, Bergsröm G, Samuelsson M, e al. eflecing peer suppor groupsin he prevenion o sress and burnou: randomized conrolled rial. J Adv Nurs.2008;63(5):506-516.

22. Jackson SH. e role o sress in anaesheiss’ healh and well-being. Aca AnaeshesiolScand. 1999;43(6):583-602.

23. Fields AL, Ceurdon T, Brasseux CO, e al. Physician burnou in pediaric criical caremedicine. Cri Care Med. 1995;23(8):1425-1429.

24. Maslach C. Burnou and engagemen in he workplace: new perspecives. e EuropeanHealh Psychologis. 2011;13(3): 44-47.

25. Osauke, ., Mohr, D., Ward, C. Civiliy, espec, Engagemen in he Workorce(CREW): Nationwide Organization Development Intervention at Veterans Health Ad-minisraion. Journal o Applied Behavioral Science, 2009; 45, 384-410.

26. Hagau N, Pop S. Prevalence o burnou in omanian anaeshesia and inensive carephysicians and associaed acors. J om Anes erap In 2012; 19: 117-124.

27. Embriaco N, Azoulay E, Barrau , e al. High Level o Burnou in Inensiviss. Prevalenceand Associated Factors. Am J Respir Crit Care Med 2007; Vol 175. pp 686–692.

28. Nyssen AS, Hansez I, Baele P, e al. Occupaional sress and burnou in anaeshesia. Bri-ish Journal o Anaeshesia.2003;90(3):333±7.

29. Lemyre L, essier , Fillion M. Mesure de Sress Psychologique (MSP): manueld’uilisaion. Canada: Universie de Laval; 1990.

30. Eienne A-M. Impac de la readapioncardiaque sur les paiensayansubi un ponageaor-o-coronarien. [ease de docora]. Belgique: Universie de Liege; 1997.

31. Hansez I, De Keyser V. El WOCCQ: una nueva herramienta en el estuche de instrumen -os conra los esresores laborales. El caso de los rabajadores de servicios publicos enBelgica. ev Psicol rabajo Y de las Organizaciones. 1999;15:173-98.




32. arasek R. Job demands, job decision laiude and menal srain: Implicaion or jobredesign. Adm Sci Q 1979; 24: 285±308.

33. Payne . Sress in surgeons. In: Payne , Cozens LF, eds. Sress in Healh Proessionals.U: John Wiley & Sons, 1987; 89±106.

34. Lederer W, inzl JF, real E, e al. Significance o working condiions on burnou in

anesheiss. Aca Anaeshesiol Scand 2006; 50: 58-63.35. Semmer N, Zap D, Dunckel H. I nsru men zur Sressbezogenen a¨igkeisa nalyse

[Insrumen or Sress relaed Job Analysis] (ISA). In: Dunckel H, ed. Handbu-ch psychologischer arbeitsanalyseverfahren. Zu¨ rich: Vdf Hochschulverlag AG,1995: 179-204.

36. amirez AJ, Graham J, ichards MA, Cull A, Gregory WM. Menal healh o hospialconsulans: he effecs o sress and saisacion a work. Lance 1996; 347: 724-8.

37. Abu YC, iapcioglu D, Erkalp . Job burnou in 159 aneshesiology rainees. Saudi J Anaesh. 2012; 6(1): 46–51.

38. Cohen S, amarck , Mermelsein . A global measure o perceived sress. J Healh SocBehav. 1983;24:385–96. [PubMed: 6668417].

39. luger M, ownend , Laidlaw . Job saisacion, sress and burnou in Ausralianspecialis anaesheiss. Anaeshesia, 2003, 58, pages 339–345.

40. oshy C, amesh B, han S, e al. Job saisacion and sress levels among anaeshesi-ologiss o souh India. Indian J Anaesh. 2011 Sep-Oc; 55(5): 513–517.

41. ukewe A, Fairegun A, Oladunjoye AO, e al. Job saisacion among aneshesiologiss aa eriary hospial in Nigeria. Saudi J Anaes h. 2012 Oc-Dec; 6(4): 341–343.

42. Lindors PM, Nurmi E, Meroja OA, e al. On-call sress among Finnish anaesheiss. Anaeshesia 2006; 61:856–866.

43. oyry S, asanen , Hirvonen M, e al. Laakarien yoolo ja uormituneisuus [Work-ing Condiions and Work Srain among Physicians]. auluk koraporti. Helsinki: SuomenLaakariliito,2000.

44. Oliveira GSD, Ahmad S, Sock C. High Incidence o Burnou in Academic Chairpersonso Aneshesiology. Aneshesiology 2011; 114:181–93.

45. Gabbe SG, Melvil le J, Mandel L, Walker E: Burnou in chairs o obserics and gynecol-ogy: Diagnosis, reamen and prevenion. Am J Obse Gynecol 2002; 186:601–12.

46. Golub JS, Johns MM 3rd, Weiss PS, amesh A, Ossoff H: Burnou in academic aculyo oolaryngology-head and neck surgery. Laryngoscope 2008; 118:1951–6.

47. Cruz OA, Pole CJ, omas SM: Burnou in chairs o academic deparmens o ophhal-mology. Ophhalmology 20 07; 114: 2350 –5.

48. Baes GW, Blackhurs DW: Leadership qualiies o obserics and gynecolog y deparmenchairmen o Unied Saes medical schools. Am J Obse Gynecol 1992; 166:1102–11.

49. Spickard A Jr, Gabbe SG, Chrisensen JF: Mid-career burnou in generalis and specialisphysicians. JA MA 2002; 288:1447–50.

50. Shanael D, Sloan JA, Habermann M: e well-being o physicians. Am J Med 2003;114:513–9.




51. Jenkins , Wong D. A survey o proessional saisacion among Canadian aneshesiolo-giss. CAN J ANESH 2001;48(7):637–645.

52. Arenson-Pandikow HM, Oliviera L, Borolozzo C, Pery S, Schuch F – Percepion oQualiy o Lie Among Aneshesiologiss and Non-Aneshesiologiss. evisa Brasileirade Anesesiologia, 2012;62(1):48-55.

53. e WHOQOL Group – Developmen o he World Healh Organizaion WHOQOL- bre. Qualiy o Lie Assessmen 1998. Psychol Med, 1998;28:551-558.

54. inzl JF, raweger C, real E e al . – Work sress and gender-dependen coping srae-gies in aneshesiologiss a a universiy hospial J Clin Anesh, 2007;19:334-338.

55. Larsson J, osenqvis U, Holmsrom I. Enjoying work or burdened by i? How anaes-heiss experience and handle difficulies a work: a qualiaive sudy. Briish Journal o Anaeshesia 99 (4): 493–9 (2007).

56. earney . Defining proessionalism in anaeshesiology. Med Educ 2005; 39: 769–76.

57. Maalon A, Granek-Caarivas M, abin S. e pleasures o docoring hrough reflecionsin Balin groups. In: Salinsky J, Oten H, eds. Proceedings o e ireenh Inerna-ional Balin Congress. e Docor, he Paien and eir Well-being-WorldWide. Berlin:e Inernaional Balin Federaion, 2003;58–62.



1.5 - Measuring proessional well-being among aneshesiologiss: Concepual ... | 119

Measuring Proessional Well-Being Among Aneshesiologiss:Concepual Srucures And Atribues O Te Insrumens

Geúlio Rodrigues de Oliveira Filho, MD, PhD Assisan Proessor o Aneshesiology Federal Universiy o Sana Caarina,

Florianópolis, Brazil

Subjecive well-being as an affecive sae

e classical definiion o subjecive well-being includes he conceps o happinessand saisacion wih lie. In a broader sense, subjecive well-being depends on plea-surable experiences, low levels o negaive moods (anxiey, rusraion, depression,or example) and high levels o saisacion wih lie. Posiive experiences encom-passed by he classical concep o well-being are he elemens ha make lie a reward-

ing experience.

Elaboraing he classical concep, Diener and colleagues developed a 5-iem scaledesigned o measure saisacion wih lie1 wih possible scores beween 5 and 35poins. In research involving american ciizens, scores above 25 poins indicaedhigher levels o saisacion wih lie hen he average populaion.

esearch based on he classical concep has shown ha predicors o greaer hap-piness: living in a rich counry and having resources o achieve personal goals.Oher deerminans o subjecive well-being include emperamen characerized by low levels o worry, he abiliy o develop realisic and meaningul personalgoals, srong social relaionships and posiive personal oulook 2. Several domainshave been shown o encompass he major componens o subjecive well-being, asshown in able 13.

We conclude, hereore, ha he subjecive well-being, more han happi nessand saisacion wih lie isel, includes several aces, grouped in a leas ourdomains. Moreover, he concep o well-being can also be seen rom he poino view o dieren aciviies and personal siuaions o he individual, such as

work, ami ly li e, aspiraions, healh, inances, ec. his complex srucu re char-acerizes subjecive well-being as a broad and muliaceed concep, demandingseveral domain-speciic measures o address he various sub-consrucs encom-passed by he consruc.

is chaper ocuses on measures o subjecive occupaional well-being.




able 1. Componens o subjecive well-being

Pleasan affec Unpleasan affecSaisacion wih

lieDomain

saisacion

Joy Guil and shameDesire o change

lie Work

Elaion Sadness Saisacion wihcurren lie

Family

Conenmen Anxiey and worry Saisacion wih

pas lieLeisureHealh

Pride AngerSaisacion wih

uureFinances

Happiness DepressionSignifican ohers’ views o one’s lie

Sel

Ecsasy Envy One’s group

Occupaional Well-Being

Unlike he classical view o subjecive well-being as a purely affecive process,researchers have also incorporaed non-affecive dimensions ino he concep o well-being. ese dimensions, as behavior and moivaion, increased he specrumo he consruc, allowing or he developmen o broader concepual rameworksdescribing occupaional well-being. e main models ha incorporaed non-emo-ional dimensions o he concep o subjecive well-being were hose o yff and

co-workers4

, Warr e al5

which are briefly described below.Ryff ’s model o subjecive well-being

yff’s model o subjecive well-being is conex-independen. I was creaed basedon mulidimensional concepual srucures o posiive psychological uncioning. Iidenifies six dimensions o wellness:

1- sel-accepance: he individual has a posiive atiude owards himsel; rec-ognizes and acceps his/her muliple aspecs, including good and bad qualiies;eels posiive abou pas lie experiences;

2- posiive inerpersonal relaionships: he individual has a saisacory rus-ing relaionship wih ohers, is concerned abou ohers well-baing, is capableo srong empahy, affecion and inimacy; and undersands he give and akenaure o human relaionships;

3- auonomy: he individual is sel-deermined and independen, is able o resissocial pressures o hink and ac in cerain ways, regulaes behavior rom innerconvicions, and bases sel-assessmen on personal sandards;

4- environmenal masery: he have a sense o masery and compeence in man-

aging he environmen, conrols complex array o exernal aciviies, makeseffecive use o surrounding opporuniies, is able o choose or creae conexssuiable o personal needs and values.



1.5 - Measuring proessional well-bei ng among aneshesiologiss: Concepual ... | 121

5) goals in lie: he individual has goals in lie and a sense o direcion, eels hahere is a meaning o he presen and pas lie, has belies ha give lie purposes,has goals and objecives or his/her exisence.

6) personal growh: he individual eels him/hersel in coninuos develop-men, growh and expansion, is open o new experiences, aims o accomplishhis/her own poenials, sees improvemen in his/her person and in behaviorover ime, is consanly changing o reflec a changing image o sel-knowledgeand efficacy.

Warr’s model o occupaional well-being

Warr and col leagues 6 ocused he creaion o heir model o wellness on heoccupaional domain. For hese auhors, he concep o occupaional well-beingis inerwined wih menal healh in he workplace and has our primary dimen-

sions: affecive well-being, aspiraions, auonomy and compeence. A fih second-ary dimension named inegraed uncioning, covers he primary dimensions andreflecs he uncioning o he whole person.

Figure 1. e main axes or he measuremen o affecive well-being

e affecive well-being expresses eelings, measured as opposies on he exremeso he scales, or example good or bad. Anoher dimension has been idenified in

some sudies and named arousal7

. O he dimensional axes represening affec-ive well-being, he pleasure-displeasure axis seems o be he mos influenial. Arousal does no correlae wih oher axes o he consruc8 , so ha is no akenino accoun in measures o affecive well-being. Aspiraion is a concep relaed oinrinsic moivaion and reers o he individual’s ineres or his work. A is mosposiive exreme, i is characerized by he individual ’s wil lingness o seek increas-ing challenges wihin he occupaional environmen. In is mos negaive orm, iis represened by apahy and conormiy wih he saus quo o he occupaionalenvironmen. Auonomy reers o he abiliy o he individual o keep and ollow

his/her opinions and belies wihin he workplace, resising o opposing pressures.Compeence reers o he individua l’s abiliy o deal wih problems in he workplaceand o remain effecive despie adversiy.




Environmenal acors also influence occupaional menal healh. Nine groups oacors were idenified by Warr e al6:

1- opporuniy o conrol he work isel

2- opporuniy o use own skills

3- exernally generaed goals4- variey o work conen and locaion

5- clariy o inormaion a work

6- availabiliy o money and maerial resources

7- physical securiy

8- opporuniies or inerpersonal relaionships

9- social and proessional value

ese environmenal acors, according o Warr, ac as promoers o menal healh inhe workplace up o a cerain poin, aer which he effec becomes consan. Someacors when operaing a higher inensiy han desirable can negaively influence worker’s menal healh. In an analogy o viamins, Warr exemplifies acors ha suchas viamins A and D, which aken in excess can cause serious side effecs, in conraso viamins C and E which, even aken in higher does do predispose individuals oserious oxic reacions. He classifies acors as AD (addiional decremen) as hosecausing decreasind menal healh aer a given poin in ime, and CD (consan

effec) as hose acors showing a nadir aer sabilizaion. Boh kind o environ-menal acors are non-linearly relaed o menal healh. Among he environmenalacors lised above, only (a) he availabiliy o money and maerial resources, (b)physical securiy and (b) social and proessional value were classified as CD acors. A y pical curve environmenal acors - occupaional healh curvilinear relaion isdepiced on figure 2.

Figure 2.



1.5 - Measuring proessional well-being among aneshesiologiss: Concepual ... | 123

Van Horn’s model o occupaional well-being

Van Horn and colleag ues9 developed a concepual model based on yff’s and Warr’s models. Van Horn’s conceptual framework of occupational well-beingincludes five domains: emoional, proessional, social, cogniive and psychoso-maic. Confirmaory acor analysis showed ha hese dimensions reflec a moregeneral underlying concep. Based on his model, he auhors concluded ha heoccupaional well-being is acually a broad concep consising o differen acesha orm he concepual core.

Measuring occupaional well-being

In medicine, research on occupaional well-being has been direced mainly ohe invesigaion o he prevalence o menal disorders among healh proession-als. Depression, alcohol and drug use, mood disorders, suicidal endencies, and

exreme aigue syndrome (burnou) have shown variable, bu significan preva-lence among docors and oher healhcare proessionals10. Emoional exausionhas been especially prevalen among aneshesiologiss and aneshesiology resi-dens11. However, as described above, occupaional well-being is a much broadermuli-aceed concep. Currenly no insrumens are available o reliably measureaneshesiologiss occupaional well-being. is secion aims o describe he mainelemens o he developmen o measures o occupaional well-being.

Research Design

e planning process should involve our phases, each represened by a quesion12:

1- Deerminaion o researcher’s/user’s needs: wha undamenal quesions mus be addressed by he research? A his sage, deermine which consruc, absracconcep or laen variable will be he ocus o he insrumen.

2- Analysis: wha kind o saisical analyses will produce meaningullanswers o he sudy quesions? - a his sage, he researcher mus deermine wha ype o analysis w ill be more appropriae. his sep is cr ucial, since he

ypes o scales, he sample size, and relevan covariaes will be deermineda his sep.

3- Daa exracion: wha kind o daa should be exraced and how will hey beabulaed o allow or he proposed analyses? - A his sage, he ypes o variablesand heir ranges should be deermined and any ransormaions programmedo allow he use o daa so as o obain valid and reliable resuls rom he pro-grammed analyses.

4- Iems: which quesions need o be creaed o elici he daa required orhe soluion o he main issues o he sudy? - his phase is crucial and should be perormed wih appropriae ech niques, such as ocus groups13 and heDelphi mehod14-17.



1.5 - Measuring proessional well-bei ng among aneshesiologiss: Concepual ... | 125

Reerences

1. Diener E, Emmons R, Larsen , Griffen S. e Saisacion wih lie scale. Journal oPersonaliy Assessmen. 1985;49:71-5.

2. Diener E. Subjecive well-being: e Science o Happiness and a Proposal or a NaionalIndex. American Psychologis. 2000;55(1):34-43.

3. Diener E, Suh EM, Lucas E, Smih HL. Subjecive well-being: hree decades o pro-gress. Psychol Bull. 1999;125(2):276-302.

4. yff CD, eyes CL. e srucure o psychological well-being revisied. J Pers SocPsychol. 1995 Oc;69(4):719-27.

5. Warr PB. A concepual ramework or he sudy o work and menal healh. Work andSress. 1994;8:84-7.

6. Warr PB. A concepual ramework or he sudy o work and menal healh. Work andSress. 1994;8(8):84-7.

7. Warr PB. e measuremen o well-being and oher aspecs o menal healh. Journal oOccupaional Psychology. 1990;63:193-2.

8. McCormick IA, Walkey FH, aylor AJW. e sress-arousal checklis: an independenanalysis. Educaional and Psychological Measuremen. 1985;45:143-7.

9. van Horn JE, aris W, Schaueli WB, Schreurs PJG. e srucure o occupaional well-being: a sudy among Duch eachers. Journal o Occupaional and OrganizaionalPsychology. 2004;77:365-75.

10. einhard , Chavez E, Jackson M, C. M. Survey o Physician Well-Being and HealhBehaviors a an Academic Medical Cener. Med Educ Online. 2005;10(6):1-9.

11. Duval Neo GF, Niencheski AH. [Analysis o brain hemomeabolism behavior du-ring caroid endarerecomy wih emporary clamping.]. ev Bras Anesesiol. 2004 Apr;54(2):162-77.

12. OECD. OECD guidelines on measuring subjecive well-being: OECD Publishing; 2013. Available rom: http://dx.doi.org/10.1787/9789264191655-en .

13. Gliz B. e ocus group echnique in library research: an inroducion. Bull Med Libr Assoc. 1997 Oc;85(4):385-90.

14. Sewar J. Is he Delphi echnique a qualiaive mehod? Med Educ. 2001 Oc;35(10):922-3.

15. Helayel PE, da Conceicao DB, da Conceicao MJ, Boos GL, de oledo GB, de OliveiraFilho G. e atiude o aneshesiologiss and aneshesiology residens o he CE/SBA regarding upper and lower limb nerve blocks. ev Bras Anesesiol. 2009 May--Jun;59(3):332-40.

16. de Oliveira Filho G, Dal Mago AJ, Garcia JH, Goldschmid . An insrumen designedor aculy supervision evaluaion by aneshesia residens and is psychomeric proper-ies. Anesh Analg. 2008 Oc;107(4):1316-22.

17. de Oliveira Filho G, Schonhors L. e developmen and applicaion o an insrumenor assessing residen compeence during preaneshesia consulaion. Anesh Analg.

2004 Jul;99(1):62-9.



1.6 - Aneshesiology residens – e imporance o occupaional well-being | 127

Aneshesiology Residens – Te imporance ooccupaional well-being

Maria-Helena Arenson Pandikow,

PhD, pro. dr. o Deparmen o SurgeryFaculy o Medicine, Federal Universiy o io Grande do SulHospial de Clínicas de Poro Alegre.

Florenino Fernandes Mendes,

PhD, pro. dr. o Aneshesiology Deparmen o SurgeryFederal Universiy o Healh Sciences o Poro Alegre

Hospial Sana Casa de Poro Alegre

Inroducion

Qualiy o lie is currenly considered a prioriy in developed counries. Brazilianmeans o communicaion highligh he imporance o liesyle changes or a healh-ier lie. ereore, innovaive and sysemaic programs are being creaed in ordero prioriize healh and human well-being1,2 . In his process, prevenive measuresrelaed o docors’ occupaional healh have been sudied as i’s known ha medicinecauses physical and menal sress ha may compromise proessionals’ qualiy o lieand perormance.

However, when i comes o aneshesiology, he concern abou psychopahological

disorders secondary o a sressul rouine does no ge enough atenion. Mos anes-hesiologiss canno balance heir proessional concerns, personal lie and doubsabou he uure.

New areas o experise in aneshesiology are simulaing and proessionals end olook or financial rewards and saus in he shor erm. Alhough here is a posiivefinancial reurn, qualiy o lie among aneshesiologiss is way below he one seenin oher medical specialies3. Young aneshesiologiss end o absorb heir supervi-sors’ rouine and values in an atemp o adap. Considering proessional saisacion

is ranslaed ino happiness and well-being, so he aim o his chaper is o discussprinciples o medical well-being, especially among aneshesiology residens.

Developmen

Impac o he problem and deerminan causes

According o WHO, qual iy o li e is an individual percepion, based on culureand values, ha considers one’s pas experience and uure goals. Aneshesiologyresidency causes many sudden liesyle and behavioral changes ha may resul in

severe physical and menal crises, depending on he residen’s level o emoionalmauriy and resiliency. Frame 1 presens possible riggers and effecs o a resi-den’s effor o adap.




Behavioral and emoional sympoms require early recogniion and promp inervenion. Curren work ing models and relaionships should be reviewed so hachanges ca n be made in order o improve proessional saisacion and reduce eco-nomical, poliical, social, environmenal and culural possible crises.

Figure 2 provides a represenaion o he main deerminans o an aneshesiolo-gis’s modus operandi. Ideally, each reader should selec one specific opic rom hecircle and sar prevenive changes in his workplace o minimize biopsychosocialrisks or he enire eam.

Figure 2 – Aneshesiology residens’ echnical epidemiological nexus o/abou healhand well-being.

Burnou

I’s a chronic occupaional sress syndrome comprised o negaive atiudes andeelings (rame 2), currenly considered a“human-work relaion blockade”. issyndrome was named firs by Freundenberg12 hrough he social-psychological view o Chrisine Maslach13 auhor o he Maslach Burnou Invenory. e burn-ou syndrome includes problems relaed o proession and work. I’s common inproessionals ha deal consanly and direcly wih human relaions, especially

when he proessional has he ask o help people (docors, nurses, eachers, judges,policemen). Associaion beween work condiions, physical il lness and menal dis-orders has been sudied or decades, bu clinical correlaion is sill small. Accord-ing o he review o Benevides-Pereira14 he incidence o burnou varies rom 30 o47% bu he repored incidence in Brazil is only 10%, which implies lack o aciveinvesigaion as “i will only be ound i i’s sough”.




Frame 2 – Burnou – riad

I Emoional Exhausion• Intense fatigue/ emotional breakdown• Higher perception of demands• No stress resistance

II Depersonalizaion• Emotional detachment/ low social cohesion• Work indierence/ loss of respect to the patient• Loss of focus• Loss of identity

III Proessional Effecivess• Lack of future perspective• Frequent frustrations• Feeling of incompetence• Low self-esteem

Source: reerences 11, 12, 13, 14

Burnou and Depression

e individual who suffers rom chronic aigue is easily labeled as depressed. In ac,here can be an overlap beween depression and he sympoms seen in he burnousyndrome (sress, anxiey)15,16.

Curren culural demands o success, beauy, happiness and joy may worsen depres-sion sympoms. ese hings ha should be a possibiliy become a social obligaion1 and he world expecs lie o be a never-ending pary. In his conex, depressed individuals end o live in a bubble and eel rejeced. ese eelings sar a cycle in which bad houghs bring up even more bad houghs and i’s necessary o avoid ideas ha“my work will never be finished in his operaing suie because here will always beanoher paien in line”.

Differences beween burnou, sress and depression

Burnou: depression seen in his siuaion is emporary and caused by one specificacor in l ie (work). I may be associaed wih coninuous sress; however i does nomean ha excessive sress was he cause. e onse o depression is slow and subleand may be underesimaed, making differenial diagnosis difficul15,16. I presen,guil ends o be more raional. Individuals can realize ha heir indecision and inac-iviy is caused by aigue. Iniial insomnia is more common.

Sress: individuals can keep hings under conrol and eel energized by he accom-plishmen o a ask; however sress can rigger a harmul cycle ha compromises

proessional raining.Depression: guil eelings compromise all areas o he residen’s daily lie. erminalInsomnia is common.




Coninuous evaluaion is necessary or he developmen o good proessionalsha rus heir own work and recognize he imporance o paien saey. Qualiyo equipmen, environmenal inrasrucure, eaching and human ineracions arerelaed o he qualiy o proessional relaionships and per operaive work.

Figures 4, 5 and 6 summarize evaluaed acors and resuls rom surveys23,24

.Figure 4 – Updae Workshop o Iner-elaionship in he peroperaive period

PAA (preanesheic assessmen), POA (pos-anesheic assessmen) (recovery room), ICU (Inensive care uniy)Noe: imporan acors relaed o low scores are associaed wih organizaion and improvemens inask division, ime and duraion o work journeys, hierarchical srucure.

Source: reerences 23, 24.

Figure 5 - Symposium: Opimized iner-relaions in he peroperaive period. Generalresuls: Proposals or changes in shared responsibiliies.

PAA (preanesheic assessmen), POA (pos-anesheic assessmen) (recovery room), ICU (Inensive care uni)I (inormaion echnology)aing scale rom 0 o 10.Source: reerence 24




e workshop was a meeing o debae problems ha affec he qualiy o work inhe peroperaive period. e penagon illusraes he six main acors ha should be sough.

Ishikawa s udied aneshesiologiss’ criical commens and, based on ha, i llus-

raed a prospecive reormaion (2006). Aneshesiologiss’ complains are pre-sened a he upper porion o igure 6. Aer he survey, in order o improvesaey, mulidisciplinariy and susainabiliy o services and opimize sysemorganizaion, he main correcive measures were deined and lised a he bo-om axis.

Figure 6 - Prospecive reorm ounded in criical commens

PAA (preanesheic assessmen), SU (surgical uniy), ASU (ambulaorial surgical uniy), OC (obs-tetric Center), RX (radiology), HD (hemodynamics), PARR (post anesthetic recovery room), Radio(radioherapy)Source: reerence 23.

Quesionnaires and mulidisciplinary workshops brough up imporan reorms haimproved proessional qualiy o lie and confirmed he imporance o he presenceo he aneshesiologis inside he room in he peroperaive period.

Bu one imporan acor was no invesigaed: aneshesiology residens’ well being.Overall, his is evaluaed by he developmen o residens’ (igure 7) skills, knowl-edge, behavior and relaionships.




Figure 7 –Crieria used o prospecively evaluae he raining process o residens indifferen areas o experise.

Qualiaive, culural, behavioral and acion scores represen he sum o differen areas o raining andlearning process under he superv ision o aneshesiologiss, nursing and admi nisraive personal.Source: eaching Forum: How o evaluae and learn aneshesiology nowadays.

A complimenary approach ocused on perormance and percepion o qualiy wasmade hrough inerviews and inquiries. Having gahered ha inormaion, he sauso he aneshesiology residency a he Hospial das Clínicas de Poro Alegre (HCPA) was i llusraed.

In summary, residen’s unsaisacions are, as expeced, relaed o overload, exremeaigue, poor relaionship wih surgeons, anxiey, lack o ime o sudy, res, sleep andleisure and inadequae die.

Anoher sudy (able 3) idenified levels o occupaional sress and working condiions oBrazilian residens.

able 3 - Sudy o Relaionship Among Occupaional Sress Level and WorkCondiions: in Aneshesiology raining Programs in Brazil

• Second year of training in Anesthesiology presented the highest rates of occupational

sress compared o oher levels o raining;• Occupational stress levels were higher in females;

• Occupational stress was higher between the ages of 25 and 35 years;

• Married group presented a lower level of stress compared to unmarried and divorcedgroups;

• e number of hospitals in which residents have their clinical activities did not aectoccupaional sress;

• Alcoholism was highly prevalent in Brazilian residents and preceptors.

• Levels of control over work dynamics, analyzed in ve dimensions; showed asaisically significan lower level o occupaional sress.

Source: reerence 6.




Imporan changes or he apprenice are being made hanks o modern pedagogicalools in laboraories, online and simulaion on mannequins. Muliple possibiliiesare available o improve aneshesiology residens’ knowledge, psychomeric andpracical skills 25,26.

Inernaional researchers have been sudying abou he imporance o emoionalinelligence, behavior and atiudes – atribues required in criical siuaions andhigh pressure work environmens27. Bu Brazilian residency programs sill havemany problems o solve, especially in he mater o apprenice suppor during behav-ioral and exisenial problems 28. ecogniion o physical and menal risks should bepar o he learning process o avoid he negaive cycle illusraed in rame 1.

Precepors or supervisors mus be valued as imporan agens in he early recogni-ion o repeiive behaviors, absence o physical, menal and moral srengh; acorsha may rigger emoional damage and risks or occupaional injuries or illness.Moreover, leadership is needed o achieve an individualized model o supervision, beyond he curren available “single model ”, as i people were al l alike. I is essenialo creae a sysem o suppor, especially during he ransiion rom he 1 s o he 2nd year o residency and hen in he end o he 3rd year. e analysis o iniial plans andfinal accomplishmens is necessary or an effecive closure o he learning cycle.

Alhough i’s known ha residens presen a high biopsychosocial risk, litle has been done o change ha. e ransormaion o an apprenice ino an aneshe-siologis should be assessed no only by his echnical skills, bu also by affecive-

culural abiliies.“... and o lisen o sories – he liberal’s dogma – skepicism mus be orgoten.”Umbero Eco. A ilha do dia anerior. 3a Ed. 1995.

I here is no real concern abou he adverse environmen presen in aneshesia residen-cies i will no possible o keep updaed in his unlimied and echnological uure 30.

Recommendaions

• Redening coordinators’ attributes and start behavioral approach.

• Analyzing the frequency and psychosocial causes of classic symptoms ofaigue.

• Exploring individual resilience and implementing measures that protect

residents’ well-being by respecting this individual’s resilience.

• Debating the subject. Respecting working-hour limits.

• Satisfactory infrastructure.

• Inquiries and interviews should be made periodically to identify advantages, disad -

vanages and difficulies a work. Annex 2 describes iems addressed o precepors.• Specifying exactly what is intended with the evaluation. Dening desired aributes.




• Feedbacks are much more than criticism. ey help professionals recognizeheir flaws and vulnerabiliies a work.

• New areas of expertise in anesthesia demand more practical skills and

training and the evaluation process should include parameters related to

residents’ well-being.

• Intervention in order to solve a reported problem increases safety and satisfac -ion a work.

• Preceptors of dierent ages should work together in order to recycle someconceps and recognize he benefis o a new model wihou disregarding oldconceps ha were once used (Figure 8).

Figure 8. Aneshesiologis Profile

radiional Curren

Loyaly o he insiuion Loyaly o sel Search or sabiliy Search employabiliy Medium level o sel-confidence High sel confidence

Focus on salary and sausDoes no expec o say in he same job oroo long

Long-erm career plansFocus on personal growh, financialopporuniy

Dream o a balanced lie Need or a balanced lieFear o change Changes are par o evoluion

esisance o new echnologies Use o new echnologiesLong working journeys esul-based evaluaionDependency on leadership equires consisen leadership

Hierarchical govern Wihou a compeen leadership, hey mayqui he job

Moo: Work hard X success Good work, enjoy work, overcomingOrganizaional leadership: inuiiveconceps

raining in hospial managemen

Social and/or policies changes increases

physical and emoional sress Deals beter wih he new imes.*Source: * reerence 29.

Remember

• Time brings changes and the ideals of an anesthesiology service should bealways updaed, as well as all residency precepors.

• Knowledge and new ideas are the result of experience and young spirit combination.

• Qualiy o lie analysis provides indicaors ha can be used by he SBA (Brazil-

ian Sociey o Aneshesia) Commission o Occupaional Healh o deend anes-hesiologiss’ ineress beore medical organizaions.

• Campaigns to minimize stress factors at the hospital should be started.




Dear Colleague

is survey is designed o collec inormaion rom aculy aiming o expand echnical,pedagogical and psychosocial resources or he raining process o he aneshesia residensand aneshesiologiss.

I- Objecives:

• Reect on current teaching practices and preferred approaches to medical residency;

• Identify strengths (that made the ex perience positive) and problems in the progression ofhe rainings offered in differen areas o care o he ormal program;

• Recognize facets of the inter - relationship / interaction with components of clinical staha add curricular o oucomes;

• Compare the results with other centers, using feedback for eective critique of partici-pans ceners.

II- Quesions or Reflecion ( no correc answer ):

Considering ha you are a aculy member o an aneshesia residency program:

1. Wha do you find mos rewarding in your job?

2. Wha do you consider major difficul ies?

3. Lis examples o characerize difficulies wih residens and in wha processes / areas oraining?

4 . Wha are he echnical and cogniive skills o eaching you eel more comorable wih?

5. Wha menoring skills would you like o improve?

6. Please circle your mehodological preerences (cases , seminars , lecure , films )

Oher; _________________________________________________________________________

III -Graduaing P (presen) or N / A elemens (no applicable) in he developmen o your opics / lessons and inerdisciplinary relaions w ihin he residency:

Adequae ime? ( )

Atenion o he audience? ( )iming , adequae space , accommodaion / comor? ( )

Perormance o residen physicians working wih paiens? ( )

Healh care eam relaionships? ( )

Environmen o rus / collegialiy among eachers? ( )

Diversiy o paiens and care areas? Library, Inerne? ( )

esidens evaluaions o insrucors? Objecives ormulaed by insr ucors or each each-ing session? Consrucive eedback o heir residens? ( )




IV – Please, grade curren saus o medical residens regarding:

Level o riendlinesscommunicaiondepressionaigueMood disordersLoss o energy now asking or helpdisciplinedorganizedrespeculehicalcommited

rusul

V – Answer he ollowing quesions:

Do you seek inormaion on he level odevelopmen o each residen /

echnical raining and ineress BEFOEiniiaing any eaching session?

e eaching session begins wih you asking

quesions? or saemens? You simulae he poenial apprenice opoliical / educaional leadership and research

In he specialy?

VI - Please lis suggesions or increasing:e level o rus and credibiliy o apprenices or heir menor:

e simulus / collaboraion o he oher componens o he aneshesia service in maters o

vocaional raining.

Atribues Poor Average Sufficien No applicable

Yes No Never




Reerences

1. ISMA-B – Inernaional Sress Managemen Associaion no Brasil - htp://ww w.isma- brasi l.com.br/

2. Journal o Consumer Psychology. 2011; 21(2), 126-30

3. Arenson-Pandikow HM, Oliviera L, Borolozzo C, Pery S, Schuch F: Percepion oqualiy o lie among aneshesiologiss and non-aneshesiologiss. ev Bras Anesesiol.2012;62(1):48-55.

4. Wes CP, Ian AD, HabermanM, e al. Associaion o residen aigue and disress wihperceived medical errors. JAM A 2009;302:1294-1300.

5. Wu AW. Medical error: he second vic im. e docor who makes a misake needshelpoo. BMJ 2000;320: 726-727.

6. Duval Neo G F, Bone F, Howard S, e al. Proessional well-being work pary da WFSA:É hora de refleir e agir em relação à saúde ocupacional do anesesiologisa. ev Bras

Anes.2011; 61: 4: 389-396.7. Epsein M, rasner MS. Physician resilience: Wha i means, why i maters, and how o

promoe i. Acad Med 2013;88:301-303.

8. Shanael D, Sloan JA, Habermann M. e well-being o physicians. e Amer J Med.2003;114:513-518.

9. Samuelsson M, Gusavsson JP, Peterson IL, e al. Suicidal eelings and work envi ronmen in psychiaric nursing personnel. Soc Psychiary Psychiar Epidemiol.1997;32(7):391-397.

10. Soares JJ, Jabloska B. Psychosocial experiences among primary care paiens wih and

wihou musculoskeleal pain. European Journal o Pain 2004;8:79-89.11. Girgis A , Hansen V, Goldstein D. Are Australian oncology health professionals burning

ou? A view rom he renches. Aus Healh ev 2002;25:109–121.

12. Freudenberger HJ. Saff burnou. J Soc Issues. 1974;30:159-65

13. Maslach C, Schaueli WB, Leier MP. Job burnou. Annual eview o Psychology. 2001;52:397-422..

14. Benevides-Pereira AM. (2002). O processo de adoecer pelo rabalho. In: Benevides--Pereira AM. (org.). Burnou: quando o rabalho ameaça o bem-esar do rabalhador.

São Paulo: Casa do Psicólogo.15. Minisério da Saúde Poraria nº 1339/GM Em 18 de novembro de 1999. Doenças rela-

cionadas ao rabalho.

16. oresen CJ, aplan SA, Barsky AP, Warren C, de Chermon . e affecive un-derpinnings o job percepions and atiudes: a mea-analyic review and inegraion.Psychol Bull . 2003 129 (6):914-495.

17. urkle Sherry - Alone ogeher: Why We Expec More rom echnology and Less romEach Oher, Basic Books 2011. htp://www.sernsourcebook.com/sherryurkle.php.

18. Iacovides A, Founoulakis N, aprinis S, aprinis G. e relaionship beween job

sress, burnou and clinical depression. J Affec Disord. 2003; 75: 209-221.




19. Ahola , Honkonen , Isomesä E, e al. e relaionship beween job-relaed burnouand depressive disorders - resuls rom he Finnish Healh 2000 Sudy. J Affec Disord.2005;88(1):55-62.

20. Delor, F., Hubert, M. Revisiting the concept of ‘Vulnerability’.Social. Science and Medi-cine 2000; 50: 1557-1570.

21. De Oliveira GS Jr, Almeida MD, Ahmad S, e al. Aneshesiology residency programdirecor burnou. J Clin Anesh. 2011;23 (3):176-182.

22. De Oliveira GS Jr, Ahmad S, Sock MC, e al. High incidence o burnou in academicchairpersons o aneshesiology: should we be aking beter care o our leaders? Aneshe-siology. 2011;114(1):181-93.

23. Weissheimer M, Arenson-Pandikow HM. Eapa da II avaliação da qualidade no serviço deanesesia e medicina perioperaória do HCPA-SAMPE. ev HCPA. 2008: 28: Supl – p. 7.

24. Arenson-Pandikow HM, Caumo W, Homrich PHP, e al. Oficina oimização. A Iner--relação no perioperaório. Pare I Panorama Geral - ev. HCPA 2009; 29: Supl – 14-15.

25. Larsson J, Holmsröm I. Undersanding aneshesia raining and rainees. Curr Opin Aneshesiol 2012,25: 681-85.

26. De Oliveira Filho G, Dal Mago AJ, Garcia JH e al. An insrumen designed or aculysupervision evaluaion by aneshesiologiss and is psychomeric properies. Anesh Analg 2008;107: 1316-22.

27. Talarico JF, Varon AJ, Banks SE et al. Emotional Inteligence and the relationship toresiden perormance: a muli-insiuional sudy.J Clin Anesh 2013- htp:// dx.doi.org/10.1016/j.jclinane.2012.08.002.

28. De Oliveira Filho GS. Fórum de Ensino: mosrando a realidade, buscando soluções. Anesesia em evisa 2012; 62: 23-25.

29. Yaegashi SF, Benevides-Pereira AM. (2010). Profissão docene, esresse e burnou: anecessidade de um ambiene de rabalho humanizador. In: Chaves M, Seogui I, Mora-es SPG. (Org.). A ormação de proessores e inervenções pedagógicas humanizadoras. 1ed. Curiiba - P: Insiuo Memória, p. 185-202.

30. Smallman B, Dexer F, Masurky D e al. ole o communicaion sysems in coordina-ing, supervising aneshesiologiss aciviies ouside o operaing rooms. Anesh Analg2013;116:898-903.

31. Diagrama-de-ishikawa: htp://www.significados.com.br/diagrama-de-ishikawa/32. Vitola, JOC. (1997). Terceira idade: tendência atualizante e sentido de vida. Dissertação

de Mesrado em Psicologia, PUCS, Poro Alegre, io Grande do Sul, Brasil.



1.7 - e proessional well-being o aneshesiologiss | 143

Te Proessional Well-being O Aneshesiologiss

Pirjo Lindors, MD, PhD, Helsinki Universiy, Finland

Tis aricle is based on and is many pars are copied om my docor’s disseraion: Lindors P. Work-

relaed well-being o Finnish aneshesiologiss. People and work. esearch repors 88, Finnish Insiue oOccupaional Healh, Helsinki 2010.

1- Concepual background o he proessional well-being o aneshesiologiss

Holisic and mulidimensional view o well-being and healh

e well-being o an individual can be undersood as he ne effec o posiive andnegaive bio–psycho–socio–culural acors. e human mind and body are in his

conex undersood holisically wihou a dualisic division ino psychological orphysical. is undersanding is suppored by sudies during he laes decade using brain imaging and elecron microscopy ha show ha menal phenomena correlae wih neuro-chemical changes and vice versa. However, or research reasons he vari-ables are caegorized as physical, menal, social, and culural.

Healh and relaed well-being can be defined in many ways. Some definiions arehe ollowing:

1. Healh, according o he World Healh Organizaion (WHO 1948), is a sae

o complee physical, menal, and social well-being and no merely he absenceo disease or infirmiy. is ideal sae is, however, unrealisic o atain, and canonly be aimed a.

2. Anonovsky (1979) inroduced a “saluogeneic orienaion” oward healh,sense o coherence (SOC), according o which a person’s healh is deermined o agrea exen by how he or she experiences he world as meaningul, comprehen-sible, and manageable. is can be seen as a paradigm shi in healh discourserom a disease-cenered model o pahogenesis o a resource-oriened saluogen-esis aimed a prevenion (Bengel e al. 1999). SOC accords wih he holisic viewo healh: I encourages an individual o srenghen he healhy aspecs o his/her organism even when suffering sympoms o illness. I also emphasizes heimporance o culure – especially morals, ehics and norms – or well-being andhealh: Acing agains one’s value sysem migh affec one’s healh.

3. e saisical norm o healh is deermined by he requency o a characer-isic o he organism: deviaions rom average values are considered o indicaedisease (Bengel e al. 1999).

4. Healh can also be undersood as a uncional norm: he person’s abiliy o

ulfill his/her role in sociey (Erben e al. 1989). A purely Wesern medical per-specive neglecs imporan dimensions o he individual’s condiion, such as heabiliy o perorm and work, and lie saisacion and well-being.




In his conex, healh is undersood as a mulidimensional concep including posi-ive body eeling, absence o complains or signs o disease; joy, happiness, job andlie saisacion, perormance, sel-realizaion and sense o meaningulness. Healhdepends on he exisence and on he percepion o sress and srain and on he meanso dealing wih i (Bengel e al. 1999).

Load–sress–srain

e concep o `sress´ is complicaed, wih differing definiions. e firs sudies onsress were based on physiology, bu since he 1950s differen psychological modelshave emerged.

Simulus-based approache word sress comes rom he Lain word sringere, draw igh. Definiions o srainand load used in physics came o express how sress affecs individuals. According o

his model, exernal orces (load) are seen as exering pressure upon an individual,producing srain (Arnold e al. 1995).

Response-based approach A second concep defines sress as a person’s response o a disurbance. Cannon(1930) sudied he figh or fligh reacion in animals and humans and observed hahese subjecs – in cold, lack o oxygen and exciemen – excreed adrenalin. Hedescribed hese individuals as being “under sress.” Selye (1946) creaed he con-cep o sress: a siuaion where a person eels ense, anxious, nervous, resless, and

has difficulies in sleeping since sressul hings are so roublesome. He describeda general adapaion syndrome (GAS) which describes hree chronologic sages oresponse in a prolonged acivaion o sressors. As he describes hem:

1. Alarm reacion: lowered resisance ollowed by a couner-shock during whichhe deense mechanisms become acive. 2. esisance: he sage o maximumadapaion and, hopeully, successul reurn o equil ibrium or he individual. 3.

Exhausion: when adapive mechanisms collapse. Laer, Selye (1974) separaedhe concep o disress rom good sress (eusress): an appropriae amoun o

sress is needed or he well-being o he organism. During opimal sress, aler-ness and awareness improve as well as many lie uncions, and physiologicalmechanisms ha increase he sensaion o well-being become acivaed.

Ineracional approachNewer heories emphasize he ineracion beween a person and his or her envi-ronmen. In Cummings and Cooper’s (1979) cyberneic ramework or occupa-ional sress, he ocus is on he sress cycle, “he sequenial evens ha repre-sen he coninuous ineracion beween person and environmen.” Accordingo his, individuals ry o keep heir houghs, emoions, and relaionships in a

seady sae. here is a range o sabiliy (homeosasis) in which he individualseel comorable. When his sabiliy is disruped, he individual has o makeadjusmens or acivae coping sraegies in order o mainain or achieve he




sabiliy again. Sress, according o hem is any orce ha pushes a psychologi-cal or physical acor beyond is range o sabiliy, producing a srain wihin heindividual. In Caplan’s person and environmen i model (1987) he ocus is onhe degree he employee’s skills, needs, and expecaions mach he employer’srequiremens and provisions.

ransacional approachIn Lazarus’s ransacional approach, sress can be undersood as a process: a mis–fi beween an individual and his paricular environmen (Lazarus and Folkman 1984).Individuals, according o his heory, make a cogniive evaluaion o hreas hacome rom he environmen. e degree o which people evaluae sress as a seri-ous hrea reveals he level o heir perceived sress. In his model more emphasis isplaced on individual differences han in he ineracive models.

Mos sudies on work sress have considered he ollowing acors in heir heorei-cal ramework: he presence o sressors, he evaluaion process, and he response.However, here is sill no consensus as o he definiion o sress, nor as o he worksress process.

Allosasis and allosaic load Adapaion in sressul siua ions involves aciva ion o neuro–immuno–endocri-nological mechanisms. is adapaion, according o Serling and Eyer (1988), iscalled “allosasis”, meaning ha an organism has regained a new sabiliy hroughchange. Allosasis is essenial in mainaining homeosasis. When hese adapive

sysems are urned on and off efficienly and no oo requenly, he body is ableo cope effecively wih sressors ha i migh no oherwise manage. However,in excessively high and longsanding sressul siuaions causing srain, allosaicsysems may become over-simulaed and ail o uncion normally. is disurbance in he al losasis sysem is called “allosaic load ” or he price o adapa ion(McEwen and Sellar 1993). Allosaic load leads o disurbances in he deensesysem o he organism, causing changes in neuro–immuno–endocrinological andpain pahways, which over ime may lead o disease (McEwen 1998, 2002, 2007).However, he deleerious effecs o chronic sress can be couneraced by sup-poring he srenghs o he individual, allowing him/her o uncion accordingo his value sysem and posiive expecaions, increasing social suppor, promo-ing healhy behaviors (physical exercise, sreching, pause gymnasics, opimalnuriion, opimal sleep and res, moderae drinking, no smoking…), opimizingergonomics and reducing srain relaed o psycho–socio–culural aspecs a he workplace (Anonovsky 1979, Hy yppä e al. 1991, Marmo e al. 1997, Bengel e a l.1999, Elovainio e al. 2002, alimo e al. 2003a, Heponiemi e al. 2006, McEwen2007, Lindors e al. 2009b,c).

When modeling our sress process i is imporan o ake ino accoun he wholeenvironmen o he aneshesiologis including organizaion, paiens, amily, sociallie, lie evens and personal demands. (Lindors P, 2010, p. 35. Figure 1)




e aneshesiologis’s work may consis o physical exerion – such as liing heavypaiens, repeiive moion, saic muscle work, mainaining he same posiion wih-ou being able o move, difficul, awkward working posiions, sanding, walking– and exposure o cold, hea, humidiy, dryness o he air, air condiioning, x-rays,magneism, chemicals (cyosaics, cemen or prosheses, gas, races o narcoics in

he air, ormaldehyde), noise, brigh ligh a nigh, inecious agens (BC, influenza,HIV, hepatitis …), wounds (needle stick), violence/aggression.

Menal workloadMenal workload can be undersood as work-relaed psycho–socio–culural acorsaffecing well-being and healh. I consiues an “umbrella concep” which includesorganizaional culure, roles in he organizaion, organizaional jusice, job conrol, workplace amosphere, job securiy, and social suppor (arasek 1979, Sherbourneand Sewar 1991, Elovainio e al. 2001, 2002, 2003, 2005).

In an aneshesiologis’s proession, oo-long working hours when on call, work wih-ou pauses, an excessive workload, oo difficul procedures or clinical asks, ear oharming paiens, emoional demands when acing paiens’ pain, suffering, anddeah, an unriendly workplace amosphere, unclear asks, lack o educaional pos-sibiliies, dangerous or ergonomically poorly designed work environmens, lack oproessional conrol and decision- making possibiliies, and ideological conflics ahe workplace may bring on harmul sress (Åkersed e al. 2002, van Amelsvoor eal. 2003, Shanael e al. 2003, Cole and Carlin 2009, Wallace e al. 2009). Sressors

ouside work can also weaken one’s managemen o work-relaed sress.

Models o psycho–socio–culural acors affecing healhree models defining sressul psycho–social acors affecing healh have beenesed: he job srain model, he social suppor model, and he organizaional jusicemodel. “ese models have all gained some empirical suppor or predicing healhproblems and can be regarded as complemenary models concenraing on differenaspecs o he perceived work environmen. e job srain model ocuses on siu-aional acors o work and arrangemens, he social suppor model on he qualiy o

cooperaion and social ineracion a work, and he organizaional jusice model ondecision-making procedures and managerial pracices” (arasek 1979, 1990, Sara-son e al. 1987, eorell 1990, Elovainio e al. 2001, ivimäki e al. 2003a, Lindorse al. 2009c).

Job srain – Karasek’s demand–conrol model A discrepancy be ween demands and capaciies, expecaions, srenghs, and needscan lead o harmul sress (arasek 1979, Munaner e al. 2006). arasek creaed amodel o sudy he effecs o psycho–socio–culural work sress on healh oucomes

(arasek 1979). According o his demand–conrol model (DC), job srain is defined by he relaionship beween wo independen inpus: job demands and conrol ohe work siuaion. e ormer reers o psychological sress, such as having oo




much or oo demanding work or boh, or ime pressure, or inerrupions. e laterinvolves employees’ auhoriy o make decisions concerning heir acual jobs andhe use o heir skills regarding heir ask variey and opions o develop and learnnew hings. High job srain, according o his model, resuls rom siuaions wihhigh job demands and low job conrol. arasek defined hese wo acors as he mos

imporan deerminans o work-relaed well-being and healh (arasek 1979). eDC-model ocuses on he organizaion, no on he individual.

Demand–conrol–social suppor modelBy refining he DC-model, arasek and eorell ormulaed a new model o workorganizaion and is psychophysiological effecs. According o his model, hose whoexperience high social suppor are less a risk in a high-srain siuaion han are hose who experience low social suppor (eorell 1990, arasek 1990).

his model has been criicized or is relevance o occupaional homogeneiy,or is sabiliy over ime, and or is concepualizaion. Working wih human beings, such as in he healh proession, is di eren rom and more complex han working wih objecs . Emoional demands (ac ing illness, pain, su ering) andcon lics beween goals and realiy are lack ing rom he conceps. he model hasalso been criicized or he inerdependence o he wo basic conceps: a worker wih good decision au hor iy over he work peror med is able o dimi nish hosedemands, which do no i he model. he job srain model became, however,more applicable o human service organizaions when social suppor was added

(Södereld 1996).

Despie criicism, his model wih is modificaion has been validaed in numerousepidemiological sudies (Bosma e al. 1998). Mea-analyses have indicaed haarasek’s model is linked wih poor healh oucomes and an increase in coronaryhear disease in paricular, which is no explained by physical or chemical exposuresa he workplace (ivimäki e al. 2006). Whiehall II sudies have shown ha low job conrol is a mediaor ha links low socio-economic saus o higher moraliyhrough cardiovascular deahs (Marmo e al. 1997). A recen sudy suggess ha he

demand–conrol–suppor model predics no only job srain, bu also job saisac-ion and organizaional commimen (odwell e al. 2009).

Boh individual and group level assessmens are imporan when sudyinghe associaions beween hese psycho-social acors and healh. Moreover,social relaions ouside work should also be aken ino accoun when sudyingemployee’s percepions o heir work. Organizaional norms governing workperormance and social relaions, and con lics in he work-amily i nerace haveexplained var iance in job sress (Hammer 2004). he mos deleerious combina-

ion is assumed o he conjuncion o high job demands, low job conrol, and lacko social suppor rom colleagues and supervisors, which is cal led isolaed srain(arasek 1990).




Approaches o social supporSocial suppor has been defined in many ways. I can be undersood as non-work-relaed suppor rom amily members, riends, and significan ohers, as well as work-relaed suppor orm co-workers, colleagues, or chies when acing difficulies (Sarasone al. 1987). I migh also mean opporuniies o inerac wih ohers or o have some-

one presen (arasek 1990). e ineracion may ake place in he orm o eedback, backup, and give one he sense o being able o conrol one’s environmen (Caplan1974). I may, in addiion, bring o an individual he awareness o his/her being amember of a social network, receiving love and respect (Cobb 1976). Various studieshave shown ha people wih greaer social suppor adjus beter o lie changes han dohose wih less suppor (Anonovsky 1974, Caplan 1974, Bell e al. 1982, Lindors eal. 2009a, 2009b, 2009c). According o Hoboll (1988), social suppor means relaion-ships ha give people real help and bind hem o he social sysem ha is believed ogive love, care, and a sense o being atached o a respeced social group or relaionship.Brugha’s (2005) sudies suggesed a minimum o our persons or he primary neworko an individual o provide adequae suppor o allow well-being and healh.

Social relaionships enable a ranser o culure. e suppor o amily and riendsappears o be more effecive han ha o co-workers, colleagues, and chies in mii-gaing he effecs o sress a work and ouside work. According o one mea-analysis,social suppor has go hree effecs: o reduce he load, he sress, and he srain(Viswesvaran et al. 1999).

Organizaional jusicee erm organizaional jusice reers o he exen o which employees are reaedin a jus way a heir workplace. I includes a procedural componen (he exen o which decision-making procedures include inpu rom he affeced paries, are con-sisenly applied, suppress bias, and are accurae, correcable, and ehical) and a rela-ional componen (polie, considerae, and air reamen o individuals). I has beenshown o be an imporan predicor o organizaional atiudes, such as commimenand involvemen, as well as o he eelings and behavior o employees (Cropanzanoet al. 2001). Various studies support the link from low organizational justice to expe-

rienced srain, and urher o sick leave and healh problems (Elovainio e al. 2001,2002, ivimäki e al. 2003b, 2003c).

Organizaional jusice is someimes suggesed o represen a shared experience beween employees in he same work uni. Some sudies, however, show ha i isindividual percepion ha is essenial or organizaional jusice o affec individualhealh (Cropanzano e al. 2001). Low-jusice work environmen, characerized by unjus organizaional policies, prac ices, and procedures, is according o cross-secional findings a greaer risk o healh han is unair reamen rom an immedi-

ae supervisor. A high sense o organizaional jusice appears o be linked o healh,especially among highly educaed people wih demanding jobs, high saus, andresponsibiliy (Elovainio e al. 2002).




Approaches o organizaional culureInormal organizaion is essenial or o successul unioning o he ormal organiza-ion (Barnard 1938). Definiions or culure and organizaion differ. Culure can bedefined as he se o meanings, behavioral norms, values, and pracices o members oa paricular sociey as hey consruc heir unique view o he world. As such, culure

deeply inorms every aspec o lie and healh. Effecive inervenions o resore andpromoe healh may hus be enhanced hrough consideraion o culural conexsand configuraions (Mezzich 2009).

In his chaper, he ollowing concep or organizaional culure was adoped: Imeans shared, learned ways o hinking and behavior among he members o heorganizaion wih he aim o develop individual and socieal growh and adapaion.I is complex comprising knowledge, moral, norms, cusoms, meanings, and sociallyransmited ways o behavior (ylor 1871, eesing 1981, Schein 1985). A member o

he organizaion grows ino he culure and becomes dependen on i. Each individ-ual, creaes and reinorces he culure (ylor 1871, eesing 1981). Codes o conducin he workplace ensure commimen, ideniy, coherence, and a sense o communiy(Barnard 1938).

According o Louis (1980): “e unspoken in an organizaion is more powerul hanhe spoken.” One gradually sars o sense he eeling o a workplace, and he wayo working. Organizaional culure may also be considered as he characer o anorganizaion, is climae, ideology and image.

e origins o he concep o organizaional culure are in anhropology. e ocuso is research has been since he 1990s on he uniquely inegraive and phenomeno-logical core o he subjec, in which he inerweaving o individuals ino a workplacecommuniy akes place, and in he noions o meaning, emergence, and uncion(Louis 1980). e research in he field has been carried on rom semioic, cogniiveand ineracional perspecives. According o Smircich (1985), culure can serve asa paradigm or undersanding organizaions and ourselves. “Culure is consanlyin dynamic usion and should no be reduced o one more variable in a saic modelo lie a work”. Culural research conribues o undersanding, o improvemen orpoeniaion – and answering he quesions: Wha should be he role o work? Howmigh individuals conribue and receive …? How should effors be organized?

Framework or he Proessional Well-being o Aneshesiologiss Working condiions in he ramework are approached rom he perspecive o perceivedphysical and menal workload relaed o on-call duy and sleep deprivaion and psycho–socio–culural acors –workplace amosphere, job conrol, organizaional jusice, socialsuppor, and he work–home inerace– and heir connecion wih job srain.

e conceps o load, sress, and srain are adoped combining hese heories: eocus is on he srain ha he aneshesiologis eels when he workload creaes sresson him/her. Lie saisacion, job saisacion, work abiliy, job urnover, and sickness




absence are oucomes o srain vs coping wih srain reflecing he mismach/ mach beween he individual and he paricular environmen. Organizaional culure –including organizaional injusice, low job conrol, lack o social suppor a work,and unriendly workplace amosphere – and being on call are hypohesized o behe bigges sressors or loading acors a work. Sress can be seen, on he one hand,

as he orce ha arises when he workload direcs a he aneshesiologis, causingsrain. On he oher hand, he “load” causing srain via sress can be inrinsic, relaedo he personal demands he aneshesiologis has pu upon him-/hersel. However,he “inrinsic load” is no shown in he ramework as such. e srain is expressedas perceived sress and sress sympoms. I he srain is oo high or longsanding or boh, coping mechanisms ai l, and he aneshesiologis ends up wih an allosaicload. Burnou and suicidaliy are oucomes o allosaic load.

Family (is consisency, sabiliy, ineracion syle), riends (heir number, qualiy,

and proximiy), and lie evens (proecive and raumaic) can be seen as personaland amily-relaed acors ha inerac wih he srain vs coping. e ramework can be seen in Figure 1.

Figure 1. Framework o he sudy: work-relaed well-being o aneshesiologiss.

Presenaion o problems in he proessional well-being o aneshesiologiss

A shor review o problems among aneshesiologissPhysicians are known o live longer han does he general populaion (öyry 2005), bu aneshesiologiss appear o be an excepion, since according o inernaionalsudies, hey oen die a an earlier age han heir colleagues (Wrigh and obers

1996, haw 1997, Svärdsudd e al. 2002). e sress levels hey experience are a ahigher range , ogeher w ih surgeons, when compared wih oher physicians (Payneand ick 1986, Cooper e al. 1999, Jackson 1999, Lindors e al. 2006, Nyssen and




Hansez 2008, Lindors 2010). Aneshesiologiss, however, suffer rom even highermomenary sress han surgeons (Payne and ick 1986), have a high on-call burden ,and will oen need o coninue on an on-call roa unil reiremen, unlike mos oherspecialiss (Saunders 2006, Lindors e al. 2006). Being on call can be sressul ormany reasons: sleep deprivaion, ime consrains, lack o possibiliies or consula-

ion, ear o harming paiens, responsibiliy or unpredicable emergency cases, andan unamiliar work environmen (Lindors e al. 2006, Malmberg e al. 2007, Gan-der e al. 2008). Especially when on call, he aneshesiologis serves as a gaekeepero keep he paien alive unil oher specialiss can ake over. e aneshesiologis will need o make quick decisions and do skillul, bu risky procedures.

Sleep deprivaion alone has been linked o higher acciden risk, serious illness sympoms,morbidiy rom sress-relaed diseases and even deah a an earlier age rom cancer orcardiovascular problems (Meier-Ewer e al. 2004, Dembe e al. 2005, Dinges e al.

2005, Megdal et al. 2005, Van Cauter 2005, Lindfors et al. 2006). Most probably theoher causes o on-call sress add o he negaive healh effecs o sleep deprivaion.

Unil recenly, aneshesiologiss have worked as surgeons’ assisans and have hadlimied conrol over heir everyday work. Organizaional problems including sruc-ural changes wih usions, layoffs, he break-up o eams, changes in he work uni,aceless leaders, and business hinking, ogeher wih economic crises, may urherincrease he on-call burden and sress on he aneshesiologis (alimo e al. 2003b, Vahtera et al. 2004, Lindfors et a l. 2006, 2007, 2009a,b,c). Since more women than

beore are working as aneshesiologiss nowadays in Finland, combining work andbeing on call wih amily lie has become an even more imporan issue (Lindors e al.2006, 2007, Lindors 2010).

Suicide has been more requen among physicians han among oher proession-als and he general populaion (Lindeman 1997, Schernhammer and Coldiz200 4, Wallace e al. 2009). Among physicians, aneshesiologiss appear o be oneo he highes in suicide risk (Lew 1979, Seeley 1996, Hem e al. 2000, Alexandere al. 2000, Hawon e al. 2001, Ohonen 2002, Schernhammer 2005, Lindorse al. 200 9b). Aneshesiologiss are known o have a higher rae o subsance–usedisorders – especially o opioids – han do ha o oher physicians (McAuliee al. 2006, Skipper e al. 2009). Alcohol (Lindors e al. 2009b) and drug abuse (Baird e Morgan 2000, Gold e al. 2005) are conneced o suicidal iy or suicidesamong anehesiologiss.

nowledge o aneshesiologiss’ work-relaed well-being is sparse and conradic-ory: According o some sudies, aneshesiologiss have higher sress levels hando oher physicians (Dickson 1996; Lindors e al. 2006), and he reasons or heirsress are relaed o organizaion and being on call (Cooper 1999, Lindors e al.

2006). However, oher sudies have shown ha heir burnou levels are lower hanhose o oher physicians, and heir job saisacion is quie good (luger e al.2003, Lindors e al. 2006).




ese acs challenge us o sudy urher he well-being o aneshesiologiss as anexample o a medical specialy experiencing high work srain in order o improve he well-being o al l physicians.

Main findings in he well-being sudy among aneshesiologiss

o my knowledge sudies based on my disseraion on he work-relaed well-being oFinnish aneshesiologiss (Lindors 2010) is he mos comprehensible effor o ry oundersand he problems in our well-being. is is why I have concluded our mainfindings here.

Our work sress derives rom high workload and being on call, and rom workamosphere and organizaional problems. Being on call migh be dangerous.

Work-relaed sress and exhausion are common among aneshesiologiss (Lind-ors e al. 2006, De Oliveira e al. 2011, ama-Maceiras e al . 2012, Lindors 2012).

e mos imporan causes o sress are work and combining work wih amily lie.e bigges worries a work are general workload and ime consrains, he workamosphere and organizaional problems, and ear o harming paiens. Being oncall is one o he mos imporan causes o our sress; aneshesiologiss oen havehe greaes on-call burden among physicians. Unlike oher specialiss we oenconinue o have an on-call commimen unil he age o reiremen. On-call duyis he greaes reason or our perceived sleep deprivaion. Being on call is signifi-canly correlaed wih various sress sy mpoms such as nausea, coordinaion dis-urbances, exhausion, dizziness, difficulies in undersanding speech, and remor.ese sympoms are associaed w ih ake-up o sick leave. Women seem o be moreaffeced by sress han are men. High job conrol and organizaional jusice maymiigae he effec o hospial on-call srain on he number o sress sympoms(Lindors e al. 2009c).

Job saisacion depends on organizaional culure and workplace amosphere.

Aneshesiologiss - even hough highly sressed - enjoy moderae or airly high job saisacion, work abiliy, and li e saisacion (Lindors e al . 2007, Lindors

2010). Job conrol, organizaional jusice and workplace amosphere are he mosimporan variables in he work-relaed well-being o he aneshesiologiss (Lind-ors 2010, ama-Maceiras and ranke 2013). Female aneshesiologiss are in a lessadvanageous work and work/amily siuaion (job conrac, job conrol, domesic work burden) han are heir male col leag ues. However, no gender differences seemo appear in levels o job saisacion, work abiliy, or lie saisacion, alhough work-relaed acors are sligh ly more imporan deerminans o hose wel l-beingindicaors in males, and amily-relaed in emale aneshesiologiss (Lindors e al.2007). Older employees appear o be more saisfied han younger ones (Hagopian

e al. 2009). Clinical work seems o cause he leas sress (luger e al. 2003).Moreover, he meaningulness o being able o help paiens, o receive immedi-ae eedback, and he respec shown o he physician’s proession seem o buffer




against work-related stress (Kluger et al. 2003, Van Ham et al. 2006). Job satis-acion is crucial in mainaining physician’s healh (Williams and Skinner 2003,Faragher e al . 2005).

Low social suppor is he main connecion o our high suicidaliy.

A quarer o he aneshesiologiss have considered suicide. Work-relaed acors asso-ciaed wih suicidaliy are conflics wih co-workers and superiors, lack o jusice ahe workplace, and being on call. Family-relaed and personal acors are poor healh,low social suppor, amily problems, raumaic lie evens, lack o riends, alcoholabuse, and smoking. Family-relaed and personal acors seem o be more relevanrisks han work-relaed acors. Accumulaion o risk acors increase prominenlyhe risk or suicidaliy. (Lindors e al. 2009b).

In conclusion

Job srain among aneshesiologiss is high when measured by a variey o indicaors,such as sress level, on-cal l burden, sress sympoms, burnou, sick leave, sleep deprivaion, suicidaliy, and low job commimen. However, he aneshesiologiss enjoyairly good job saisacion, work abiliy, and lie saisacion. is may depend inheir good coping mechanisms in sressul siuaions.

e mos imporan work-relaed acors associaed wih well-being are on-call burden, job conrol, organizaional jusice, and social relaions a work. e work

siuaion o emalevs

male aneshesiologiss is disadvanageous. Among emaleaneshesiologiss, acors ouside work are more imporan han in men.

On-call work-burden, job conrol, and airness o decision-making procedures, andinerpersonal relaionships should be he ocus in aiming o increase work-relaed well-being o aneshesiologiss.

oday’s challenges in he medical proession: dehumanizaion o medicine

Since our sudies poined ou he imporance o he medical culure in he well-beingo aneshesiologiss I would like o bring a delicae subjec ino discussion: he dehu-manizaion o he medical culure.

Laely, a coninuing discussion has been aking place in he medical communiy:During recen decades ogeher wih he developmen o modern medicine, he phy-sician’s work has become more dehumanized. New echnologies and organizaional,changes ogeher wih increased accounabiliy have alered he docor–paienrelaionship. Subspecialized physicians know more abou less. Docors rea dis-eases, ignoring illness. Evidence-based medicine oen does no ake ino accounhe individual suffering o he paien. Medical schools each science bu ignore he

ar o medicine and moral undersanding. Bureaucracy akes over a large par o heresearch, and compeiion or research unding increases. Healh care sysems areoen unjus and broken. Many hospials have become huge, cold “markeplaces”




where ewer personnel mus ake care o more paiens (Edwards e al. 2002,Shanael e al. 2003, Cole and Carlin 2009, Wallace e al. 2009). Physicians alsoconron increasing regulaions, malpracice suis, and an expanding knowledge base (Shanael e al. 2003). Furhermore, physicians, especially aneshesiologiss, work in emoionally charged siuaions associaed wih suffering, ear, ailure, and

deah, which may culminae in difficul ineracions wih paiens, amilies, andmedical saff (Wallace e al. 2009).

Moreover, academic medicine has been accused o being inatenive o humanisic values, which has caused reenion problems in he medical aculies (Lieff 2009).Proessional developmen has been claimed o lack meaning, purpose, and proes-sional ulfillmen, and possibiliies o reflec on hese issues.

According o Cole and Carlin (2009): “Medicine is filled wih many people o good

will, inegriy, and commimen who srive o provide compassionae and ehicallysound care, each and menor sudens, mainain scienific sandards o pracice,keep curren wih he mos recen lieraure in one’s field and underake biomedicalresearch.” Ye curren condiions preven physicians rom living up o heir require-mens and ideals. is conflic is born when organizaions ignore exising workingcondiions and rigidly enorce moral rules, doing ehical violence (Cole and Carlin2009). “is may cause a cogniive dissonance among physicians, leading o disil-lusionmen, sel-doub, dis-ease, and rerea rom ideals.”

e conradicory ac ha many physicians have los sigh o heir own well-being– and hink ha illness has nohing o do wih hem – migh worsen heir siuaion.ey work when ill and expec heir colleagues o do he same. Moreover, wih alru-isic inen, physicians oen place proessional responsibiliies above personal ones(Shanael e al. 2003, Wallace e al. 2009). is kind o behavior has been connecedo cerain personaliy rais, such as perecionism, neuroicism, work holism, con-scieniousness, ambiiousness (Schernhammer and Coldiz 2004, yssen e al. 2007, Wallace e al. 2009). e effec o proessional and personal acors on physicians’ wellness is exacerbaed by he endency o many physicians o proec he privacy

o heir impaired colleagues (Wallace e al. 2009).Wallace & colleagues (2009) con-clude in heir review: “e culure o he medical proession has been recognized as akey acor ha migh deer docors rom aking care o hemselves.”

Agains his backdrop, i is no surprising ha physicians are unwell: raes o sress, burnou, anxiey, depression, and suicide have been repored o be higher han amonghe general populaion (Schernhammer and Coldiz 2004, Cole and Carlin 2009, Wal-lace e al. 2009). Moreover, impared physicians have also been shown o pose risks orpaien care and negaively affec healh care sysems (Wallace e al. 2009).

ese dehumanizing rends are eviden worldwide especially in he wesern medi-cal culure and affec as well he well-being o aneshesiologiss whose job is moreechnical and less human han ha o oher physicians.




Recommendaions or improvemen o he proessional well-beingo aneshesiologiss

Organizaional inervenionsIn order o reduce he occupaional sress o he aneshesiologiss on an organiza-

ional level inervenions are needed o limi he on-cal l work burden, improve orga-nizaional culure – especially workplace amosphere, organizaional jusice and jobconrol – and make i possible o combine work wih amily and social lie.

On-call burden may be bes reduced by limiing he number o shis and shoreninghe on-call work period. Work arrangemens such as limiing he nigh work onlyo emergencies and improving consulaion possibiliies could also reduce on-call-relaed sress. Liberaion o he senior aneshesiologiss aer a cerain age limi (50 years) and hose wih serious healh problems, rom any on-call-duy obligaion would be recommendable.

Conflics a he workplace can be reduced by various measures o esablish rus,muual commimen, effecive communicaion, and building o individual relaion-ships. Offering social suppor, showing respec and graiude, being flexible, andmaximizing he use o each individual ’s capaciies and acual srenghs migh help inreaching hose arges.

In order o increase aneshesiologiss’ job conrol hey should receive a possibiliyo affec he changes made in daily asks a work, order o he asks, use o ime, paceo work, working mehods, division o asks, decisions regarding co-workers, and heools and machines worked wih. All asks need proper descripions. e amouno work and hours o working should be limied in relaion o human endurance.Individual need or res should be respeced and sufficien suppor organized. Pre-dicabiliy o he asks should be maximimal and inerrupions minimized.

e aneshesiologis’s experience o organizaional jusice can be maximized i i isclear ha decisions are made based on accurae inormaion, incorrec decisions can be changed, ever yone can express an opinion concerning decision-making relaedo he work, decisions made are consisen, effecs o he decisions are invesigaed,

inormaion on he effecs delivered, and addiional inormaion on he grounds ohe decisions is available.

Opporuniies or a flexible inegraion o work wih amily lie and or allowing imeor personal lie and recovery rom work-relaed sress are also essenial o ensureaneshesiologiss’ high lie saisacion. is requires promoion o a more flexible working culure and par-ime opions. W ha deserves atenion is he enhancemeno he disadvanageous siuaion o emale vs male aneshesiologiss regarding jobconrol, permanen job conracs, domesic workload and relaed srain.

Emphasis should be placed upon improving superiors’ leadeship skills. Conversa-ions, menoring, and exernal counseling − wih he suppor o an occupaionalhealh care sysem − should orm a naural par o workplace problem solving.




egular annual assessmen o job and lie saisacion, as well as o sress levels andperceived healh and heir connecion wih relaionships beween superiors andcolleagues, and one’s involvemen wih organizaional decision-making and careerdevelopmen is necessary a he workplace in coordinaion wih he occupaionalhealh care sysem. Employers could become more moivaed in organizing hese

assessmens and possible inervenions, i heir ocus was on physician wellness as aqualiy indicaor o he healh care sysem (Wallace e al. 2009).

Occupaional healh care and proessional inervenions

e physicians’ healh care sysem needs o be organized so ha i is o high level, con-fidenal, and available or all physicians regardless o he workplace, working ime, jobconrac, or he posiion. A pre-employmen healh check-up by an occupaional physi-cian and periodic healh examinaions (every 5 years) wih increasing requency wih

advancing age (every 3 years) should be organized or all physicians, bu especially or heaneshesiologiss, because o heir highly sressul job. I would be o umos imporanceor healh care proessionals o recognize suicidal physicians. A screening healh ques-ionnaire including suicidaliy ogeher wih known risk acors including hose reporedin his sudy could be used a all occupaional healh check-ups and when needed duringoher visis o he occupaional physician. Focus should be upon any accumulaion o riskacors. Work-place risk assessmens should no concenrae only on chemical exposuresor ergonomic problems. Much more emphasis is needed on he menal burden linked oconflics a he workplace and problems in he organizaional culure.

Occupaional healh pracices developmen could involve a projec in coordinaion wih he workplace saey organizaion in order o sensiize physicians boh on anorganizaional and individual level o noice, ace, discuss, and help solve healhproblems o hemselves or o colleagues. Sory-elling or Balin groups could oserawareness o and reflecion on problems relaed o workplace amosphere, paiencare, or one’s own healh.

Psychological esing beore enering medical school could be considered or screen-ing sudens suiable or he sressul medical proession or in need o herapeuic

inervenions. is could be repeaed during he las year o medical school o helpgraduaing physicians in choosing heir uure specialies. Courses in philosophyand psychology o enhance sel-awareness and o mainain one’s inegriy, eam work skills educaion, and sress managemen should be considered obligaor y ormedical sudens, along wih reresher courses or specialis physicians.

Personal inervenions Appropriae herapy – including cogniive behavioural and relaxaion echniques –should, when necessary, be organized or each individual wih neiher ear o job loss

nor o breaching paien confidenialiy. Srenghening bonds – marial, and wihamily and riends – needs emphasis. Physicians’ herapies have been shown o bemore successul han hose o he general populaion (Wallace e al. 2009).




Successul organizaional, proessional, and personal inervenions may dramai-cally enhance he healh and well-being o aneshesiologiss and reduce heir sresslevels, depression and inenions o commi suicide.

Reerences

1. Alexander B.H., Checkoway H., Nagahama S.I., Domino .B., 2000. Cause–specificmoraliy risks o aneshesiologiss. Aneshesiology 93, 922–930.

2. Anonovsky A., 1974. Concepual and Mehodological Problems in he Sudy o e-sisance esources and Sressul Lie Evens, in: Dohrenwend, B.S., Dohrenwend, B.P.(Eds.), Sressul lie evens: eir naure and effecs. Wiley, New York, NY, pp. 245–258.

3. Anonovsky A., 1979. Healh, Sress and Coping: New Perspecives on Menal and Phy-sical Well-being. Jossey-Bass, San Fransisco.

4. Arnold J., Cooper C.L., oberson I.., 1995. Work Psychology. Undersanding HumanBehavior in he Workplace. Piman publishing, London.

5. Baird W.L., Morgan M., 2000. Subsance misuse amongs anaesheiss. Anaeshesia 55,943–945.

6. Barnard C., 1938. e Funcions o he Execuive. Harvard Universiy Press, Cambridge, MA.

7. Bell .A., Leoy J.B., Sephenson J.J., 1982. Evaluaing he mediaing effecs o socialsuppor upon lie evens and depressive sympoms. J. Communiy Psychol. 10, 325–340.

8. Bengel J., Sritmater ., Willmann H., 1999. esearch and Pracice o Healh Promo-tion Volume 4. What keeps people healthy? e Current State of Discussion and theelevance o Anonovsky’s Saluogenic Model o Healh. 4, 1–130.

9. Bosma H., Peer ., Siegris J., Marmo M., 1998. wo alernaive job sress models andhe risk o coronary hear disease. Am. J. Public Healh 88, 68–74.

10. Brugha .S., Weich S., Singleon N., Lewis G., Bebbingon P.E., Jenkins ., MelzerH., 2005. Primary group size, social suppor, gender and uure menal healh sausin a prospecive sudy o people living in privae households hroughou Grea Briain.Psychol. Med. 35, 705–714.

11. Cannon W.B., 1930. e auonomic nervous sysem: An inerpreaion. Lance I, 1109–1115.

12. Caplan G., 1974. Suppor Sysems and Communiy Menal Healh. Behavioral Publica-ions, New York, NY.

13. Caplan .D., 1987. Person-environmen fi heory and organizaions: Commensuraedimensions, time perspectives, and mechanism. Journal of Vocational Behavior 31,248–267.

14. Cobb S., 1976. Presidenial Address–1976. Social suppor as a moderaor o lie sress.Psychosom. Med. 38, 300 –314.

15. Cole .., Carlin N., 2009. e ar o medicine. e suffering o physicians. e Lance,374, 1414–1415.

16. Cooper C.L., Clarke S., owbotom A.M., 1999. Occupaional sress, job saisacion and

well-being in anaesheiss. Sress Med. 15, 115–126.17. Cox ., ial-Conzález E., 2000. esearch on Work-elaed Sress. European Agency or

Saey and Healh a Work, Luxembourg.




18. Cropanzano ., Byrne Z.S., Bobocel D.., upp D.E., 2001. Moral virues, airness heu-ristics, social entities, and other denizens of organizational justice. J. Vocat. Behav. 58,164–209.

19. Cummings .G., Cooper C.L., 1979. Cyberneic Framework or Sudying OccupaionalSress. Human elaions, 395–418.

20. Dembe A.E., Erickson J.B., Delbos .G., Banks S.M., 2005. e impac o overime andlong work hours on occupaional injuries and illnesses: new evidence rom he UniedSaes. Occup. Environ. Med. 62, 588–597.

21. De Oliveira G.S. Jr.; Ahmad S., Sock M.C., Harer L.L., Almeida M.D., Fizgerald P.C.,MaCarhy .J. 2011. High incidence o burnou in academic chairpersons o aneshe-siology: should we be aking beter care o our leaders? Aneshesiology. 114(1), 181-93.

22. Dickson D.E., 1996. Sress. Anaeshesia 51, 523–524.

23. Dinges D., ogers N., Baynard M., 2005. Chronic Sleep Deprivaion, in: ryger M.H.,

oh ., Demen W.C., (Eds.), Principles and Pracice o Sleep Medicine, 4h ed. ElsevierSaunders, Philadelphia.

24. Edwards N., ornacki M.J., Silversin J., 2002. Unhappy docors: Wha are he causes and wha can be done? BMJ 324, 835–838.

25. Elovainio M., ivimäki M., Helkama ., 2001. Organizaion jusice evaluaions, jobconrol, and occupaional srain. J. Appl. Psychol. 86, 418–424.

26. Elovainio M., Kivimäki M., Vahtera J., 2002. Organizational justice: evidence of a newpsychosocial predicor o healh. Am. J. Public Healh 92, 105–108.

27. Elovainio M., Kivimäki M., Vahtera J., Ojanlatva A., Korkeila K., Suominen S., Helenius

H., oskenvuo M., 2003. Social suppor, early reiremen, and a reiremen preerence: asudy o 10,489 Finnish aduls. J. Occup. Environ. Med. 45, 433–439.

28. Elovainio M., van den Bos K., Linna A ., Kivimäki M., Ala-Mursula L., Peni J., Vahtera J., 2005. Combined effecs o uncerainy and organizaional jusice on employee healh:esing he uncerainy managemen model o airness judgmens among Finnish publicsecor employees. Soc. Sci. Med. 61, 2501–2512.

29. Erben ., Franzkowiak P., Wenzel E., 1989. Die Ökologie Des örpers. onzepuelleUberlegungen Zur Gesundheisörderung. , in: Wenzel, E. (Ed.), Die Ökologie des ör-pers. Suhrkamp, Frankur, pp. 13–120.

30. Faragher E.B., Cass M., Cooper C.L., 2005. e relaionship beween job saisacion andhealh: a mea-analysis. Occup. Environ. Med., 62, 105–112.

31. Gander P., Millar M., Webser C., Merry A., 2008. Sleep loss and perormance o anaes-hesia rainees and specialiss. Chronobiol. In. 25, 1077–1091.

32. Gold M.S., Fros-Pineda ., Melker .J., 2005. Physician suicide and drug abuse. Am. J.Psychiary 162, 1390.

33. Hagopian A., Zuyderduin A., yobuungi N., Yumkella F., 2009. Job saisacion andmorale in he Ugandan healh workorce. Healh. Aff. (Millwood) 28, 863–75.

34. Hakanen J., 2009. Do engaged employees perorm beter a work? e moivaing powero job resources and work engagemen on uure job perormance. Working papers, Nor-dic projec “Posiive acors a work”. Finnish Insiue o Occupaional Healh.




35. Hammer .H., Saksvik P.O., Nyro ., orvan H., Bayazi M., 2004. Expanding hepsychosocial work environmen: workplace norms and work-amily conflic as correlaeso sress and healh. J. Occup. Healh Psychol. 9, 83–97.

36. Hawon ., Clemens A., Sakarovich C., Simkin S., Deeks J.J., 2001. Suicide in docors:a sudy o risk according o gender, senioriy and specialy in medical praciioners in

England and Wales, 1979–1995. J. Epidemiol. Communiy Healh 55, 296–300.37. Hem E., Grønvold N.T., Aasland O.G., Ekeberg O., 2000. e prevalence of suicidal ide-

aion and suicidal atemps among Norwegian physicians. esuls rom a cross-secionalsurvey o a naionwide sample. Eur. Psychiary 15, 183–189.

38. Hemsröm O., 2001. Working condiions, he work environmen and healh. Healh inSweden: e Naional Public Healh epor 2001. Scand. J. Public. Healh. Suppl. 58,167–184.

39. Heponiemi ., Elovainio M., ivimäki M., Pulkki L., Putonen S., elikangas-JärvinenL., 2006. e longiudinal effecs o social suppor and hosiliy on depressive endencies.

Soc. Sci. Med. 63, 1374–1382.40. Heponiemi T., Kouvonen A., Vänskä J., Halila H., Sinervo T., Kivimäki M., Elovainio M.,

2008. Effecs o acive on-call hours on physicians’ urnover inenions and well-being.Scand. J. Work Environ. Healh 34, 356–363.

41. Hoboll S.E., 1988. e Ecology o Sress. Hemisphere Publishing Corporaion, New York.

42. Hochkiss N., Early S., 2009. e Difference in eeping Boh Male and Female Physi-cians Healhy. e Healh Care Manager 28(4), 299–310.

43. Hyyppä M.., ronholm E., Matlar C.E., 1991. Menal well-being o good sleepers in a

random populaion sample. Br. J. Med. Psychol. 64 ( P 1), 25–34.44. Jackson S.H., 1999. e role o sress in anaesheiss’ healh and well-being. Aca Anaes-

hesiol. Scand. 43, 583–602.

45. alimo ., Pahkin ., Muanen P., oppinen-anner S., 2003a. Saying well or burningou a work: work characerisics and personal resources as long-erm predicors. WorkSress 17, 109–122.

46. al imo ., aris .W., Schaueli W.B., 2003b. e effecs o pas and anicipaed uuredownsizing on survivor well-being: an equiy perspecive. J. Occup. Healh Psychol.8, 91–109.

47. arasek .A., 1979. Job Demands, Job Decision Laiude, and Menal Srain – Implica-ions or Job edesign. Adm. Sci. Q. 24, 285–308.

48. arasek ., 1990. Healhy Work: Sress, Produciviy, and he econsrucion o Working Lie. Basic Books, New York.

49. eesing ., 1981. Culural Anhropology. A Conemporary Perspecive. Hol, ineharand Winson, New York.

50. haw .., 1997. Which docors die firs? Lower mean age a deah in docors o Indianorigin may reflec differen age srucures. BMJ 314, 1132.

51. Kivimäki M., Elovainio M., Vahtera J., Virtanen M., Stansfeld S.A., 2003a. Association beween organizaional inequiy and incidence o psychiar ic disorders in emale em-ployees. Psychol. Med. 33, 319–326.




52. Kivimäki M., Head J., Ferrie J.E., Shipley M.J., Vahtera J., Marmot M.G., 2003b. Sicknessabsence as a global measure o healh: evidence rom moraliy in he Whiehall II pros-pecive cohor sudy. BMJ 327, 364.

53. Kivimäki M., Vahtera J., Elovainio M., Peni J., Virtanen M., 2003c. Human costs oforganizaional downsizing: comparing healh rends beween leavers and sayers. Am. J.

Communiy Psychol. 32, 57–67.54. Kivimäki M., Virtanen M., Elovainio M., Kouvonen A., Väänänen A., Vahtera J., 2006.

Work sress in he eiology o coronary hear disease – a mea-analysis. Scand. J. WorkEnviron. Healh 32, 431–442.

55. luger M.., ownend ., Laidlaw ., 2003. Job saisacion, sress and burnou in Aus-ralian specialis anaesheiss. Anaeshesia 58, 339–345.

56. Kouvonen A., Kivimäki M., Väänänen A., Heponiemi T., Elovainio M., A la-Mursula L., Virtanen M., Peni J., Linna A., Vahtera J., 2007. Job strain and adverse health behaviors:he Finnish Public Secor Sudy. J. Occup. Environ. Med. 49, 68–74.

57. Lazarus ., Folkman S.,1984. Sress, appraisal and coping. Springer, New York.

58. Lew E.A., 1979. Moraliy experience among aneshesiologiss, 1954–1976. Aneshesio-logy 51, 195–199.

59. Lieff S.J., 2009. e Missing Link in Academic Career Planning and Developmen: Pur-sui o Meaningul and Aligned Work. Academic Medicine 84(10), 1383–1388.

60. Lindeman S., 1997. Suicide among physicians. Academic disseraion. Universiy o Oulu.

61. Lindors P.M , Nurmi K, Meretoja OA, Luuk konen , Leino TJ, Viljanen A-M, HärmäM., 2006. On-call sress among Finnish anaesheiss. Anaeshesia. 61, 856–866.

62. Lindors PM, Mereoja OA, öyry SM, Luukkonen R, Elovainio MJ, Leino J., Jobsaisacion, work abiliy and lie saisacion among Finnish anaeshesiologiss. Aca Anaeshesiol Scand. 2007; 51, 815–22.

63. Lindors P.M., Mereoja OA, Luukkonen R, Elovainio MJ, Leino J., 2009a. Atiudeso job urnover among Finnish anaesheiss. Occup Med (Lond).59, 126–9.

64. Lindors P.M., Mereoja OA, Luukkonen R, Elovainio MJ, Leino J., 2009b. Suicidaliyamong Finnish aneshesiologiss. Aca Anaeshesiol Scand. 53, 1027–35.

65. Lindors P.M., Heponiemi ., Mereoja O.A., Leino .J., Elovainio M.J., 2009. Mi-igaing on-call sympoms hrough organizaional jusice and job conrol: a cross--secional sudy among Finnish aneshesiologiss. Aca Anaeshesiol. Scand. 53,1138–1144.

66. Lindors P., 2010. Work-relaed well-being o Finnish aneshesiologiss. People and work.esearch repors 88, Finnish Insiue o Occupaional Healh, Helsinki.

67. Lindors P. , 2012. educing sress and enhancing well-being a work: are we looking a he righ indicaors? European Journal o Anaeshesiology. 29; 7, 309-310.

68. Louis M.., 1980. Organizaions as Culure-Bearing Milieux, in: Pondy, L.. , Fros P.,Morgan G., Dandridge . (Eds.), Organizaional Symbolism. JAI, Greenwich, C.

69. Malmberg B., Persson ., Jonsson B.A, Erurh E.M., Flisberg B., anklev E., OrbaekB., 2007. Physiological resiuion aer nigh-call duy in anaeshesiologiss: impac onmeabolic acors. Aca Anaeshesiol. Scand. 51(7), 823–830.

http://tuhat.halvi.helsinki.fi/portal/fi/persons/pirjo-lindfors(843a906a-4012-4e5a-af38-020696b4a79c).html

http://tuhat.halvi.helsinki.fi/portal/fi/publications/reducing-stress-and(c3ee114a-e96b-4430-bcb7-76e46042c7ef).html




http://tuhat.halvi.helsinki.fi/portal/fi/persons/pirjo-lindfors(843a906a-4012-4e5a-af38-020696b4a79c).html




70. Marmo M.G., Bosma H., Heming way H., Brunner E., Sanseld S., 1997. Conribuion o job conrol and oher risk acors o social variaions in coronary hear disease incidence.Lance 350, 235–239.

71. Maslach C., Schaueli W.B., Leier M.P., 2001. Job burnou. Ann. ev. Psychol. 52,397–422.

72. Maslach C., 1996. Maslach Burnou Invenory Manual, 3rd ed. Consuling PsychologissPress, Palo Alo, Cali.

73. McAuliffe P.F., Gold M.S., Bajpai L., Merves M.L., Fros-Pineda ., Pomm .M., Gold- berger B. A., Melker .J., Cendán J.C., 2006. Second-hand exposure o aerosolized inravenous anesheics propool and enanyl may cause sensiizaion and subsequen opiaeaddicion among aneshesiologiss and surgeons. Med. Hypoheses 66(5), 874–882.

74. McEwen B.S., 1998. Sress, adapaion, and disease. Al losasis and allosaic load. Ann.N. Y. Acad. Sci. 840, 33–4 4.

75. McEwen B.S., 2002. Sex, sress and he hippocampus: allosasis, allosaic load and heaging process. Neurobiol. Aging 23, 921–939.

76. McEwen B.S., 2007. Physiology and neurobiology o sress and adapaion: cenral role ohe brain. Physiol. ev. 87, 873–904.

77. McEwen B.S., Sellar E., 1993. Sress and he individual. Mechanisms leading o disease. Arch. Inern. Med. 153, 2093–2101.

78. Megdal S.P., roenke C.H., Laden F., Pukkala E., Schernhammer E.S., 2005. Nigh work and breas cancer risk: a sysemaic review and mea-analysis. Eur. J. Cancer 41,2023–2032.

79. Meier-Ewer H.., idker P.M., iai N., egan M.M., Price N.J., Dinges D.F., Mull ing-on J.M., 2004. Effec o sleep loss on C-reacive proein, an inflammaory marker ocardiovascular risk. J. Am. Coll. Cardiol. 43, 678–683.

80. Mezzich J.E., Caracci G., Fabrega H.,Jr., irmayer L.J, 2009. Culural ormulaion gui-delines.ransculural Psychiary 46(3), 383–403. Mion G., icouard S., 2007. es orsaey: which sakes?[in French] Ann. Fr. Anaesh. eanim. 26(7–8), 638–648.

81. Munaner C., Benach J., Hadden W.C., Gimeno D., Benavides F.G., 2006. A glossary orhe social epidemiology o work organisaion: par 1, erms rom social psychology. J.Epidemiol. Communiy Healh 60, 914–916.

82. Nyssen A-S. and Hansez I., 2008. Sress and burnou in anaeshesia. Curren Opinion in Anaeshesiolog y 21, 406– 411.

83. Ohayon M.M., Parinen M., 2002. Insomnia and global sleep dissaisacion in Finland. J. Sleep es. 11, 339–346.

84. Ohonen P., Alahuha S., 2002. Moraliy among Finnish aneshesiologiss rom 1984–2000. Aca Anaeshesiol. Scand. 46, 1196–1199.

85. Payne .L ., ick J.., 1986. Hear rae as an indicaor o sress in surgeons and anaeshe-iss. J. Psychosom. es. 30, 411–420.

86. ama-Maceiras P., Parene S., ranke P., 2012. Job saisacion, sress and burnou in anaeshesia: relevan opics or anaeshesiologiss and healhcare managers? European Journal o A naeshesiolog y. 29 (7) 311-319.

http://journals.lww.com/ejanaesthesiology/Abstract/2012/07000/Job_satisfaction,_stress_and_burnout_in.4.aspx







87. ama-Maceiras P., ranke P., 2013. Working condiions and proessional well-being: A linkeasy o imagine bu difficul o prove. European Journal o Anaeshesiology. 30 (5), 213-15.

88. odwell J., Noble A., Demir D., Seane P., 2009. e impac o he work condiions oallied healh proessionals on saisacion, commimen and psychological disress. Heal-h Care Manage. ev. 34, 273–283.

89. Sarason I.G., Sarason B.., Shearin E.N., Pierce G.., 1987. A brie measure o social sup-por: pracical and heoreical implicaions. Journal o Social and Personal elaionships4, 497–510.

90. Saunders D., 2006. e older anaesheis. Bes Prac. es. Clin. Anaeshesiol. 20, 645–651.

91. Schauel i W.B., Enzmann D., 1998. e Burnou Companion o Sudy and Pracice: ACriical Analysis. aylor & Francis, London.

92. Schaueli W.B., aris .W., 2005. e concepion and measuremen o burnou:common grounds and worlds apar. Work sress 19, 256–262.

93. Schein E.H., 1985. Organizaional culure and Leadership. Jossey-Bass, San Fransisco.94. Schernhammer E.S., Coldiz G.A., 2004. Suicide raes among physicians: a quaniaive

and gender assessmen (mea-analysis). Am. J. Psychiary 161, 2295–2302 .

95. Schernhammer E., 2005. aking heir own lives – he high rae o physician suici-de. N. Engl. J. Med. 352, 2473–2476.

96. Seeley H.F., 1996. e pracice o anaeshesia – a sressor or he middle-aged? Anaeshesia 51, 571–574.

97. Selye H., 1946. e general adapaion syndrome and he diseases o adapaion. J.Clin. Endocrinol. 6, 117–230.

98. Selye H., 1974. Sress wihou Disress. Lippencot, New York.

99. Shanael .D., Sloan J.A.,Habermann .M.,2003. e Well-Being o Physicians. Associaion o Proessors o Medicine 114, 513–519.

100. Sherbourne C.D., Sewar A.L., 1991. e MOS social suppor survey. Soc. Sci. Med.32, 705–714.

101. Skipper G.E., Campbell M.D., Dupon .L., 2009. Aneshesiologiss wih subsanceuse disorders: a 5-year ouome sudy rom 16 sae physician healh programs. Anesh. Analg. 109(3), 693–694.

102. Smircich L., 1985. Is he Concep o Culure a Paradigm or Undersanding Organiza-ions and Ourselves?, in: Fros J.P., Moore L.F., Louis M.., Lundberg C.C., Marin J.(Eds.), Organizaional Culure. Sage, Newbury Park, Caliornia, pp. 55–72.

103. Sanseld S.A., Bosma H., Hemingway H., Marmo M.G., 1998. Psychosocial work cha-racerisics and social suppor as predicors o SF–36 healh uncioning: he WhiehallII sudy. Psychosom. Med. 60, 247–255.

104. Serling P., Eyer J., 1988. Allosasis: A New Paradigm o Explain Arousal Pahology., in:Fisher S., eason J. (Eds.), Handbook o Lie Sress, Cogniion and Healh. J. Wiley Ld.,New York, pp. 631.

105. Suadicani P., Hein H.O., Gynelberg F., 1995. Do physical and chemical working condi-ions explain he associaion o social class wih ischaemic hear disease? Aherosclerosis113, 63–69.




106. Svärdsudd ., Wedel H., Gordh .,Jr, 2002. Moraliy raes among Swedish physicians:a populaion-based naionwide sudy wih special reerence o aneshesiologiss. Aca Anaeshesiol. Scand. 46, 1187–1195.

107. Södereld B., Södereld M., Munaner C., O C̀ampo P., Warg L.-E., Ohlson C-G., 1996.Psychological work environmen in human service organizaions: a concepual analysis

and developmen o he demand-conrol model. Soc. Sci. Med., 1217–26.108. Theorell T. , Orth-Gomer K. , Eneroth P. , 1990. Slow-reacing immunoglobulin in re-

laion o social suppor and changes in job srain: a preliminary noe. Psychosom Med52(5), 511–516.

109. öyry S., 2005. Burnou and Sel-epored Healh among Finnish Physicians. Univer-siy o uopio, uopio.

110. ylor E., 1871. e Primiive Culure. esearches ino he Developmen o Myhology,Philosophy, eligion, Language, Ar and Cusom. John Murray, London.

111. Tyssen R., Hem E., Gude T., Grønvold N.T., Ekeberg O., Vaglum P., 2007. Lower lifesaisacion in physicians compared wih a general populaion sample. Soc. PsychiaryPsychiar. Epidemiol. 44, 47–54.

112. Vahtera J., Kivimäki M., Peni J., Linna A ., Virtanen M., Virtanen P., Ferrie J.E ., 2004.Organisaional downsizing, sickness absence, and moraliy: 10–own prospecive co-hor sudy. BMJ 328, 555.

113. Van Amelsvoort L.G., Kant I.J., Bultmann U., Swaen G.M., 2003. Need for recoveryaer work and he subsequen risk o cardiovascular disease in a working populaion.Occup. Environ. Med. 60 Suppl 1, i83–87.

114. Van Cauter E., 2005. Endocrine Physiology, in: Kr yger M.H., Roth T., Dement W.C.,(Eds.), Principles and Pracice o Sleep Medicine 4h ed. Elsevier Saunders, Philadel-phia, pp. 266–282.

115. Van Ham I., Verhoeven A .A ., Groenier K.H., Grootho J.W., De Haan J., 2006. Job sa-isacion among general pracioners: a sysemaic lieraure review. Eur. J. Gen. Prac.12(4), 174–180.

116. Vis wesvaran C., Sanchez J.I., Fisher J., 1999. e Role of Social Support in the Process of Work Stress: A Meta-Analysis. Journal of Vocational Behavior 54, 314–334.

117. Wallace J.E, Lemaire J.B, Williams A.G., 2009. Physician wellness: a missing qualiy

indicaor. e Lance 374, 1714–1721.118. WHO, 1948. Official ecords o he World Healh Organizaion, no. 2., p. 100.

119. Williams E.S., Skinner A.C., 2003. Oucomes o Physician Job Saisacion: A Narraiveeview, Implicaions, and Direcions or Fuure esearch. Healh Care Manage. ev.28(2), 119–140.

120. Wrigh D.J., obers A.P., 1996. Which docors die firs? Analysis o BMJ obiuar y colu-mns. BMJ 313, 1581–1582.

121. Åkersed ., Fredlund P., Gillberg M., Jansson B., 2002. Work load and work hours inrelaion o disurbed sleep and aigue in a large represenaive sample. J. Psychosom. es.53, 585–588.

http://www.refworks.com/Refworks/~0~








- Part 2 -Institutional responsibility forphysician (anesthesiologist)

occupational well-being



2.1 - Correlaion beween aneshesiologiss’ occupaional well-being and surgical ... | 167

Correlaion Beween Aneshesiologiss’ Occupaional Well-being and Surgical Paien Saey

Pro. Dr. Gasão F. Duval Neo,SA, PhD

Proessor in he Deparmen o Aneshesiolog y, School o Medicine UFPelChairman o he Occupaional Healh Comission o he Brazilian Sociey o Aneshesiology

Chairman o he Proessional Well-being Commitee o W FSA

Inroducion

e correlaion beween aneshesiologiss’ occupaional healh and he incidenceo criical adverse evens in clinical aneshesiology has been well evidenced in helieraure. In his area o medicine, occupaional aigue is one o he main acors

accounable or he high prevalence o crises1-5.

A large number o publicaions indicae ha excessive workload among physicians(average working hours, including shis), including aneshesiologiss, resuls in highlevels o aigue and a marked decrease in produciviy and proessional perormance.ese characerisics conribue o an eviden increase in he incidence o criicalevens, medical malpracice included, in surgical paiens, compromising heir saey.

I should be acknowledged ha muliple acors conribue o he esablishmeno occupaional aigue, as well as is consequences: burnou syndrome, chemical

dependency, menal depression, suicidal ideaion and ohers.is chaper aims o discuss he responsibiliy o medical insiuions ha conrolhe qualiy o medical raining and clinical pracice in atemping o also conrol heeiological acors o pahological condiions ha aler he occupaional healh oaneshesiologiss, hus enhancing paien saey.

able 1 – Basic conceps on occupaional wel l-being on medicine. Classes o recommendaionand Levels o evidence.

Classes o ecommendaion

I Consensus and evidence avoring indicaionIIa Divergence exiss, bu he majoriy avors indicaionIIb Divergence and division o opinionsIII No recommended

Levels o Evidences A Muliple conrolled and randomized clinical rialsB Single conrolled and randomized clinical rial, non-randomized clinical rials,

well-designed obser vaional sudiesC Case series or case repors

D Exper consensus All he iems ha comprise he bibliography o his chaper are raed level o evidence A and B accordingo he classificaion o he Oxord Cenre or Evidence-Based Medicine. Figure 1




“Te secre o healh or boh mind and body is no o mourn orhe pas, worry abou he uure, or anicipae roubles, bu olive in he presen momen wisely and earnesly”

Buddha

Alhough Occupaional well-being is a difficul opic o address, in 2005, he WorldHealh Organizaion (WHO) defined i as6: “An individual’s percepion o heirposiion in lie in he conex o he culure and value sysems in which hey live andin relaion o heir goals, expecaions, sandards and concerns.”

his percepion can be alered by a complex range o siuaions, includinghe physical or menal sae o proessionals , heir personal belies and socio-

proessional approach o signiican evens in heir lives, including he work-place environmen.

ese heoreical conceps raise a quesion o pracical imporance: How do I eelmenally and physically each momen o every day regarding my proessional aciv-iy, my relaionships and my workplace environmen?

When aced wih his quesion, one should ponder wheher he is merely acingdifficulies and rusraions in he managemen o common sressul siuaions or wheher he has progressed ino a depressive syndrome as a resul o biased inerpre-

aion o proessional siuaions as excepionally sressul (he capaciy or percep-ion o occupaional sress varies widely beween individuals).

Proessor Hugo Hans Selye sudied individual adapabiliy and described sressas he insidious desrucion ha resuls rom cumulaive depleion o inernalresources. us, i is essenial o undersand ha each individual has heir ownhreshold o inernal capaciance or coping healhily wih sress and ha, since hisabiliy varies among individuals, i is no liable o inerpersonal comparisons. ere-ore, he esablishmen o conduc guidelines in relaion o clinical aciviy mus

respec proessionals’ singulariy 6. Anes hesiologiss are o en araced o he specia l y due o he saisacionderived rom shor bu inense conac wih paiens, he developmen omanual echnical skills, knowledge and handling o increasingly echnologicequipmen, he conac beween dieren specialies and he abiliy o seeimmediae resuls o inervenions. On he oher hand, oen he price o bepaid upon enering his proessional realiy is recurren loss o conrol, whichor some people means he ra nsiion rom posiive sress o a pahological con-

diion described as psychogenic disress (see Figure 1). Disress or negaivesress is he excessive sress ha occurs when one goes beyond personal limisand deplees his adapive resources.




Figure 1 - Correlaion beween sress/occupaional anxiey and perormance/proessional efficiency

Occupaional well-being o a healhcare proessional is one’s personal undersanding onposiive or negaive acors ha he or she is subjeced o during rouine clinical pracice.

e human body and he psyche should be viewed holisically, wihou dichoomicdivisions. is concep is suppored by neuroimaging and elecron microscopy sud-

ies ha prove ha menal phenomena are closely associaed wih neurochemicalchanges and vice versa.

Aneshesiology is a specialy considered o have promped major advances in surgi-cal paien saey over he las decades. ere has been significan improvemen inraes o morbidiy and moraliy due o innovaions in monioring and grea prog-ress in he undersanding o pharmacology applied o clinical pracice. However, inspie o scienific and echnological evoluion, paien harm coninues o exis as aresul o criical adverse evens caused by aneshesiologiss (medical malpracice).

One o he main causes o medical malpracice, well documened in he medicallieraure, is he level o occupaional sress and is consequences on saff (aigue, burnou, addicion, menal depression, ec..). is siuaion oen develops in aninsidious, cumulaive ashion7.8.

he growing demand o psychological pressure a work, associaed wih per-sonal and social commimens, can be a heavy burden o carry, oen resulingin occupaional aigue syndrome or disrupion o occupaional well-being inclinical aneshesiologiss.

Occupaional Faigue (also known as exhausion, iredness, lehargy, aigue, apa-hy, prosraion and lassiude) can be differeniaed based on predominance o iseffecs on he physical or psychological level.




Physical aigue can be defined as he inabiliy o mainain ull operaion o one’sechnical and scienific skills and usually becomes clearly visible during inenseclinical pracice, ranging rom a general sae o lehargy o a specific sensaion ogrea physical exhausion3.

On he oher hand, menal aigue (cogniive dysuncion) is seen as he main caus-aive agen o medical malpracice and criical incidens among aneshesiologiss. Imaniess as drowsiness, loss o concenraion and, consequenly, inabiliy o per-orm accurae clinical assessmens and impaired decision-making when acing emer-gencies. A presen, his is he psychological condiion ha mos direcly impacshe perormance o aneshesiologiss, placing he saey o surgical paiens a risk 9.

For decades, he work o he aneshesiologis has been described as “hours o bore-dom inerspersed wih momens o error”. e key quesion is wha measures can beaken o preven edious hours rom inerering wih physician perormance whenhe momens o error occur.

Careul analysis o inormaion regarding physician occupaional healh, paricu-larly among aneshesiologiss, leads o he very disurbing conclusion ha effeciveinsiuional suppor sysems or occupaional diseases are almos non-exisen inhe world (see he survey o he Proessional Well-being Commitee o he WorldFederaion o Socieies o Aneshesiology).

Imporan inormaion abou suppor sysems o physician occupaional healh is

provided hrough a Canadian organizaion called Physician Healh Program (OMAOnario Medical Associaion). Figure 2 shows saisics rom his cener, demon-sraing significan dispariy beween somaic and psychiaric pahologies and high-lighing he clear prevalence o psychiaric disorders in relaion o somaic ones10.

Figure 2 - Case series o he Suppor o Canadian Physicians’ Healh Program




In Brazil, a research insiue or he reamen o addiced physicians (UNIAD)rom he Universiy o São Paulo, presened a case series, shown in able I , including57 aneshesiologiss wih clinical evidence o drug addicion reaed in ha depar-men. (Inernal hospial inormaion daa)

able II demonsraes he requency o psychiaric comorbidiy among aneshesi-ologis addics reaed in UNIAD. As noed earlier, here is an obvious correlaion beween psychogenic pahologies developed while pracicing aneshesiology andhe esablishmen o chemical dependence.

able II – Preva lence o comorbiies in drug addics rom Uniad (São Paulo)

Diagnosis o psychological diseases (CID 10)

n %

oal number o cases wih morbidiiesDepression (F32 e F33)Personaliy disurbances (F60)Bipolar disurbances (F31) An xiey disurbances (F41)Schizophrenia (F20)

24126541

42,121,010,58,77,01,7

e agens mos oen used by his group o paiens were opioids (53%), benzodiaz-epines (30%) and alcohol (23%). Chemical dependence in aneshesiologiss shows a

srong prevalence o opioids in relaion o oher drugs. Easy access o hese drugs inoperaing suies, recovery rooms and pos-operaive care unis (able III) increasessignificanly he difficuly in providing psychiaric suppor, reamen and effeciverehabiliaion o specialiss in aneshesiology. e risks are high or relapse anddeah by suicide or overdose (alered geneic coding).

able III – Case series rom Cener or reamen o Physicians Uniad – Uniesp (São Paulo)

Mos used drugs

Drugs oal Alarming Use

n (%) Addicion

n (%)

AlcoholBenzodiazepinesOpioidsCocaine and crack Marijuana AmpheaminesInhalaional drugs

20 (35,1)20 (35,1)34 (59,6)

3 (5,2)6 (10,5)6 (10,5)1 (1,8)

7 (12,3)3 (5,2)4 (7,0)3 (5,2)4 (7,0)2 (3,5)1 (1,8)

12 (22,8)17 (29,8)30 (52,6)

0 (0)2 (3,5)4 (7,0)0 (0)

Summary - A presen, concerns abou occupaional well-being o aneshesiologissas well as he prevalence o is disrupions and heir consequences (aigue, sress,menal depression, addicion, suicidal ideaion and ohers) are well esablished in




he lieraure. is indicaes he need or awareness and insiuional acions aimeda addressing he problem in is muliple aspecs.

Curren Saus o Occupaional Well-being in Medical Educaion (medical su-dens and residens) and in he pracice o Aneshesiology

Occupaional well-being is a direc reflecion o he proessional’s psychic saisacionin he workplace, he lack o which inereres markedly wih he aneshesiologis’squaliy o lie and endangers his healh as well as paien saey. Cerainly, inegraing working condiions wih physician qualiy o lie in order o provide menal balanceand personal saisacion will lead o higher levels o occupaional well-being.

Occupaional well-being disurbances have significan prevalence in medicine,saring as early as in medical school.

During basic raining, residens in aneshesiology as well as heir supervisors should be alered by he insiuions responsible or medical raining (Medical Schools andCeners o Clinical Learning and raining) abou he risks or and consequenceso pahologic disrupions o occupaional well-being. ose include aleraions inclinical perormance, increased risks or paiens under heir responsibiliy and risko deah due o chemical dependency. Increasing awareness and creaing srucuredsuppor sysems are exremely valuable, especially or inerns, residens and heirmenors under increased risk o developing addicion, such as hose wih high levelso sress and depression.

e sudy o occupaional aigue in physicians who work in clinical or experimenalenvironmens is highly complex due o is muliacorial naure, variaion over imein psychologically differen people and overlapping wih associaed condiions, suchas high level o occupaional sress, burnou syndrome, addicion and suicidal ide-aion. However, he sudy o occupaional aigue and he bes means o conrollingi is o criical imporance or he mainenance o aneshesiologiss’ occupaionalhealh and paien saey.

Docors are rained o ocus exclusively on he paien in heir clinical pracice, osuch a grea degree hey oen ignore heir own healh and sae o occupaional well- being. However, i should be emphasized ha physician healh has a direc impac onpaien saey, hereore insiuions should also urn heir atenions o healhcareproviders’ well-being. a kind o atenion should be specifically highlighed con-cerning occupaional aigue o he aneshesiologis and is consequences, in order opreven his oen laen hrea rom progressing ino damage o he paien11.

e medical lieraure has shown a significanly higher prevalence o pahologicaldisurbances o occupaional well-being, such as burnou syndrome, in docors and

nurses when compared wih he general populaion in he U.S. Docors who perormheir aciviy on he ron line o medical care (Inensive Care Uni and Emergencyoom) are more predisposed o hese complicaions12.




In recen decades, he work perormed by aneshesiologiss has changed dramai-cally in naure and inensiy. e adven o new echnologies has expanded he surgi-cal horizon and allowed surgical inervenions o be perormed in paiens wih morechallenging medical condiions. ese acs, coupled wih he suracing o more di-ficul cases, o increasing emoional pressure, consan economic compeiiveness

and he need o do “more” wih “reduced” workorce significanly raise he incidenceo occupaional sress and disress and all heir consequences in he clinical praciceo aneshesiology.

Curren epidemiologic sudies on physician occupaional healh ocus mainly oninvesigaing he prevalence o somaic and/or psychological pahologies, such asdegeneraive, cardiovascular, inecious and oxic diseases, aigue and exhausion,menal depression and addicion13,14. On he oher hand, i is eviden how litle has been done regarding he prevenion o hese healh issues and he ongoing maine-

nance o he occupaional well-being o physicians. As commened earl ier in he ex, occupaional diseases have an early onse inhe proessional lives o physicians, chiely in basic medical educaion, i.e., medi-cal school.

A sysemaic analysis o aricles on he incidence o depression, an xiey and burnousyndrome among medical sudens in he U.S. and Canada reached he conclusionha medical school is a period o inense occupaional sress in one’s lie, oen lead-ing o pahological condiions as psychogenic disress. Unorunaely, curren sci-enific knowledge is insufficien in mehodological qualiy and number o esablishhe causaive acors and he insiuional courses o acion o be aken regardinghis issue. ereore, i is necessary o develop epidemiological sudies, especiallymulicener prospecive cohor sudies wih adequae saisical power o ideniyindependen predicors, eiher individual or relaed o medical raining, which con-ribue o he developmen o depressive, anxiey and burnou syndromes amongmedical sudens. Subsequenly, he relaionship beween siuaions o psychogenicdisress and universiy raining regimen can be invesigaed in deph (e.g. revision o

he curriculum o medicine and medical residency programs). Surely his is a matero insiuional responsibiliy or he qualiy o basic medical raining and here is apressing need or policies o esablish diagnoses and implemen suppor mechanismsor rainee docors15.

Psychological disress is quie prevalen among medical sudens, so curriculumorganizaion and inrinsic requiremens or he evaluaion o progress wihin universiy srucures can be exremely imporan in alering he sae o occupaionalhealh in his group o novices.

A recen sudy evaluaed he relaionship beween curricular srucure and level odemands in differen universiies and heir repercussions in he occupaional well- being o medical sudens. is survey included academics rom 12 medical schools




reurned o medicine could successully resume heir raining in aneshesiology and9% died premaurely (overdose, suicide?). e auhors concluded ha aneshesiol-ogy rainees ha develop addicion during he residency may be beter off choosinga differen medical specialy wih lower risk or psychogenic disorders19.

A sudy invesigaing he rouine pracice o exra-curricular aciviies (physicalexercise, non-medical culural aciviies and ohers) developed by he residens ascompared wih hose developed by medical sudens and/or docors aer residency,shows ha he firs group perorm significanly lower levels o hese aciviies hanhe oher wo. is may be one o he acors ha conribue o he esablishmen opsychopahological syndromes as burnou during he medical residency 20.

Lieraure shows a consisen increase in he prevalence o burnou syndrome(diagnosed wih he Maslach Quesionnaire) during residency programs in variousspecialies, amouning o 76% in Inernal Medicine programs, 90% in Obserics-Gynecology, 74% in Pediarics, and 27% in Oolaryngology and Family Medicine.Furhermore, he incidence is significanly higher among rainee docors hanheir supervisors21.

e abovemenioned siuaion is no differen in Aneshesiology: a sudy developedin Belgium addressed he incidence o burnou syndrome in aneshesiology residensand aculy supervisors (n = 318) and showed high prevalence o his syndrome,mainly in young residens. 40.4% o he sudy subjecs showed moderae o severelevels o he syndrome. (able IV )22

able IV – Levels o burnou according o age ranges o aneshesiologiss *

Levels o Burnou

Ages Low Moderae High

<3030-35

35

48

11

342112

241215

* Br J Anaesh, 2003;90(3):333-373

Medical lieraure suggess he exisence o a significan number o predicors or heesablishmen o syndromes secondary o disrupions in he occupaional well-beingo young aneshesiologiss. Some o hem are he number o working hours, he levelo occupaional sress in he workplace, negaive signs o personaliy as inense pes-simism, loss o sel-confidence, lack o social and echnical suppor and sympomso burnou. In addiion, oher acors such as unsable and disorganized personaliyprofile and he absence o regular perormance assessmen ( eedback) conribue ohe onse o psychiaric syndromes in his group o docors.

A recenly published sudy showed ha burnou syndrome, depression and suicidalideaion have been very prevalen in aneshesiology residens. e deleerious effecs




Curren realiy o he correlaion beween aigue and Medical Malpracice(responsible or criical incidens)

Occupaional aigue is regarded as a laen cause o medical error, leading o prevenable criical incidens which occasionally resul in serious consequences 25-26.

Cerain characerisics inheren o curren anesheic pracice may correlae wihpsychological pahology. ere should be awareness o he risks o acue and chronicaigue and high levels o occupaional sress in he clinical pracice o aneshesiolo-giss, as well as residency programs (insiuional responsibiliy).

ecenly, Proessor Olli Mereoja published he aricle We should work less a nigh ,concluding ha:

“ere is a growing amoun o evidence ha physicians’ perormance is lower i hey works excessively long shis or a nigh. ese working paterns diminish he san-

dard o care and increase healh care expenses. Nigh-ime work is non-physiologicaland poses risks o workers’ healh. Effecive ways o reducing he effecs o aigueinclude minimizing he amoun o work carried ou a nigh and esablishing ruleson a maximum number o hours or each shi” 27.

e definiion o stress, occupational distress and fatigue helps o undersand he corre-laion beween occupaional well-being, paien saey and insiuional responsibiliy 1-3.

Sress – physical or emoional ension ha develops when here is an imbalance beween he demands required o a person and heir abiliy o endure hem.

Disress - inense psychic sympoms in response o disrupions in occupaional well- being; in he case o healh care proessionals, mainly depression and anxiey. esesympoms correlae well wih decreased proessional perormance rom medicalsudens, residens, clinicians and nurses.

Faigue - eeling o need o res (sleep) accompanied by an inense effor o sayawake and significan loss o cogniive and physical capabiliy. Because i is such anunspecific sympom, i is difficul o evaluae and o approach.

Circadian rhyhm – he human body uncions in 24-hour sleep-wake cycles whichinfluence digesion and endocrine secreion as well as atenion levels, emoional andmoor perormance3. Is disrupions have been proven deleerious o aneshesiolo-giss’ clinical perormance.

A growing number o scienific sudies correlae psychopahologic aleraions indocors, residens and nurses (e.g.: high level o occupaional sress and is conse-quences) wih he risk o criical incidens (medical error)4-9.

e definiion o medical malpractice is a subjec o conroversy, bu mos consensus

guidelines consider i a siuaion in which docors choose and/or engage in inappropriaeatiudes or execue acions incorrecly. Medical misakes are hus described as “ human

error in the clinical care of patients” . However, here is a wide range o severiy, and




adverse oucomes are rarely repored or quanified. I is imporan o menion ha mal-pracice in aneshesiology is usually linked o perioperaive criical incidens, which cansignificanly aler he morbidiy and someimes moraliy o surgical paiens.

Occupaional aigue can be inerpreed as a laen acor, a pre-condiion ha may

influence he incidence o medical malpracice and increase he incidence o criicalmedical incidens28.

In 2008, he Briish Medical Journal eaured a prospecive cohor sudy on heprevalence o sel-repored misakes in drug adminisraion among residens suffer-ing rom depression or burnou. e conclusions were ha he incidence o malprac-ice was higher among depressed residens when compared o hose suffering rom burnou syndrome and ha boh condiions are highly prevalen during medicalresidency 10. (see Figures 3,4)

Figure 3. Incidence o medicaion errors among depressed and non-depressed residens andhose presening or no presening burnou syndrome.

Fahrenkop A M e al. BMJ 2008;336:488-491

Figure 4. Sponaneous repor o medical errors o burnou and depressed residens as

compared o hose no suffering rom burnou or depressive sympoms.

Fahrenkop A M e al. BMJ 2008;336:488-491




Anoher sudy showed ha he risk o malpracice increases exponenially aer nineconsecuive working hours. A 24 hours o susained wakeulness, he impairmen inphysicians’ psychomoor uncion was equivalen o a blood alcohol concenraion o0.1%, a or above he legal limi or driving in mos saes o he U.S29.

Alhough physical aigue may be experienced during a day o inense aciviy, emo-ional aigue is seen as he main promper o medical malpracice among aneshe-siologiss. I can manies as drowsiness, impairmen o concenraion, analysis anddecision-making skills, especially in emergency siuaions. is psychological condi-ion impacs he perormance o aneshesiologiss worldwide, which may jeopardizehe saey o housands o surgical paiens3.

A presen, insiuions responsible or conrol ling basic medical raining (medicalschool), clinical raining programs (medical residency programs) and he clinicalpracice o aneshesiology (medical councils) have been atemping o esablisheffecive prevenive measures or psychiaric diseases o occupaional origin. Medi-cal rainees as a group are increasingly vulnerable o his ype o pahology.

ecenly, inormaion abou risk acors or somaic and/or psychologic diseasesrelaed o sressul clinical pracice has improved diagnosis, prevenion and manage-men o hese condiions3.4. Aneshesiologiss should be aware o he mos disress-provoking aspecs o heir pracice and know wha working condiions o srive or.Sysemaic evaluaions o aneshesiologiss’ well-being and suppor mechanisms ohose in disress, provided by medical associaions, conrol insiuions or universi-

ies, have been shown o improve precarious occupaional healh.Insiuional medical councils, naional specialy socieies and inernaional educa-ional bodies which conrol he learning and pracice o Medicine in he world oendefine medical error as “Inadequate professional conduct which implies technical

failure and can cause injury to the life or health of others, characterized by incom-

petence, recklessness or negligence.”10. All causes o occupaional diseases in anes-hesiologiss may have significan impac on he physical and menal healh o hemedical proessional and, consequenly, o he saey o he surgical paiens. ese

acs are confirmed by epidemiological sudies.In 1999,Te Norh American Insiue o Medicine published To Err Is Human: build-

ing a safer health system , which showed ha more han 98,000 paien deahs werecaused by medical error, making i he sixh o he eigh mos prevalen causes odeah in he Unied Saes. Medical malpracice is, hereore, poenially more lehalhan breas cancer, AIDS and deahs rom raffic accidens. is global problemdoesn’ seem o have been addressed effecively hus ar30.

e aoremenioned insiue also published, in 2006, he sudy “Sleep disorders

and sleep deprivation: an unmet public health problem” , which concluded hasleep disorders such as insomnia and sleep deprivaion have a cumulaive effec ,highlighing he chronic naure o his poenial pahology 31.




Anoher sudy conduced a Harvard Universiy assessed he incidence o adverseevens in 30121 paiens adm ied o emergency rooms in 51 New York hospials .he esimaed incidence o adverse evens was 3.7% and 69% o hose were dueo negligence32 .

Using he same mehodology, a sudy o he Ausralian healh sysem observed a 16.6%incidence o adverse evens, o which 13% resuled in permanen disabiliy and 4.9%resuled in deah. Imporanly, 51% o hese evens were idenified as poenially pre-

venable causes (echnical error and/or inappropriae drug adminisraion)33.

Deailed reviews o adverse evens caused by negligence reveal inormaion omis-sion, i.e. mos medical malpracice acs go unrepored in paien chars.

Employmen o a compuerized model o compulsory medical repors revealedadverse evens in 1.6% o paiens hospialized in Sal Lake Ciy, Uah, U.S. 16. On

he oher hand, evaluaion based on sel-reporing and elecronic records showedan incidence o 6.5% in paiens admited o wo hospials in Boson, U.S. 28% odrug-relaed adverse evens were due o medical errors, and 7.3% o hem resuled inserious and poenially prevenable sequelae34.

Summary - Insiuions involved in medical educaion, regulaion o medical prac-ice and occupaional healh proecion have he power no only o improve medicalproessional healh, bu also o ameliorae paien saey.

Insiuional Responsibiliy or Aneshesiologiss’ Occupaional Well-beingand Surgical Paien Saey

ere is a close link beween occupaional aigue in aneshesiologiss and he inci-dence o adverse evens in surgical paiens. A subsania l number o sudies corrobo-rae ha excessive workload leads o a psychologic illness o cumulaive characercalled occupaional aigue and aler o he resulan decrease in efficiency, produc-iviy and saey o aneshesiology pracice1-,6.

e above menioned sudies show ha occupaional aigue leads o increased risksor boh docors and surgical paiens hrough muliple mechanisms:

• Lapses o atenion and inabiliy o ocus;

•

Decreased moivaion o work;

• Menal conusion;

• Irriabiliy;

• Memory lapses;

• Communicaion difficuly;

•

Slow processing o medical ideas, conclusions and atiudes;• Slow psychomoor response;

•

Emoional indifference and loss o empahy.




Evens like excessively long or requen shis affec he sleep paterns o healh providers and conribue o he increased incidence o medical occupaional aigue.Ulimaely, his enails significan decline in proessional perormance , impairing hesaey o medical care as well as heir own 25.26.

Epidemiological daa gahered by he Onario Medical Associaion show an increasein he number o psychopahological disorders relaed o medical pracice in com-parison wih sricly somaic pahologies such as inecion, radiaion, blood con-aminaion and inhaled gas, as evidenced in Figure 2.

Based on he atenion given o occupaional healh, specifically o medical well-being,in Canada, Dr. Michael Myers, Proessor o Psychiary a he Universiy o BriishColumbia, published a book by he Canadian Medical Associaion, warning o he riskacors or riggering occupaional pahologies. e book was used o raise unds orhe diagnosis, reamen and suppor o occupaional diseases in Canada. Cerainly,his is an iniiaive o be ollowed by oher medical insiuions in he world35.

Chrisopher P. Landrigan ( Direcor o he Sleep and Paien Saey Program o he Brigham and Women’s in Boson) is menioned in he ex o he American JoinCommission Seninel Even Aler o emphasize he imporance o he opic hroughhe ollowing saemen: “ We, aneshesiologiss, have a culure o long hours ouninerruped work, and he impac o aigue on our occupaional healh is litlerecognized as an acual issue.”

is and oher auhors emphasize he need or regulaion o he workload perormed by aneshesiologiss and nurses (day shis and daily/weekly rouine) by he medicalinsiuions, especially insiuions wih effecive execuive conrol over he qualiy omedical care and medical educaion. Expansion o epidemiological research in his sec-or is necessary as well. I is imporan o highligh he direc correlaion o disrupionsin sleep paterns and circadian cycle wih changes in cogniive perormance36-38.

e repor o he American Insiue o Medicine - “o err is human: building a saerhealh sysem reveals anoher aspec o his issue: medical errors conribue o manyhospial deahs and serious adverse evens in surgical paiens39.

I is exremely imporan ha aneshesiologiss be aware o specific aspecs o heirdaily pracice ha are mos likely o cause sress, as well as how o ameliorae work-ing condiions in search o a healhier working lie.

Signs o acue or chronic aigue and high levels o occupaional sress should beclosely observed during aneshesiologiss’ cl inical pracice.

In 2005, he Proessional Commitee o he WFSA well-being (a he ime he WorkPary Proessional Well-being) conduced a prospecive epidemiological cohor

sudy on he occupaional healh o aneshesiologiss in he world, using a quesion-naire addressing he presidens o he socieies o aneshesiology ha are members o WFSA ( n. 103), o which 57% responded.




Docors are rained o ocus heir atenion on he paien, which means hey re-quenly ignore heir own healh and occupaional well-being. ey mus, however,urn he atenion o hemselves, since physician psychic healh has direc impacon paien well-being. Wih regard o aigue, his means learning o ideniy i andminimize is deleerious effecs11.

Some counries are already aking measures o correc he issue o long workinghours leading o aigue. e Grea Briain and Ireland socieies o aneshesiology, orexample, published a documen comprising 25 pages o recommendaions on eamand paien saey 40. Similarly, he Ausralian and New Zealand College o Anaeshe-iss has also produced a saemen on occupaional aigue in which principles andresponsibiliies are oulined or aneshesiologiss and insiuions ha conrol medi-cal pracice in an effor o diminish aigue and resulan medical malpracice acs41.

e workload (shis and rouine) perormed by residens has been he subjec oseveral sudies. e American Accrediaion Council or Graduae Medical Educa-ion (ACGME) implemened resricions on he working hours o rainee docors,limiing he maximum shi hours in 30 and he workweek a 80 hours. I becameclear in subsequen sudies ha, even so, he risks or surgical paiens and or resi-dens hemselves remained high, especial ly in cases o more han 24 consecuive work ing hours36.42.

In Sepember 2010, he ACGME has published a final version o he new guidelines, which became effecive in he U.S. in July 2011 and can be ound a www.acgme-

2010sandards.org43.e Join Commission Journal on Qualiy and Paien Saey , published in November,2007, srongly suggess ha long working hours and shis raise he incidence ooccupaional aigue, which resuls in diminished proessional perormance and cul-minaes in impaired physician and paien saey. is paper revealed ha residens who worked in recurren 24-hour shis44-48:

• Were involved in 36% more preventable adverse eects when compared withcolleagues who didn’ work more han 16 consecuive hours;

• Commied 5 times as many diagnostic errors as the other group;

• Showed twice the amount of aention lapses while working at night;

• Had 61% more needlestick accidents aer their 20th consecutive working hour;

• Exhibited 1.5 to 2 negative standard deviations in their performance whencompared o heir baseline levels;

• Reported that they had experienced intense fatigue at the time of critical inci -dens leading o paien deah.

In 2009, anoher sudy documened ha physicians who had had less han 6 hourso coninuous sleep had more complicaions while perorming medical proceduresa nigh49.




Based on he scienific evidence described above, members o he Join Commissionrecommend some acions or he insiuions responsible or conrolling he qualiyo medical pracice37-39, 50-54:

• To warn, formally and with the aid of scientic evidence, directors of health

care insiuions abou he risks o occupaional aigue and o highligh he needor adequaion o workdays and shis boh in requency and number o uniner-ruped hours;

• To emphasize at every opportunity the scientically proven correlation beween occupaional aigue, sress and all heir consequences;

• To stimulate partaking of all team members in eorts to plan adequate workregimes, allocaing hours in a democraic manner in order o minimize occupa-ional aigue;

• To create, within medical institutions, plans of action to approach occupationalissues, such as:

• Establishing discussion forums;

• Forging mechanisms for eective action about the theme;

• Diminishing the constant use of caeine during medical practice;

• Establishing routine resting periods of no more than 45 minutes during medi-cal pracice;

• Fostering opportunities for medical team members (anesthesiologists) to

express heir opinions and suggesions abou occupaional healh and work-place saisacion;

• Creating methods for systematic evaluation of occupational stress levels, as well as providing specialized suppor or proessionals acing hose issues;

• Developing nancial support systems for anesthesiologists temporarily unableo work due o occupaional healh disrupions.

Conclusions

Medical lieraure has shown ha he workplace o healhcare proessionals is laden wih much higher levels o sress han oher proessional aciv iies. is group o pro-essionals is consanly exposed o work overload, inense social pressure, unclearrole definiions, unrelening clamor rom paiens and risks o needlesick accidensleading o conaminaion wih inecious diseases. Such physical and psychologicsressors can resul in an increase in criical incidens and medical malpracice.

Healh care insiuions and docors hemselves have been encouraged o akeacion o diminish sress levels and associaed complicaions. Alhough insiu-

ional inervenion is mos pressing, combined collecive and individual iniiaiveshave more consisen resuls in he prevenion, diagnosis and reamen o occupa-ional diseases.




How can occupaional sress be conrolled by insiuional involvemen in order oimprove proessional perormance and saey o anesheic-surgical care?

Iniiaives should ocus primar ily on he need o l imi excessive working hoursand o encourage aneshesiologiss o parake acively in he planning o healhy

and air working regimes. he resul o hese should be a more balanced work-lie relaionship.

Some issues shall be observed in he search or a healhier work regime:

• Night shis must be reduced in length and frequency and institutional proto -cols mus be acualized o enable sricly urgen procedures o be perormed anigh, hereby avoiding elecive surgeries during ha period;

• It is highly recommendable that anesthesiologists of a certain age (>60 yearsold) be exemped rom nigh shis;

• Conicts arising at work must be avoided or minimized through eective andhones eam communicaion in order o esablish healhy inerpersonal relaionsa he workplace;

• Institutions must aord social support, showing appreciation and gratitude tomedical proessionals, and be flexible in heir guidelines, maximizing personalcapabiliies and allowing docors o reach proessional goals wihou pahologi-cal occupaional sress;

• Institutions must value to the maximum the opinion of anesthesiologists

regarding working regime decision-making.How can occupaional sress be conrolled by naional or inernaional insiuionalinvolvemen in order o improve proessional perormance and saey o anesheic-surgical care?

Based on he experience described in previous secions, here are womain recommendaions:

1. Srucuring an agenda or inernaional collaboraive research o be unded anddeveloped wih he primary goal o generaing inormaion on cos-effeciveness o various sraegies o improve occupaional well-being. is agenda should comprise3 deparmens:

a. esearch on acors ha aler proessional perormance , w ih he ineniono develop esable heories o explain occupaional healh issues;

b. Esablishmen o sric mehodological sraegies o evaluae cos-effecivenesso epidemiological sudies regarding occupaional healh;

c. Assembling o sudy resuls in order o develop and implemen guidelines

abou physician occupaional healh.is approach should be praciced hrough consanly updaed reviews, publicaionsin peer-reviewed journals and providing ree access o elecronic libraries. Scienific




13. Insiue o Medicine: Sleep disorders and sleep deprivaion: an unme public healhproblem. March 21, 2006, htp://www.iom.edu/epors/2006/Sleep-Disorders- and--Sleep-Deprivaion-An-Unme-Public-Healh-Problem.aspx.

14. Insiue o Medicine: esiden duy hours: enhancing sleep, supervision, and saey. De-cember 15, 2008, htp://www.iom.edu/epors/2008/esiden-Duy-Hours-Enhancing

Sleep, Supervision-and-Saey.aspx.15. Shanael D - Academic Medicine. 2006, 81 (4) :354-373.

16. eed DA - Academic Medicine. 2011, 86 (11) :1367-13.

17. Shanael D - Personal Lie Evens and Medical Sudens Burnou: A Mulicener Sudy. Academic Medicine 2006, 81 (4) :374-384.

18. Clever LH - Who is sicker: paiens or residens? Ann In Med 2002, 136:391-393.

19. GB Colllins - Chemical Dependency reamen Oucomes o esidens in Aneshesiolo-gy: esuls o a Survey. Anesh Analg 2005; 101:1457-62.

20. Hull S. Prevalence o healh-relaed behavior among physicians and medical rainees. Acad Psychiar y. 2008, 32: 31-38.

21. A Leebvre. esiden Physician Wellness: A New Hope. Acad Med 2012, 87:598-602.

22. Nyssen AS. Occupaional sress and burnou in aneshesia. Br J Anaesh. 2003, 90(3): 333-373.

23. GS De Oliveira Junior. Anesh A nalg 2013; 117 (1): 182-198.

24. Duval Neo, GF - Proessional Well-being Work Par y o WFSA: I is ime o ink andake Acion egarding he Occupaional Healh o Aneshesiologiss. Bras Anesesiol.2011, 61: 4: 389-396

25. ogers AE, e al: e working hours o hospial saff nurses and paien saey. Healh Affairs, 2004, 23 (4) :202-212.

26. rinkoff AM, e al: Work schedule, needle use, and needlesick injuries among regiserednurses. Inecion Conrol and Hospial Epidemiology, February 2007; 28:156-164.

27. Mereoja OA - cornichons work less a nigh. Aca Anaeshesiol Scand 2009; 53:277-279.

28. eason J. Human Err. Cambridge, England: Cambridge Universiy Press, 1990.

29. Howard S osekind M, az JD e al. - Faigue in aneshesia. Implicaions and srae-gies or paien and provider saey. Aneshesiology. 2002, 97:1281-1294.

30. ohn L - o Err Is Human: Building a Saer Healh Sysem. November 1999. Commiteeon Qualiy o Healh Care in America - Insiue o Medicine - Naional Academy Press Washingon, DC, w ww.nap.edu.

31. Colen H - Sleep Disorders and Sleep deprivaion: AN unme Public Healh Problem- Commitee on Sleep Medicine and esearch Board on Healh Sciences Policy - Insiu-e O Medicine o he Naional Academie s - e Naional Academies Press, Washingon,DC. www.nap. edu.

32. Brenann A - Incidence o adverse evens and negligence in hospialized paiens: resulso he Harvard Medical Pracice Sudy I . Wha Sa Healh Care 2004, 13: 145-151.

33. Brennan A, Localio A, Leape LL, e al. Idenificaion o adverse evens Suffered byhospialized paiens: a cross-secional sudy o liigaion, qualiy assurance, and medicalrecords a wo eaching hospials. Weahering Ann Med 1990, 112: 221.




34. HH Hiat, Barnes BA, A Brennan, e al. A sudy o medical injur y and medical malprac-ice: an overview. N Engl J Med 1989, 321: 480-485.

35. M. Myers CMA guide o physician healh and well-being: acs, advices, and resources orcanadian docors. 10 Ed. Otawa: Canadian Medical Associaion, 2003.

36. Landrigan CP, e al: Inerns’ compliance wih Accrediaion Council or Graduae Me-

dical Educaion work-hour limis. Journal o he American Medical Associaion, 2006,296:1063-1070.

37. Czeisler, CA. e gordon Wilson lecure: work hours, sleep and paien saey in residencyraining. ransacions o he American Clinical and Climaological Associaion, 2006;117.

38. Czeisler, CA. Medical and geneic differences in he adverse impac o sleep loss onperormance: ehical consideraions or he medical proession. rans Am Clin Climaol Assoc. 2006;117:159-188.

39. Saemen o aigue and he anaesheis. Ausralian and New Zealand College o Anaesheiss;jul. 2004.

40. ANZCA. Saemen on aigue and he anaesheis- 2007. [inene]. Disponível em:htp://ww w.anzca.edu.au/resources/proessional-documens/documens/proessional--sandards/proessional-sandards-43.hml

41. Landrigran CP, e al. Effecs o he Accrediaion Council or Graduae Medical Edu-caion duy hour limis on sleep, work hours, and saey. Pediarics. 2008;122:250-258.

42. ACGME. Qualiy Care and Excel lence in Medical Educaion. [inerne]. Disponível em:htp://www.acgme.org/acgmeweb/abid/287/GraduaeMedicalEducaion/DuyHours/Archive.aspx

43. Lockley SW, e al. Effecs o healh care provider work hours and sleep deprivaion onsaey and perormance. e Join Commission Journal on Qualiy and Paien Saey.2007;33(11)7-18.

44. Landrigan CP, e al. Effec o reducing inerns’ work hours on serious medical errors ininensive care unis. New England Journal o Medicine. 2004;351:1838-1848.

45. Lockley SW, e al. Effec o reducing inerns’ weekly work hours on sleep and atenionalailures. New England Journal o Medicine. 2004;351:1829-1837.

46. Ayas N, e al: Exended work duraion and he risk o Sel-epored percuaneous injuriesin inerns. Journal o he American Medical Associaion , Sepember 6, 2006, 296:1055-1062.

47. Barger L, e al: Impac o exended-duraion shis on medical errors, adverse evens,and atenional ailures. PloS Medicine , December 2006; 3: E487.

48. ohschild JM, e al: isks o complicaions by atending physicians aer perormingnightime procedures. Journal o he American Medical Associaion , Ocober 14, 2009,302:1565-1572.

49. Blum, AB, e al: Implemening he 2009 Insiue o Medicine recommendaions on resi-den physician work hours, supervision, and saey. Naure and Science o Sleep , 2011; 3:1-39.

50. osekind, M, e al: Faigue Counermeasures: Alerness Managemen in Fligh Opera-

ions. Naional Aeronauics and Space Adminisraion, Souhern Caliornia Saey Ins-iue Proceedings, Long Beach, Cali., 1994 htp://human-acors.arc.nasa.gov/zeam/cp/pubs/scsi.hml.




51. Rosekind, MR, et al: Crew Factors in Flight Operations XIV: Alertness Managementin Fligh Operaions egional Educaion Module. Naional Aeronauics and Space Adminisraion, February 2002 htp://human-acors.arc.nasa.gov/zeam/PDF_pubs/REGETM_XIV.pdf.

52. Agency or Healhcare esearch and Qualiy: Paien Saey and Qualiy: An Evidence-

-Based Handbook or Nurses . AHQ Publicaion No. 08-0043, April 2008 htp://www.ahrq.gov/qual/nurseshdbk/ .

53. owe A. How can Achieve and Mainain high-qualiy perormance o healh workers inlow-resourses setings? e Lance. 2005; 366:1026-1035.

54. ain ZN, Chan M, az JD, Fleisher L, Doler J, oseneld LE. Aneshesiologiss andacue perioperaive sress: a cohor sudy.Anesh Analg. 2002;95:177-83.



- Part 3 -Biological risks and

occupational health



3.1 - adioproecion or aneshesiologiss | 193

Radioproecion or Aneshesiologiss

Anonio Fernando CarneiroSA/SBA

Brazilian Socie y o Aneshesiology (SBA), PhD, Head o Surgery Depar men, Goiás Federal

Universiy; Direcor o SBA Proessionals Deense Deparmen; Specialis in Inensive Care Medicine.Onore Alves Neo

SA/SBA, PhD, Aneshesiology Proessor, Goiás Federal Universiy, Goiânia- GO; esponsible or he 9172 SBA

eaching and raining Cener Hospial o UFG.

Inroducion

In he 70’s, environmenal polluion and oxiciy caused by inhaled anesheics

and heir meabolies were he main concern o aneshesiologiss when discussingoccupaional risks1. Effecs o anesheics and heir meabolies on paiens, surgicaleam and aneshesiologis were deeply sudied and he issue was discussed in mosimporan exbooks2, 3. In he 80’s, he main concern became inecious diseases,such as HIV and hepatitis. Nowadays, many scientic publications list a wide rangeo occupaional risks in aneshesiology.

e Brazilian Sociey o Aneshesiology (SBA) is concerned abou aneshesiologiss’occupaional healh. esearch, norms and resoluions are requenly published4 and

an Occupaional Healh Commitee was creaed in order o sudy and provide inor-maion abou occupaional risks and measures o preven complicaions.

In he pas, aneshesiologiss’ exposure o ionizing radiaion was occasional, basi-cally when portable X-ray devices were used especially in orthopedics procedures.Currenly, aneshesiologiss are being exposed o ionizing radiaion more oen, asaneshesia or diagnosic and reamen procedures becomes more common (inervenional medicine, pain reamen, inensive care unis and vascular procedures)5.Fluoroscopy is now widely used and even aneshesiologiss may use i during cenral venous caheerizaion and epidural procedures.

Ionizing radiaion is an imporan ool or diagnosis and reamen in many siua-ions, bu he ranserence o high energy associaed wih i represens a risk. Anes-hesiologiss are increasingly concerned abou radioproecion, which is defined asa se o measures ha may proec humans and he environmen rom he poenialhazards o ionizing radiaion.

ypes o Radiaion

Elecromagneic radiaion can be classified as ionizing and non-ionizing:

A- Ionizing Radiation - has enough energy to ionize atoms and molecules. X-raysand radioacive isoopes are he mos popular ypes. Gamma ray or alpha and bea




adiaion can be refleced by suraces, increasing exposure levels and occupaionalrisk or people inside he room.

e main hazards caused by ionizing radiaion include leukemia, hyroid cancer,caarac and geneic aleraions o germinaive cells (especially in women), increas-

ing he chance o malormaion. Following echnical sandards is essenial orradioproecion, such as proecive clohing (heavy and uncomorable), equipmenshields and secure disance rom he radiaion source, as he inensiy o radiaionis inversely proporional o he square o he disance. Even wih hese precauions,skin and eyes are sill exposed8.

Ideally, he paien should be he only one exposed o radiaion. e use o fluoros-copy wih an energy o 1,5mAmp or en minues is equivalen o 69 ches radio-graphs (0.27 EM is he average dose per radiograph)9.

Non-ionizing radiaion

In medicine, non-ionizing radiaion is represened by laser, which can produce inra-red, visible or ulraviole ligh. Non-ionizing radiaion resuls in differen ypes odamage hanks o is inensiy and he release o byproducs o issue desrucion 10.

Laser devices are inernaionally classified11 as:

• Class I - Sources that do not exceed the MPE (maximum permissible exposure)o he eyes.

• Class II – Lasers with visible beams, sources with energy higher than 1 mW –eyes are proeced by blinking reflex, every 0.25 second.

• Class IIIa – Class II expanded, sources of energy with up to 5 mW radiation –eyes are proeced by blinking reflex.

• Class IIIb – High energy sources, up to 0.5 W – direct vision is dangerous.

• Class IV - Sources of more than 0.5 W – extremely dangerous for eyesight.

Most laser equipment used in operating rooms are Class IV.

Eyeball injuries aer exposure o direc ligh or refleced radiaion are requen(corneal and reina burns, opic nerve damage and caaracs). ereore, proeciveeyewear wih special filers agains laser radiaion should always be used.

Unlike ionizing radiaion, disance rom he source o non-ionizing laser radiaiondoes no reduce exposure12.

Alhough human skin is less vulnerable han he eyes, exposure o high inensiyradiaion can cause burns and muagenesis13.

Laser vaporizes he issue and releases an ill-scened smoke ha may be muagenic(similarly o cigarete smoke) and may conain paricles o DNA virus. us, con-inuous renewal o he air inside he surgery room is imporan.




e associaion o high concenraions o oxygen or nirous oxide and laser repre-sens an addiional risk or aneshesia, as his combinaion may sar a fire. Atenionshould be paid especially during oorhinolaryngeal surgeries. Precauions o be con-sidered are: avoidance o flammable anesheics; use o non-reflecive insrumens(black); oxygen concenraions up o 25%, i possible; use o non-flammable endo-

racheal ubes (special maerial or aluminum cover)11

Aneshesia Radioproecion

Ulrasound And Mri Rooms

ese devices are no sources o ionizing radiaion and no specific proecion is necessary.

Convenional Radiology Porable Equipmen

Radiographs inside he ICU or Operaing Suie

ese devices have low kilovolage and milliamperage. ere’s usually a remoe con-rol (long wires, around 2 meers). I he healh proessional is able o keep a womeer disance o he source, no radioproecion is necessary.

omography rooms

CT scanners are just large X-ray equipments and therefore release ionizing radiation.Every proessional ha needs o say inside he C room during he exam (aneshe-siologiss managing inubaed paiens) should use a lead cloak, hyroid collar andkeep a disance rom he source o radiaion.

Hemodynamic procedure rooms/ Inervenional radiology

ese rooms are an exension o he operaing suie and require careul cleaning anddisinfection methods. X-ray hemodynamics equipment release continuous ionizingradiaion hroughou he exam.

Once inside he room, i is necessary o use o lead cloak and hyroid collar andkeeping appropriae disance rom he source o ionizing radiaion in order ominimize exposure.

Use O Laser

Laser is characerized by high incidence o energy per area uni and precise beamdirecion. Aneshesia or laser procedures in dermaology and ophhalmologyare common and eyes and skin are he mos vulnerable areas or laser eecs. Iis essenial o use personal proecive equipmen (proecive glasses, clohing

and gloves).




Conrolling Ionizing Radiaion

adioproecion principles or proessionals exposed o radiaion are:

• Avoiding unnecessary human and environmental exposure or contamination;

• Keeping exposure levels as low as possible and always below legally

permied limis;• Continuous evaluation of exposure conditions (usual or accidental);

• Authorization and licensing for the use of radioactive sources;

• Seing dose limits;

• Reinforcing group and individual protection; monitoring individual dosim-eers (a group o expers qualified by he Healh Minisry should be responsibleor ha ollow-up);

• Complying with the existing legislation regarding radiation use: Law-DecreeNo 348/89 o 12/10/89 ha esablishes sandards and guidelines or proec-ion agains ionizing radiaion and Decree No. 9/90 o 04.19.90, as amended byDecree No. 3/92.

Reerences

1. Alves Neo, e - Bioransormaion relaed o he oxiciy o inhaled anesheics. evBras Anesesiol 1986, 36:6:459-475

2. VJ Collins - Hazards in anesthesia practice. Ch 39 - Principles of anesthesiology -0 Gene-ral and regional aneshesia - 3rd ed. Lea & Febiger, Philadelphia, 1993, 1149-1178

3. Xavier L - Safety and anesthesia. In: E Cremonesi - emes A nesthesiology, Sarv ier, SãoPaulo, 1987, 369-376

4. AF Carneiro – Occupaional healh: basic principles o radiaion proecion. Aneshesiain eview, SBA, 2001.

5. aylor J, Chandramohan M and H Simpson - adiaion saey or anesheiss. ConinEduc Anaesh Cri Care Pain 2013; 13 (2) :59-62.

6. Nicholau D and WP Arnold III - Environmenal saey including chemical dependency.

Chapter 101. In: RD Miller - Miller’s Anesthesia - 7th ed., Vol. 2, Churchill Livingstone,Elsevier, 2010, 3053-3073

7. Anasasian Z, Srozyk D, Gaude J E AL - Aneshesiologiss a risk or radiaion expo-sure Significan During neuroinervenional procedures. Neuroinerven J Surg 2009; 1(1) :78-79

8. az JD - adiaion exposure o aneshesia personnel: he impac o an elecrophysiologylaboraory. Anesh Analg 2005; 101 (6) 1725-6

9. De Paolis MV and Cotrell JE - Miscellaneous hazards: radiation disease infections, che-mical and physical hazards. Inen Clin Anesh 1981, 19:131

10. Milam DF - Physical principles o laser energy. In: Smih JA Jr, Sein BS, Benson C -Laser in urological surgery. 3ed. 1994, S. Louis, Mosby-Year Book, 9.1




11. Moyle JB, Davey and Ward C - Equipmen or aneshesia Ward. 4h Ed Armed, Poro Alegre, 2000, 449-452

12. Pashayan AG - Lasers and laser saey. In irby , Gravensein N (ediors) - Clinicalaneshesia pracice. Philadelphia, WB Saunders, 1994; 370-9

13. Braz JRC, Vane LA and AE Silva - Risk professional anesthesiologist - Chapter 7. In: SA

ESP - reay o aneshesiology, 7h Ed, 2011, Aheneu, São Paulo.



3.2 - Mechanical occupaional risks i n aneshesiology | 199

Mechanical Occupaional Risks In Aneshesiology

Anenor Muzio Gripp Maser in Healh Sciences by he Universiy o Brasília (UnB)

Member o he Occupaional Healh Commitee o he Brazilian Sociey o Aneshesiology

Luiza Alves Casro Arai Maser in Healh Sciences by he Universiy o Brasília (UnB) e direc or o he

Aneshesiology raining Program o he Universiy o ocanins, Brazil

Aneshesiologiss are exposed o a number o occupaional hazards as a resulo workplace condiions and proessional aciviy, such as oxiciy o anesheicgases, occupaional exposure o blood and secreions resuling in risk o ineciousdiseases, laex allergy, and exposure o ionizing radiaion. Oher risks involve elec-

rocuion, fire and explosions. ecenly, new hazards have been idenified: drugaddicion and burnou, which are difficul o quaniy, bu may have serious conse-quences or he aneshesiologis1.

In general, aneshesiologiss are knowledgeable o chemical, biological, physical andpsychosocial risks, since inormaion regarding hese is widely available in lieraure.However, mechanical risks are usually only briefly menioned, which leads o litlerecogniion rom aneshesiologiss.

According o he Oxord Dicionary o English:

Mechanical – adjecive 1. operaed by a machine or machinery; relaing o machinesor machinery 2. (o an acion) done wihou hough or sponaneiy; auomaic. 3. relaing o physical orces or moion; physical2.

Occupaional – adjecive relaing o a job or proession2.

Mechanical hazards are associaed wih poor physical and echnological condiionso he workplace ha can cause accidens, endanger he physical saey o he workeror inflic damage o machines and aciliies3.

Facors bound o cause accidens include equipmen devoid o proecion mecha-nisms, inadequae layou o he workplace, improper or flawed ools, elecriciy,poisonous animals, requen shiing o equipmen rom one place o anoher, inad-equae sorage soluions, vacuum-sucion devices and ohers. ese acors can rig-ger occupaional accidens, physical sress, aigue, shor-circuis, elecric shocks,fires, explosions or occupaional diseases3.

Physical damage infliced by elecrical discharge seems o be he mos prominen(43.10%), ollowed by needlesick injury (33.30%) and colliding agains objecs/urniure (33.30%)4.

e Operaing Suie (OS) requires a specific se o srucural characerisics andequipmen ha ulimaely predispose paiens and proessionals o various risks,




such as fire (which is exacerbaed by he combinaion o oxygen-rich circuis andelecriciy-based machinery) and physical injuries by handling heavy equipmen andmaerials, like image inensifiers, as well as various oher devices whose handlingrequires subsanial know-how 4.

e risk o accidens in he OS has escalaed considerably in recen years due o heincreased use o elecrical and elecronic equipmen and he expansion o elecro-surgery 5 Mos o hese accidens are caused by inadequaely grounded currens andsaic elecrical discharge6.

Fires and explosions can be iniiaed by elecrical sparks in a room wih highly flam-mable maerials such as rubber and plasic and high concenraions o flammablegases like oxygen and nirous oxide8. Misaking alcohol gel or conducive gel hasalso caused explosions wih severe burn injuries o he aneshesiologis.

e saey o elecrical equipmen involves9

: appropriae mainenance rouines wih periodic equipmen inspecion; inac wires and hree-pronged plugs, elecri-cal grounding, atenion o he connecion o he grounding pin o he oule andavoidance o exension cords and muliple adapers, as well as adequaely posiioned,sufficienly numbered and good qualiy power oules.

In Brazil, here has recenly been a change in he patern o elecrical plugs and sock-es. As o Augus 2007, naionwide guideline NB 14136 deermines ha here bean indenaion in he power socke o preven he pins rom being accessible o ouch

when parly insered and ha he exisence o a hird prong or elecrical ground-ing be mandaory 10. is change enhances saey agains accidens8.

e requen use o elecrical equipmen exposes proessionals o elecric shocks. is can be aggravaed by lack o prevenive periodic mainenance and equipmen wear and ear5.

Fracures, back pain and varicose veins can be a resul o requen weigh liing whenhandling and ransporing paiens or equipmen, inadequae posure and requenspinal flexion aciviies. Ergonomic acors like equipmen design, workplace lay-ou, design o work aciviy and eam communicaion inerere in he relaionship

beween worker and work 4

.e aneshesiologis’s insrumen o work, i.e., he aneshesia worksaion, has severalinerconneced elemens, such as corrugaed hoses and Y-piece connecors. Added ohese inheren aneshesia delivery machine componens, several oher insrumensare superimposed: moniors and is cables, ransducers and elecric power con-necors, pulse oxymeer, capnography and elecrocardiography cables, BIS sensorcables, invasive hemodynamic monioring devices’ cables and ohers, which makehe saion someimes ac as a rap, especially in emergencies, resuling in he all o

hese moniors on he aneshesiologis.e aneshesiologis’s workplace is raugh wih risk acors ha can rigger mechan-ical accidens, such as needle devices le unpackaged on workops, he ac o break-



3.2 - Mechanical occupaional risks in aneshesiology | 201

ing glass vials, elecrical adapers, elecrical exension cords conneced o muliplepieces o equipmen, poor lighing o he rooms and operaive field by broken ligh bulbs, elecrical wires on he ground a leg level leading o he risk o alls and he vacuum-sucion devices’ hoses placed direcly on he ground.

Needlesick injuries and alls are among oher mechanical risks. e poenial oralls is increased when proessionals wear clohing bigger han adequae, which cancause angling in cables.

Oher mechanical accidens can occur in he ransporaion o criically ill paiens beween hospial unis. ese paiens are usually ranspored under assised veni-laion, moniored, on beds supplied wih oxygen anks. e srecher matress andeveryhing on i (he paien himsel, as well as moniors, inusion pumps and fluid botles) can all during ranspor, i no secured properly. Given he ension andurgency o ransporing criically ill paiens, someimes he proessional helping ocarry he srecher pushes he aneshesiologis agains walls, especially in corridors wih curves, leading o conusion rauma.

Bruising a he high level is common among aneshesiologiss due o direc rauma by cranks o operaing ables, especially in cases o emergencies where speed is oprominen imporance and here is a endency or aneshesiologiss o orego sel-preservaion concerns.

Mos conaminaions wih blood-borne pahogens ha occur in hospials arise

primarily rom mechanical injury. Finger cus caused by breaking o glass vials andneedlesick injuries can be prevened by educaion and proecive equipmen.

I is noeworhy ha mechanical risks in hospials are especially due o direcassisance rom healh proessionals o paiens in varying degrees o severiy, which involves handli ng heav y equipmen and needles ick devices, preparaionand admin israion o medicaions, disposal o conaminaed maerials in medi-cal wase, inerpersonal relaionships, irregular work schedules and sleep dis-rupion, he emoional srain rom dai ly conac wih pain, su ering and deah,among ohers11,12.

I is imporan ha rainee aneshesiologiss learn how o recognise and proechemselves agains mechanical risks inheren o he pracise o he specialy.

Conrol Measures:

Educaion and raining in occupaional saey.

e prevenion o occupaional adverse evens enails early recogniion o risk siua-ions by saff and improvemen in working condiions1.

e main sep owards prevenion o accidens caused by mechanical hazards iso conduc saey inspecion programs. rough careul examinaion o all heequipmen and aciliies, accidens and poenially hazardous siuaions can be pre-




vened. Prevenive and sysemaic mainenance is he mos efficien means o elimi-nae he risks o mechanical accidens3.

Beore he sar o a working day, he aneshesiologis usually perorms a checkliso maerials and equipmen necessary or paien saey. I is advisable ha some

mechanical hazards are added o i: checking or mulipliciy o devices conneced oa single elecrical socke, ensuring ha cables and wires are no blocking circulaionareas and ha moniors posiioned on op o worksaions are no unsable.

Definiion o Workplace Saey

Occupaional saey is an area concerned wih raising awareness o he imporanceo acions o recognize, assess, conrol and reduce unsae condiions in he work-place in order o preven accidens and healh injuries o employees.

is area o sudy invesigaes risks relaed o he workplace environmen ha mayaffec he employee physically, decreasing heir abiliy o work.

“Workplace saey is a se o resources ha aims a reducing he incidence o acci-dens, hereore i is concerned primarily wih prevenive measures.”

In order o ensure he effeciveness o conrol measures, i is necessary or aneshesi-ologiss o know he local official saey regulaions. Below are a ew poins o ineresin Brazilian egulaory Sandards (S).

Brazilian Regulaory Sandardse egulaory Sandards or Workplace Saey and Occupaional Medicine wereapproved as Ordinance No. 3214 in 08/06/1978, by he Minisry o Labour and Employ-men (MLE) - (BRZIL, 1978). In order or law enorcemen o be carried ou, bohemployers and employees need o be knowledgeable abou occupaional hazards13.

RS-1 General Provisions

According o he MLE (Brazil, 2002), egulaory Sandards, regarding saey andoccupaional healh, are obligaory or privae and public companies and or publicinsiuions o direc and indirec adminisraion, as well as legislaive and judicialgovernmen bodies whose employees are proeced by he Consolidaion o LaborLaws (CLL).

1.1.1. e provisions conained in he egulaory Sandards apply, as appropri-ae, o independen workers, o he eniies or companies ha employ hem ando he unions represening heir respecive proessional caegories.

1.7 I is up o he employer:

a) o abide by he laws and regulaions on saey and occupaional medicine. b) o issue orders on workplace saey and occupaional medicine and o makeemployees aware o hem, wih he ollowing objecives:




I- prevening unhealhy acs in he perormance o work;

II- publicise he obligaions and prohibiions ha employees should knowand abide by;

III- make employees aware ha hey will be liable o punishmen or ailure

o comply wih orders issued;IV- determine the procedures to be undertaken in case of occupationalaccidens or diseases;

V- adopt measures as determined by MTE;

VI- take actions to eliminate or neutral ize unhealthy and unsafe working condiions.

c) Inorm he workers o:

I- occupaional risks ha may arise in he workplace;

II- means o preven and limi such risks and he measures adoped by hecompany;

III- he resuls o diagnosic exams o which he workers are subjeced;

IV- the results of environmental assessments conducted in the workplace.

d) Allow ha employee represenaives accompany he surveillance o legal dic-aes and regulaions on workplace saey and occupaional medicine.

1.8. I is up o he employee:

a) o comply wih he laws and regulaions on workplace saey and occupaionalmedicine, including orders issued by he employer;

b) o use personal proecion equipmen provided by he employer;

c) o submi o examinaions as enunciaed in he egulaory Sandards

d) o collaborae wih he company in he enorcemen o egulaory Sandards.

RS-5 – Inernal Commission or he Prevenion o Accidens (ICAP)

Goal5.1 Te Inernal Commission or he Prevenion o Accidens (ICPA) - aims orhe prevenion o accidens and illnesses resuling rom work in order o make hepreservaion o workers’ lives and promoion o heir healh permanenly compaible wih labour.

RS-6 - Personal Proecion Equipmen (PPE)

6.1 For he purpose o his Regulaory Sandard , Personal Proec ion Equip-

men (PPE) reers o any device or produc designed or individual use by heemployee, or he proecion rom risks likely o hreaen his saey and healha work.




RS-9- Environmenal R isk Prevenion Program

9.1 Purpose and Scope

9.1.1 his egulaory Sandard esablishes he obligaion o all employersand insiuions ha admi workers as employees o design and implemen

an Environmenal isk Prevenion Program (EPP) in order o proec hehealh and inegriy o workers hrough he prevision, recogniion, evalua-ion and conrol o environmenal hazards ha exis or may come o exis inhe workplace environmen, aking ino accoun he proecion o he envi-ronmen and naural resources.

RS-10 - Saey in Elecriciy Insallaion and Services


10.1.1 is egulaory Sandard esablishes minimum requiremens and condi-ions aiming or he implemenaion o conrol measures and prevenion sysemso ensure he saey and healh o workers who direcly or indirecly inerac wihelecrical insallaions and services wih elecriciy supply.

10.1.2 is egulaory Sandard applies o he phases o generaion, ransmis-sion, disribuion and consumpion o elecrical insallaions, as well as hesages o heir design, consrucion, insallaion, operaion, mainenance and anyproceedings in heir viciniy. Official echnical sandards esablished by he com-peen auhoriies should be observed and, in he absence or omission o hose,applicable inernaional sandards should hen be ollowed.

10.2 Conrol Measures

10.2.1 Prevenive measures o conrol he risk o elecric shock and oher adverseevens mus be designed hrough risk analysis echniques in order o ensure he workers’ saey and healh in all iner venions in elecrical insallaions

10.9 Proecion Agains Fire and Explosion

10.9.1 All areas where here are elecrical insallaions or elecrical equip-men shall be provided wih proecion agains ire and explosions, as saed by S-23.

10.9.2 e maerials, pars, devices, equipmen and sysems inended or use inelecrical environmens wih poenially explosive amosphere mus be evalu-aed or compliance wih he Brazilian Sysem Cerificaions.

10.14 Final Provisions

10.14.1 Employees mus inerrup heir asks, exercising he righ o reusal,

whenever here is evidence o serious and imminen risk o heir healh andsaey or ha o ohers, immediaely communicaing he ac o his hierarchicalsuperior, who will hen ensure ha adequae acions are aken.




RS-12-Machinery and Equipmen

12.1 Faciliies and Areas o Work

12.1.1 e floors o workplaces where machinery and equipmen are insalledshould be inspeced and cleaned, whenever hey presen risks rom he presence

o grease, oil and oher subsances ha make hem slippery.12.1.2 Circulaion areas and spaces around machinery and equipmen mus beappropriaely sized so ha processed maerial, workers and ransporers canmove around saely.

12.1.3 Among he moving pars o machinery and / or equipmen here shall bea ree variable range o 0.70m (seveny cenimeers) o 1.30m (one meer andhiry cenimeers), a he discreion o he compeen auhoriy in saey andoccupaional medicine.

RS-32- Workplace Saey and Healh in Healh Care Services


32.1.1 is egulaory Sandard esablishes he basic guidelines or he imple-menaion o measures o proec he workplace saey and healh o workersin healhcare services, as well as hose who perorm healh care promoion andassisance in general.

32.1.2 For he purpose o he implemenaion o his egulaory Sandard, he

erm healh care services includes any building inended or he provision ohealh care o he populaion, as well as all buildings designaed or healh promo-ion, resoraion, care, research and healh educaion a any level o complexiy .

Reerences

1. Oliveira CD. Exposição ocupacional a resíduos de gases anesésicos. ev Bras Anese-siol. 2009; 59:110-24.

2. Oxord Dicionary o English. 3rd Ed. Oxord Universiy Press, 2010.

3. Segurança no rabalho. iscos mecânico. HTP://pc Moraes.md.comunidades.ne/index.php?pagina=1671589459.Acesso:04/04/2013.

4. Canedo C. Acidenes de rabalho no cenro cirúrgico do Hospial do Câncer II HCII- INCA. [Disseraion]. io de Janeiro (J): Fundação Oswaldo Cruz, 2009.

5. Sousa FMS. Condições de rabalho de ambiene cirúrgico e a saúde dos rabalhadoresde enermagem [disseraion]. io de Janeiro (J): Universidade do Esado do io de Janeiro, 2011.

6. Silva DEF. O desgase do rabalhador de enermagem: relação rabalho de enerma-gem e saúde do rabalhador. [hesis] São Paulo (SP), Universidade do Esado de São

Paulo, 1998.7. Lit L, Ehrenwerh J. Elecrical saey in he operaing room: imporan old wine, dis-

guised new botles. Anesh A nalg. 1994, 78 (3): 417-9.




8. Braz JRC, Vane LA, Silva A E. isco Profissional do Anesesiologisa. raado de Anese-siologia Saesp, Vol 1, 7th Ed, São Paulo, Ed, Atheneu, 2011; (7) :76-77

9. orres MLA, Mahias S. Complicações com o uso de moniorização. Segurança no usodo equipameno elero-médico. ev Bras Anesesiol. 1992:42 (2) :91-101

10. Associação Brasileira de Normas écnicas. ABN, Norma NB14136. Plugues e oma-das para uso domésico e análogo aé 20A/250A em correne alernada - Padronização,2002; versão corrigida, 2008.

11. Secco IAO, obazzi, MLCC, Guierrez P, Masuo . Acidenes de rabalho e iscosOcupacionais no dia-a-dia do rabalhador hospialar: desafio para a saúde do rabalha-dor. Ccs.uel.br/espaço para saúde-/doc/hospiais.doc /. Acesso:04/04/2013.

12. Barbosa A. iscos ocupacionais em hospiais: um desafio aos profissionais da área desaúde ocupacional. [Disseraion]. Florianópolis (SC): Universidade Federal de SanaCaarina, 1989

13. Segurança e Medicina do rabalho, 59h Ed, São Paulo, Ediora Alas SA, 2006.11-46.



3.3 - Ergonomic occupaional risks in aneshesiology | 207

Ergonomic Occupaional Risks in Aneshesiology

Luiz Alredo JungSA, SBA

Inroducion

egardless o exernal acors, on is own, aneshesia managemen requires inensephysical and cogniive aciviies, complex manual skills, coninuous vigilance,inensive monioring and precise decision-making. On he oher hand, or manyreasons, i excels oday as a medical specialy capable o offering considerable lev-els o saey.

ese acs aknowledged, wo poins relaed o daily pracice are sill disurbing:he high number o paiens who suffer he consequences o proessional malprac-ice relaed o one or more aspecs o he aneshesiologiss’ responsibiliies1 and henumber o aneshesiologiss whose physical and/or psychological healh have beendegraded due o heir aciviies2.

Anesheics and opioids, whose pharmacological properies are now consideredavorable, are also very poen; moniors oen provide inormaion overload; opera-ing rooms (O) are workplaces wih special eaures and he group o people who work in hem is heerogeneous. us, susained atenion (vigilance) is necessar yand one o he specialy’s key aspecs. Besides, in many siuaions, he proessionalis orced o work under ime pressure in order o opimize he O use. As a conse-quence aneshesiologiss use o work long hours; have o manage cos-relaed issues; work in a high complexiy sysem; and are affeced by he surrounding poliical,economical and social environmen. us, aigue is a poenial companion and has been given special atenion in recen lieraure3,4. Disinguishing aigue rom ohercondiions ha are requenly correlaed, such as burnou syndrome, drug addic-ion, depression, or simply sress, exceeds he scope o his chaper, bu negligence

regarding uncional aspecs o aneshesiology daily pracice cerainly adds risk ordeveloping all hose condiions.

e burnou syndrome and is requenly associaed depressive sympoms afflica considerable number o aneshesiologiss. Burnou is defined as a siuaion wheredemands exceed proessionals’ physical and/or psychological resources. Myers, a psy-chiaris and member o he Canadian Medical Associaion, recommends humaniza-ion o he workplace as a prophylacic measure5. Humanizaion is a broad concep;however one should always have i in mind while building a healhy workspace.

Whaever he reasons or human error in aneshesiology pracice, is effecs on whoever was responsible or associaed wih i can be devasaing and are, undoub-edly, he origin o many occupaional condiions and diseases. Ergonomics aims o




decrease he chances or errors by sudying he daily asks and behaviors o hoseinvolved in a given proession.

In realiy, mos operaing rooms are projeced wih minimal consideraion regardinghe needs o anaeshesiology personnel. When i comes o diagnosic or minimally

invasive oupaien procedures perormed ouside he O, he siuaion is even worse. Bu ha is no he only reason why he expression “ergonomic malpracice”6 has been requenly used. Besides physical characerisics o he workplace, lighingand noise, here are oher aspecs o daily pracice ha mus be considered, suchas amiliariy wih aneshesiology apparel (differen ypes o moniors and oherequipmen). I is also imporan o analyze proessionals’ comor condiions whileperorming manual asks, such as racheal inubaion and vessel caheerizaion,given he poenial musculoskeleal harm. In principle, every rouine ha brings oraugmens physical or psychological aigue mus be careully evaluaed.

is chaper will highligh many aspecs o aneshesiology pracice in he O hashould be beter undersood in order o avoid medium or long-erm hazards o pro-essionals’ healh and possibly jeopardize paien care.

Ergonomics and he Work o he Aneshesiologis

Ergonomics is he discipline ha gahers inormaion abou people’s needs, char-acerisics, abiliies and limiaions, inegraing all ha o creae, develop and esequipmen, insrumens, sysems, rouines and proocols6. Is main goal is maxi-

mizing man-o-man and man-o-machine inerace. Applied o aneshesiology, hisdiscipline seeks o opimize work environmen, improve perormance and offerphysical and menal well-being7.

aking hese aspecs ino accoun is imporan or aneshesiologiss’ workplaceimprovemen8. No long ago, new equipmen and moniors were jus piled over olderones, wihou any concern abou opimizing heir spaial disribuion or beter com-or and efficacy o hose using i.

In order o achieve is goals, ergonomics analyzes specific asks, sudies he amoun

o work necessary o perorm each ask, including analysis o criical incidens, sud-ies atenion and vigilance and he role o auomaion and new echnologies6.

Sudies on aneshesiologiss’ asks

One o he firs sudies o analyze he aciviies o aneshesiologiss in an O wasperormed by Alber Drui, mechanical engineer a he Universiy o Washingonin Seatle. rough a series o videos, he divided hem ino 24 differen caegories.en, he evaluaed he ime, imporance, knowledge, and manual skill necessary operorm each ask. e asks were classified as low, medium or high relevance and

grouped according o prioriy in recreaing hem. Many recommendaions weremade aer his sudy, such as he creaion o a compuerized aneshesia orm, sug-gesions o new locaions or sphygmomanomeers and new design or aneshesia




equipmen; i was proven ha 42% o he ime was spen on asks away rom hepaien and surgical field9.

Aer his, a series o sudies wih he same goals showed similar resuls. ey poinedo he significan amoun o ime spen on asks only indirecly relaed o he paien

and or heir disribuion, influenced by he sage o he procedure. ere were di-eren responses o he sudies among equipmen indusries and even proessionalshemselves, as many o hem were resisan o he paradigm-shiing changes10-14.

Saey equipmen o preven incidens were inroduced (disconnecion alarms, pulseoximery, capnography, and auomaed blood pressure measuremen) and he acingprofile o he aneshesiologis has been changing. McDonald e al, in 1989, repro-duced a sudy abou ha which had been conduced originally earlier in he decade.rough videos, McDonald’s sudy revealed an increase in ime dedicaed o hepaien and surgical field, direcly (44.8%) or hrough moniors (14.3%). However,manually recording inormaion on aneshesia orms occupied 10-12% o he ime15.

Aneshesiology pracice requires a wide range o skills, experience and knowledge andalso differen execuion imes. From venipuncure o exubaion, rom preparaion ora peripheral nerve block o major anesheic monioring, each ask consumes a variableamoun o physical and/or menal work and leads o cerain amouns o psychologicalsress. Considering hese aspecs, a group o proessionals was asked o graduae hedifficulies o perorm a series o acions ino hree levels (low, medium or high). isinquiry developed a workload acor or each ask 16. Muliplying his specific acor by

he ime spen o perorm i provided he ask densiy o each sage o aneshesia, whichis sill one o he mehods used or measuring work in he O oday.

Sudies on aneshesiologiss’ workload

Workload is an expression creaed o describe he amoun o physical or cogniiveresources ha an operaor consumes o execue a given ask 17. Accessing and analyz-ing i allows he developmen o equipmen wih a more ergonomic design, changesin rouine and proocols, and modificaions o he work environmen. Curren moni-or screens inegrae inormaion and localize i visually, inelligen alarm sysemsand closed loop conrolled inusion pumps are some examples o he applicaion oergonomics18. Evaluaing i also allows o measure aneshesiologiss’ cogniive andphysical reserve and, hereore, heir apiude o perorm addiional asks. Workloadis assessed hrough cogniive, psychological and physical acors ha can resul in per-cepion, communicaion, inerrelaion or moor overload6. Among he mehods usedor workload quanificaion, he ones ha evaluae proessionals’ perormance whenhe primary ask is modified or when a secondary ask is added play an imporan role.

Simple mahemaical problems (secondary ask) were presened o a group o resi-

dens perorming a primary ask (aneshesia managemen) a differen momens.e auhors, Gaba and Lee, observed ha he secondary ask perormance wascompromised in 40% o he samples, because i was simply omited or because he




proessional ook an excessively long ime o respond. ese findings were more re-quen during inducion and anesheic recovery, while perorming manual asks, and while alking o he assisan physicians, showing ha a leas during hese momens,residens were overloaded by he primar y aciviy while more experienced aneshesi-ologiss were able o mainain a slighly higher surveillance capaciy 19.

Oher sudies associaed echniques o evaluae perormance a real ime. Weinger 20 analyzed primar y asks during medium size surgical procedures under general anes-hesia; a secondary ask was inroduced (visual vigilance evaluaion es); workload was assessed (subjecive opinions o he aneshesiologiss involved and a singleexernal observer) and ask densiy was measured during aneshesia. e sudy wasperormed wih wo groups o proessionals: supervised residens, wih only wo oeigh weeks o experience (11 general aneshesias wih racheal inubaion or smallor medium size surgeries and duraion o up o 4 hours) and hird-year residens or

anesheiss nurses under limied supervision (11 similar surgeries). e secondaryask was he idenificaion o a ligh signal placed near he ECG monior ha wasperiodically and randomly riggered by he observer. Every en minues he work-load was subjecively measured by a numerical scale rom 6 (no effor) o 20 (maxi-mum effor required). Sudy showed ha inexperienced aneshesiologiss were ableo perorm ewer primary asks per minue (lower densiy o asks), required moreime o achieve almos every ask; repored greaer overload; spen more ime alk-ing o supervisors and surgery eam, and had a longer laency ime o ideniy heligh signal acivaion (lower vigilance capabiliy). e periods o maximum over-

load correlaed wih lower vigilance.

In his paricular sudy, inducion was repored as he period wih highes workload, bu is inensiy and lengh depended on he y pe o surgery. I is suggesed ha dur-ing an average aneshesia, high workload is presen during 20-30% and low workloadin 30-40% o he ime when aneshesiologiss are physically and menally acive andable o respond o addiional asks6.

Work load ca n be assessed by physiolog ical changes presened by aneshesiolo-

giss. Weinger17

ried o assess i in 2004 in wo dieren groups: proessionals wih or wihou eaching responsabiliies . During 12 smal l and medium size sur-responsabiliies. During 12 smal l and medium size sur-. During 12 small and medium size sur-geries, assisan physicians were working wih residens wih dieren clinicalexperiences; in he oher 12 cases, he proessional had no eaching asks. Holermonior was used o measure assisans’ hear rae changes, adding more inor-maion o he assessmen o work overload previously done15. esuls suggesedha inraoperaive eaching asks overloaded he insrucors (psychologicallyand in relaion o asks) and may reduce heir surveillance capabiliy. However,hear rae was signiicanly elevaed during inducion and exubaion in boh

groups, wih no signiican dierence beween hem. Again, a decrease in askdensiy and workload during aneshesia managemen in low complexiy surger-ies was eviden.




ese sudies highligh he differences in inraoperaive aciviies and workloadamong aneshesiologiss wih differen levels o clinical experise. During anesheicinducion and recovery, he number o asks is higher, generally lowering vigilancecapaciy. During he procedure, he amoun o asks may all, depending on manyacors, such as anesheic echnique, complexiy and duraion o surgery and he

paien’s clinical condiion. Beween hese wo periods, or example, experiencedproessionals spend more ime observing he surgical field20 , bu is ha really neces-sary? I is always valuable o aknowledge he progress o he procedure, bu mayberequen verbal communicaion wih he surgical eam can emporarily replaceaneshesiologiss’ prolonged and someimes monoonous observaion, allowing heproessional o perorm oher imporan asks, or even a menal shor break.

Te role o new echnologies

e impac on workload exered by new echnologies is anoher aspec ha needs o be considered. Weinger and Gaba16 sudied he effec o using an elecronic recordo aneshesia and ransesophageal echocardiography on ask disribuion, subjecive workload, workload densiy 6 , and surveillance capabiliy, rom inducion o aneshesiaunil he sar o cardiopulmonary bypass (CPB) in 20 cases o cardiac surgery. Inor-maion or en o hese were recorded manually and or he oher en wih an elecronicsysem. During inducion, here were no differences beween groups regarding henumber o asks and he ime spen on each. In 16 ou o weny cases, in his period,here were no records on aneshesia orm in boh groups. When boh groups were

analyzed ogeher, manual venilaion by mask occupied 24.8% o he ime, wach-ing he moniors comprised 18.6%, and drug adminisraion, 9.0%. During he res ohe sudy, groups differed very litle in relaion o asks perormed and ime spen ineach. e elecronic recording mehod group spen less ime on his ask or setingor waching echocardiography images, and more ime waching he moniors. Onceagain, when he wo groups were analyzed ogeher, 24.7% o he ime was used orobservaion o moniors, 11.5% or recording inormaion, 8.1% or adjusing ubes andinravenous inusions and 7.7% or echocardiography adjusmens or observaion. esubjecive measure o workload showed no significan difference wheher evaluaed

by he proessional himsel or by an exernal observer. ere was also no difference beween he groups, bu workload was higher during inducion/inubaion. egard-ing monioring, aneshesiologiss rom boh groups showed greaer laency o ideniyhe li lamp during inducion (medium ime = 57 sec) han aer inubaion and unilhe end o he sudied period (31 sec, P <0.001). en, auhors compared surveillancecapabiliy o boh groups while perorming he our mos common asks beore CPB.During inormaion recording, here was no difference, bu when perorming adjus-mens o he ransesophageal echocardiography, examining is images or working ininravenous lines, surveillance capabiliy was significanly reduced in boh groups.

ere are wo divergen rends regarding elecronic mehods advanages or aneshe-sia records6. On one hand, is use is encouraged in order o decrease aneshesiologiss’




workload, allowing more ime or oher asks, beter observaion o he paien andmoniors. I could even offer he aneshesiologis some ime o res21,22. On he oherhand his echnology ends o ake away he proessional’s atenion rom he paien-moniors-aneshesiologis scope, increasing he disance beween paien and aneshe-siologis and decreasing aneshesiologiss’ global percepion (awareness)23. While he

aneshesiologis manually uses he moniors o obain and regiser paiens periodicalinormaion, he is always aware o paien’s rends and migh anicipae and inerveneearly in possible complicaions.

In an atemp o assis aneshesiologiss during aneshesia managemen and o helpin he decision making process, sowares have been developed o analyze mulipledynamic physiological processes (hear rae and respiraory rae, blood pressure,SaO

2 ECO

2, idal volume, minue volume) and ideniy changes in heir paterns,

considering heir saisical properies22. Sowares are able o inegrae inorma-

ions on he paien’s previous sae, conex-sensiive hal-lie o drugs and sageso aneshesia. e inormaion may be caegorized as an ariac (sudden change inhear rae caused by he use o cauery), clinically insignifican (elevaion o sysolic blood pressure 110 o 120 mmHg), clinically significan (increased hear rae rom50 o 90 bpm) or inormaion ha requires immediae decision making (SaO

2 all

rom 100 o 90%). is promising echnology is being developed.

Faigue caused by alarms

Monior and inusion pump prolieraion brough he noise o counless alarms o he

operaing room, which may become an imporan source o disracion. Such alarmsare essenial o provide securiy and auxiliary surveillance, bu hey end up creaingchallenges and developmen opporuniies or ergonomics. rigger limis improp-erly adjused may cause consan acivaion o alarms and lead he proessional odisregard hem and pospone decision-making24. I is esimaed ha 85-99% o rig-gered alarms do no require clinical inervenion, because hey were adjused wihinnarrow ranges; sandard limis were no replaced by ones adaped o he paien orpopulaion; sensors were misplaced; or here was an inererence wih oher elecri-cal equipmen in he room25. is creaes a daily cacophony o sounds o bells, beepsand horns. As a resul, he proessional becomes desensiized o he sounds and over-load o useless inormaion and may reduce alarm volumes or rese hem ino valuesha are no sae24.. Sill, every alarm acivaion simulaes, consciously or no, heaneshesiologis’s brain and consumes energy. Unable o disinguish a alse alarmrom a real one, he proessional deals wih wo possibiliies: becoming aigued(aer so many alarms and inense vigilance) or ignoring he alarm and being a riskor malpracice and is psychological consequences, including guil, in case an acu-ally hreaening siuaion was disregarded.

An ideal alarm sysem should: 1) provide a warning ligh or sound, whenever a risk olie occurs, 2) deermine wheher he limi was exceeded due o he paien or oherexernal acors and 3) differeniae and repor alarms riggered by changes in he




paien rom he ones riggered by he equipmen and 4) provide diagnosic inorma-ion or explain he physiological drive21. Is negaive predicive value and sensiiviyo lie-hreaening siuaions should be approach 100%. e posiive predicive valueand specificiy are low even or he mos common problems.

Sudies o criical incidensCriical Incidens (CI) are siuaions where human error occurs and can, i nodiagnosed and reaed in ime, lead o undesirable oucomes, varying rom longerhospializaion unil deah26. When repored, heir analysis may resul in changes inaneshesia pracice, new equipmen designs, beter raining and oher inervenionsha increase he saey o aneshesia and end o improve working condiions. ishas been happening or a long ime, in oher areas o aciviy, such as aviaion27 , basedon inerview echniques applied volunarily and anonymously o people involved inprocedures deemed unsae. In aneshesia pracice, Cooper26 in 1978, was he firs oneo sudy criical incidens. 359 IC were repored rerospecively by 47 aneshesiolo-giss, residens and nurse anesheiss in a single hospial in Boson, where he basedhis sudy. Laer, in a new publicaion, i was exended o five oher hospials in hesame ciy, increasing he number o proessionals involved o 139, adding up o 1089repors o IC28. Human error was poined as he main cause o approximaely 70% oIC. Six y-seven o hem resuled in significan damage o he paien; echnical errorshappened in 28, 23, and 13 judgmen errors and misakes in surveillance. Finally,proocols suggesed syringe and drug idenificaion, re-evaluaion o aneshesia cir-

cui or prevening disconnecion and he use o flowmeers o avoid dangerously lowoxygen concenraions. Oher common IC causes were inadequae communicaionamong eam members, disracion and lowered levels o precauions. us, abou 20 years beore he Insiue o Medicine published “o Err is Human: Building a SaerHealh Sysem” 1 which saed ha “sysems, processes and equipmen are commonlyprone o ailure, leading men o make misakes or ail o preven hem”, Cooperalready poined in ha direcion29.

Subsequenly, a series o sudies wih criical incidens repored righ aer heir occur-rence, showed similar paterns, again suggesing he presence o human error30-32. euse o checkliss and improvemen o specific proocols have been recommended33 as well as replacing old aneshesia appliances wih new ones and ormal discussion abouIC inside he aneshesia deparmen.

From he lae 70’s, muliple acors led o significan changes in aneshesia pracice,including he creaion o naional (Aneshesia Paien Saey Foundaion in 1985 in heUnied Saes) and coninenal insiuiions (Ausralian Paien Saey Foundaion, in1988 in Ausralia and he Saey Commitee o he Associaion o Anaesheiss o Grea

Briain & Ireland in 1974). ese insiuions prioriize paien saey, bu hey also

consider working condiions and aneshesiologiss’ healh. In 1993, he Ausralianinsiuion published is findings on he firs series wih 2000 cases o criical inci-dens colleced rom 90 hospials in Ausralia and New Zealand34. Auhors believed




ha human errors were involved in 83% o hem; and in 17% a beter ineracion wihequipmen and devices would have been able o preven he IC. en, 111 sugges-ions were presened o change sysems, processes and equipmens; hose are gener-equipmens; hose are gener-; hose are gener-ally included in curren anesheic pracice.

Warning and Surveillance Atenion is defined as a “conscious effor o say aler and able o undersand andprioriize inormaion”. Monioring is defined as a “sae o susained atenion”35. Inaneshesia, i can be perceived as a sae o consciousness ha allows he anicipaionand recogniion o clinical changes or hazardous condiions35. Along wih memoryand decision-making, surveillance comprises one o he mos vulnerable aspecs omenal aciviy – men are known o be bad a being vigilan. Our surveillance abiliydecreases rapidly and is exhaused aer abou 30 minues o coninuous monioring,

since severe phenomena (crises) are inrequen and coninuous wachulness or arare poenial even migh be boring35.

As in oher areas o aciviy, vigilance is affeced by environmenal acors (noiseand oher ypes o polluion), personal acors (aigue, sleep deprivaion, boredom,sress, illness, and medicaion use) and man-machine inerace.

nowledge abou brain aciviy has accumulaed since “he decade o hemind” projec, a global iniiaive rom 200736 ha simulaed a mulidisciplinarysudy. Concerned wih he cogniive aspecs o equipmen users, he Human

Facors and Ergonomics Sociey creaed a mulidisciplinary group o sudyman-machine exchange o inormaion and many decisions arose rom i 37. Foraneshesia, a specialy comprised mainly by menal asks, including a close rela-ionship beween man and echnological devices, his concern is easily jusi iedand provides argumens or he creaion o inegraed paien monioring andaneshesia equipmen38 .

Monioring, one o aneshesiologiss’ mos imporan asks, is mainly perormed byhe human senses o hearing and vision. A sudy coordinaed by Cooper and Cullen

proved ha audiory vigilance

39

is more efficien han visual vigilance, which wasinvesigaed by Loeb40. I ook 34 seconds (2 o 457)39 or he occlusion o he chessehoscope o be noed by aneshesiologiss while visual idenificaion o a discreeligh signal in he ECG monior ook 61 ± 61 seconds40 , hose inervenions weremade randomly. Simulaneous asks, criical sages o aneshesia (inducion andaneshesia recovery) and conversaions resuled in longer periods or he idenifica-ion o boh ypes o inervenion.

ecen sudies on human vision show ha men have significan visual limiaions while hey execue simulaneous asks: a) Only a ew simulaneous iems can be

observed and ollowed, b) New objecs or unexpeced evens can be los or over-looked, c) Changes, even when significan, repeaed and expeced, may go unnoicedand d) An observer can no ake noice o wo aleraions a he same ime41.




e layou in which inormaion is displayed on differen monior screens andaneshesia devices may influence aneshesiologiss’ percepion and diagnosis. Easyinake o visual inormaion allows quicker and less energy-consuming decision-making. However, hese improvemens can only be made by analyzing operaors’perormance, discussing daily challenges and soluion ideas. ese limiaions

should be considered by manuacurers early on in he creaive process o a newdevice model. Sandards issued by Medical and Healhcare producs regulaoryagencies42 mus be observed and publicaions wih guidelines ha ake human ac-ors ino accoun are already available43. For hose reasons, ergonomics and humansciences should be combined.

Easy and inuiive inerace and operaion modes should be a prioriy while develop-ing any new device. Naurally or hrough as learning, every acion mus be iner-nalized, so ha i will evenually become auomaic. Anoher imporan sep in a

good projec is o resric he amoun o opions and possible acions, guiding heuser o he bes and/or only answer. Finally, he possibiliy o an operaor misakemus always be considered6. Compliance wih hese recommendaions is vial uponhe suracing o an anesheic crisis.

Preparaion o drug syringes or inusions and equipmen checks require grea aten-ion – drug adminisraion errors were responsible or 23% o he criical incidenscaaloged by Cooper in 197826. e use o color-coded, sandard-orma labels oreach drug or drug class and he creaion o a sequence o individual or insiuionalpreparaion o drugs help preven his ype o error.

Careully designed proocols wih precise indicaion and specialized echniquesor he execuion o specific manual procedures, such as perorming cenral orperipheral nerve blocks, cenral venous and arerial caheerizaion or difficulairway managemen, improve he perormance o aneshesiologiss and offersinsiuional saeguard.

ouines should be planned and esablished or each and every sep o aneshesiapracice: rom overloaded momens (inducion and aneshesia recovery) o he sim-ples and “edious” momens. During periods wih lower workload, less challengesand less simulaion, secondary asks or jus a change in he sequence o asks canhelp he aneshesiologis keep his abiliy o surveillance44. Aneshesia deparmensshould be able o organize shor breaks (in beween surgeries or wih he replace-men o he aneshiologis or a shor period) or aneshesiologiss ha are goinghrough momens o boredom or aigue.

ese shor breaks can be wisely organized by individuals or insiuions. eyincrease paien saey, since hey allow he aneshesiologis o res his mind andrecover wachulness or new evens. ose new evens may be complex siuaions

ha arise suddenly and require he use o so-called “non-echnical skills”, such asatenion, pre-esablished menal maps, ask prioriizaion (ocus), siuaion aware-ness and decision-making45.




Siuaion awareness

e concep o siuaion awareness consiss in he abiliy o be aware o wha is hap-pening around onesel and o undersand he meaning o each and every incominginormaion, which will allow predicion and preparaion or he nex sep 46. An individual who has his abiliy mainains conrol over he siuaion and he environmenduring complex and dynamic crises, when hings change rapidly and ime worksagains him. Siuaion awareness unolds in hree hierarchical levels: percepion (levelI), undersanding (level II) and projecion (level III)47 and is considered an essenialnon-echnical skill. Ergonomics and psychology, among oher specialiies, highlighhe need or siuaion awareness. Gaba inroduced his concep ino aneshesiology in199548. Several findings and resuls came rom observaions and experimens in realis-ic simulaors, always poining o he relaive inabiliy o proessionals o handle all heincoming inormaion rom differen sources. In addiion, during crisis siuaions, he

abiliy o dynamically change he ocus and o share he atenion and aciviies wihoher proessionals are criical and commendable characerisics.

Final Toughs

Aneshesia has developed during is nearly 170 years o exisence, and is currenlyable o offer very high levels o saey. In order o wach over saey, proessionalsshould never exceeded heir working capaciies, alhough exposed o long journeyso work, high levels o sress, and many oher harmul siuaions. Sress aigue andphysical or menal occupaional illness shouldn’ be a par o aneshesiologiss lie.

Bu jus as general praciioners, aneshesiologiss are known or recklessness wihheir own healh and a resisance o ask or help when overloaded49. a’s a currensocial problem, as healhy aneshesiologiss will offer beter saey condiions orheir paiens and he reamen o occupaional illnesses coss more han prevenivemeasures50. Ergonomics is a science ha aims o improve he workplace (making imore pracical and comorable) and offer beter and easier inormaion abou hepaien. Ergonomics can be seen in every aspec o daily pracice. Aneshesiologiss benefi rom he advanages o applied ergonomics hrough guidelines, specificproocols or guidance or ask prioriizaion. For all ha, aneshesiologiss shouldalways have ergonomy in mind in order o improve saey o aneshesia and long-erm proessional healh.

Reerences

1. ohn L, Corrigan JM, Donaldson MS - o Err is Human: Building a Saer Healh Sys-em. Washingon, DC, Naional Academy Press, 1999; 1-223.

2. Howard S, osekind M, az JD, e al - Faigue in aneshesia: implicaions and srae-gies or paien and provider saey. Aneshesiol, 2002, 97 (5) :1281-1294.

3. Ward ME, Bullen , Charlon E, Coley , D’Auria D, Dickson D, Hun S, Johnson I,Gareld M - Fatigue and Anaesthetists: Expanded Web Version. e Association of Ana-esheiss o Grea Briain and Ireland, June 2005: 1-28. ( i www.aagb. org ).




4. Saemen on Faigue and e Anaesheis. Ausral ian and New Zealand College o Anaesheiss, June 2007:1-4 ( www.anzca.edu.au ).

5. M Myers - Geting beter a being well: Ediorial in M Myers - Canadian Medical As-sociaion Guide o Physician Healh and Well-Being. Otawa, ON. Canadian Medical Associaion Publisher, 2003; 3-4.

6. Loeb G, Weinger MB, Berry JM - Ergonomics o he aneshesia workspace in Ehrenwer-h J, Eisenkra JB, Berry JM - Aneshesia Equipmen: Principles and Applicaions. 2ndEd Philadelphia, PA, & Saunders Elsevier, 2013, 485-506.

7. Wik lund ME, Weinger MB - General Principles in Weinger MB, Wicklund ME, Gardner--Bonneau DJ - Handbook o Human Facors in Medical Device Design. 1 o Ed. Bocaaon, FL, aylor & Francis, 2011; 2-22.

8. az JD - Occupaional Healh Consideraions or Aneshesiologiss: From Ergonomicso Economics. ASA e r Courses in Aneshes, 2011; 39:65-71.

9. Drui AB, J Behm, Marin WE - Predesign invesigaion o he aneshesia operaionalenvironmen. Anesh Analg 1973, 52 (4) :584-591.

10. JB Cooper, S Newbower, Moore JW, e al - A new aneshesia delivery sysem. Aneshe-siol 1978, 49 (5) :310-318.

11. LL Blum - Equipmen design and human limiaions. Aneshesiol 1971, 35 (1) :101-102.

12. CS Ward - e prevenion o accidens associaed wih anesheic apparaus. Bri J Ana-esh 1968, 40 (9) :692-701.

13. Eger EI, Epsein M - Hazards o anesheic equipmen. Aneshesiol 1964, 25 (4):490-504.

14. JB Cooper, S Newbower - e aneshesia machine: An acciden waiing o happen inM Picket, J riggs - Human Facors in Healh Care. Lexingon, Mass. LexingonBooks, 1975, 345-358.

15. JS McDonald, Dzwonczyk , Gupa B - e second ime-sudy o he anesheis’s inra-operaive period. Bri J Anaesh 1990, 64 (5) :582-585.

16. Weinger MB, Herndon OW, Gaba DM - e effec o elecronic record keeping andransesophageal echocardiography on ask disribuion, workload, and vigilance Duringcardiac aneshesia. Aneshesiol 1997, 87 (1) :144-155.

17. Weinger MB, eddy SB, Slagle JM - Muliple Measures o aneshesia workload Duringeaching and noneaching cases. A nesh Analg, 2004, 98 (5) :1419-1425.

18. J Saunders, W Jewet - Sysem inegraion - he need in uure aneshesia deliverysysems. Insrucion Med, 1983, 17:389-392.

19. Gaba DM, Lee - Measuring he workload o he aneshesiologis. Anesh Analg 1990,71 (4) :354-361.

20. Weinger MB, Herndon OW, Zornow MH e al - An objecive mehodology or ask analy-sis and workload assessmen in aneshesia providers. Aneshesiol, 1994, 80 (1) :77-92.

21. M Imhoff, uhls S - Alarm algorihms in criical care monioring. Anesh Analg 2006;

102 (5) :1525-1537.22. Ansermino JM, Daniels JP, e al Hewgill - An evaluaion o a novel soware ool or

deecing changes in physiological monioring. AneshAnalg, 2009; 108 (3) :873-880.




23. J Saunders - e auomaed anesheic record wil l no auomaically solve problems inrecord keeping. Monioring o J Clin 1980; 6 (4) :334-337.

24. Mcee - Medical device saey in hospials and alarm “alarm aigue”. e Join Commis-sion Seninel Even Aler, 2013; 50, April 8:1-3.

25. e onkani, Oakley B, J Bauld - educing hospial noise: a review o medical device

alarm managemen. Biomedic Insrumenaion & echnology, 2012, 46 (6) :478-487.26. Cooper JB, Newbower S, Long CD e al - Prevenable aneshesia mishaps: a sudy o

human acors. Aneshesiol 1978, 49 (6) :399-406.

27. JC Flanagan - e criical inciden echnique. Psych Bull 1954, 51 (4) :327-358.

28. Cooper JB, Newbower S, iz J - An analysis o major errors and equipmen ailures inaneshesia managemen: consideraions or prevenion and deecion. A neshesiol 1984;60 (1) :34-42

29. Pierce EC Jr - Looking back on he aneshesia criical inciden sudies and eir role in

caalysing paien saey. Qualiy and Saey in Healh Care, 2002, 11 (3) :282-283.30. Craig J, Wilson ME - A survey o anesheic misadvenures. Anaesh 1981, 36 (10): 933-936.

31. Kumar V, Barcellos WA, Mehta MP, et al - An analysis of critical incidents in a teachingdeparmen or qualiy assurance: a survey o mishaps During aneshesia. Anaesh , 1988,43 (10) :879-883.

32. LA Jung, Cézanne ACO - Complicaions relaed o aneshesia. ev Bras Anes, 1986, 36(3) :4 41-448.

33. LA Jung, Jung DA, Oliveira C - Complicaions relaed o aneshesia: Influence o hepresence o docors in raining. ev Bras Anes, 1993, 43 (2) :113-117.

34. unciman WB, Sellen A, Webb e al - Errors, incidens and accidens in anesheicpracice. Anaesh Inens Care , 1993, 21 (5) :506-519

35. Weinger MB, Berry JM - Vigilance, Alarms, Monitoring and Integrated Systems inEhrenwerh J, Eisenkra JB, Berry JM - Aneshesia Equipmen: Principles and Applica-ions. 2nd Ed Philadelphia, PA, & Saunders Elsevier, 2013, 448-484.

36. Albus JS, GA Beckey, JH Holland e al. - A proposal or a decade o he mind iniiaive.Science , 2007, 317 (5843): 1321.

37. M Endsley, Hoffman , D aber e al. - Cogniive engineering and decision making: an

overview and uure course. O J Cogn Eng Making and Dec, 2007; 1:1-21.38. Peffer S, Maier , and Sricker e al. - Cogniive ergonomics and load inormaory in

aneshesia. Biomed ech, 2012, 57 (Suppl 1) :947-950.

39. OJ Cooper, Cullen BF - Observer reliabili y in deecing surrepiious random occlusionso he monaural esophageal sehoscope. J Clin Moni , 1990, 6 (4) :271-275.

40. Loeb G - A measure o inraoperaive atenion o monior displays. Anesh Analg ,1993, 76 (2) :337-341.

41. ensink R - Percepual limis on visual monioring ask. Procc Con IEEE Eng MedBiol Soc , 2008; 1030-1031.

42. Associaion or he Advancemen o Medical Insrumenaion (AAMI) - Human acorsengineering - Design of medical devices. (ANSI/AAMI HE-75-2009), 2009. Arlington, VA.




43. Weinger MB, Wiklund M, Gardner-Bonneau D - Handbook o Human Facors in Medi-cal Device Design. 1 o Ed. Boca aon, Florida. In 2011.

44. Weinger M, Englund C - Ergonomic and human acors affecing anesheic vigi lance andmonioring perormance in he operaing room environmen. Aneshesiol, 1990, 73 (5):995-1021.

45. Flecher GCL, McGeorge P, Flin H e al - e role o non-echnical skills in aneshesia:a review o curren lieraure. Bri J Anaesh 2002, 88 (3) :418-429.

46. Schulz CM, Endsley M, EF ochs e al - Siuaion awareness in aneshesia: Concep andresearch. Aneshesiol, 2013; 118 (3) :729-742.

47. M Endsley - owards a heory o siuaion awareness in dynamic sysems. Human Fac-ors 1995, 37 (1): 32-64.

48. Gaba DM, Howard S, Small SD - Siuaion awareness in aneshesiology. Human Fac-ors, 1995, 37 (1) :20-31.

49. Arnez BB - Psychosocial challenges acing physicians o oday. Social Science and Medi-cine, 2001, 52 (2) :203-213.

50. Wallace JE, Lemaire J - Physician well being and qualiy o paien care: An exploraorysudy o he missing link. Psychol, Healh & Medicine, 2009, 14 (5) :545-552.



3.4 - Biological occupaional risks in aneshesiology | 221

Biological Occupaional Risks in Aneshesiology

Anonio Fernando CarneiroSA-SBA, PhD, Head o Deparmen o Surgery, Federal Universiy o Goiás, Direcor o he

Deparmen o Deense SBA Proessional, Specialis in Inensive Care Medicine

Fabiana Ferreira AP Bosco BoscoSA, PhD, Associae Proessor a he Federal Universiy o Goiás, co-head o he CE / SBA, Federal

Universiy o Goiás

Many proessional aciviies may avor conac wih biological agens such as bace-ria, viruses, ungi, parasies and proozoa. ese agens are capable o causing dam-age o human healh hrough inecions, allergic reacions, auoimmune diseases,riggering umors or malormaions.

e operaing or invasive medical procedure room is a scenario where he exposureo he healh proessional o blood and secreions is common and can cause con-aminaion wih blood-borne pahogens1. A surgeon in business or en years hasa 95% probabiliy o having suffered some kind o conaminaion in his scenario 2.Usage o needles wih proecion mechanisms and o he elecrocauery when appli-cable seem o lessen he chance o conaminaion among hese proessionals3. Onhe oher hand, ew auhors have sudied he incidence and means o occurrenceo conaminaions among aneshesiologiss and oher praciioners o he surgical

environmen or needlesick injuries or conac wih secreions. A mulicener sudy by Greene e al. (1998) invesigaed he incidence o percuaneous injuries wih con-aminaed maerial among aneshesiologiss and repored ha 74% were relaed o blood conaminaion and 30% were high risk, having occurred during cenral venouscaheer inserion or blood sampling4. Anoher sudy o he same group revealed hahe majoriy o lesions repored by aneshesiologiss were moderae or severe andmos oen in he hands5.

Albei oen coming in conac wih blood and bodily fluids or secreions, aneshesi-ologiss requenly ail o repor and invesigae hem properly, reaing hese evensas inocuous even in ceners wih biosaey programs2. In emergency siuaions orcriical momens o hemodynamic insabiliy such as during on-pump hear bypasssurgery, a series o misakes and he inense concern wih he paien’s lie increasehe risk o exposure o biological maerial6,7.

Needlesick injuries, oher percuaneous injuries and conac wih body fluids arehe mos common causes o disease ransmission among aneshesiologiss in he workplace, and hepaiis C virus is he pahogen mos oen ransmited o aneshe-siologiss hrough conac wih conaminaed blood rom paiens8 , mainly hrough

he ocular conjunciva9. Aneshesiologiss don’ seem o be aware o he risks o bio-logical conaminaion a he workplace, no even when he paien is considered ahigh risk of being infected. e fact that pre-operative HIV testing of patients has




no been proven o reduce he incidence o accidenal exposure o blood by healhproessionals corroboraes his concern1.

ereore, i is necessary o go beyond discussing his issue on specialy conerencesand o acually inculcae in rainee aneshesiologiss he prevenive acions and mea-

sures o ake in he ace o a possible conaminaion. Alhough prevenion o expo-sure o blood and bodily fluids is he mos effecive measure o avoid occupaionalinecions, proper pos-exposure conduc is also essenial in proessional saey.

Risk o Occupaional ransmission o Human Immunodeficiency Virus (HIV)

e risks for occupational transmission of HIV are described and vary according tohe ype and severiy/inensiy o he occupaional exposure10. In prospecive sud-ies, the average risk for HIV transmission aer percutaneous exposure to infected blood is approximaely 0.3% (0.2-0.5 / CI: 95%) 11 and aer conac wih he mucosa

i is 0.09% (CI = 0.006% - 0.5%)10. Conac wih damaged skin seems o enail asmuch risk as conaminaion o mucous membranes. e risks associaed wih occu-paional exposure o issues, bodily fluids or secreions rom ineced paiens haveno been quanified, bu should be less han ha resuling rom conac wih blood.Fluids considered poenially inecious are: cerebrospinal fluid, synovial fluid,pleural fluid, perioneal fluid, pericardial fluid and amnioic fluid. Feces, saliva, spu-um, swea, ears, urine and vomi are no considered inecious unless hey conain blood11. Compared wih exposiion o hepaiis B or C viruses, he probabiliy ocontamination with HIV is much lower.

Epidemiological and laboraory sudies sugges ha muliple acors are responsiblefor the risk of HIV transmission aer occupational exposure. In a retrospective,case-control survey of health professionals who had percutaneous injuries with HIV-ineced blood, he ollowing characerisics were associaed wih higher risk:

• gross conaminaion o he needle (or peroraing maerial) wih blood oineced paiens;

• inravenous or inra-arerial locaion o he needle involved in he acciden;

• deph o he wound;• conaminaion wih blood rom paiens wih end sage disease;

• amoun o conaminaed blood.

Quantication of plasma viral load (RNA/HIV) reects only the level of free virus(i.e. no atached o cells) in peripheral blood. However, cells wih laen inecioncan ransmi he disease even in he absence o viremia. A low (<1500 NA copies/ml) or undeecable viral load probably indicaes exposure o low iers o virus, budo no exclude he possibiliy o ransmission10.

Even though the risks of HIV infection are low in comparison with Hepatitis B andC and he human immunodeficiency virus resiss poorly o serilizaion mehods, i




cases when hree classes o drugs were combined. ese reamen ailures wereassociaed wih high iers o viral load, size o inoculaion, lae onse, shor dura-ion, characerisics o he physician who had he acciden (immunodeficiency)and viral srain10.

Out of ve classes of drugs available for treatment of HIV infection, only the onesapproved by he FDA (nucleoide reverse ranscripase inhibiors, non-nucleoidereverse ranscripase inhibiors and proease inhibiors) are available or prophy-laxis, which is adminisered according o he risk o ransmission.

Wih regard o he y pe o exposure, in he case o superficial lesions or hose w ihsolid needles, PEP is recommended wih wo classes o drugs when he inecedpaien is ype 1 [i.e. asympomaic or wih low viral load (<1500 NA copies/mL)] and wih hree or more classes o drugs when he ineced paien is ype2 [sympomaic, wih immunodeficiency syndrome, acue seroconversion or high viral load]. In all cases, he sar o PEP should be immediae. For siuaions whenhere is no serology (deceased paien), PEP is no recommended; however, onecan inst itute PEP with two drugs in case the patient had risk factors for HIV. Like- wise, when conaminaion occurs w ih needles rom conainers, he risks and ben-efis o PEP should be discussed wih he exposed person. Moreover, in accidensresuling in serious injur ies and/or wih large amoun o blood, PEP is modified ohree classes o drug, even i he ineced paiens are asympomaic or have low viral load10.

In cases o exposure o mucous membranes or skin lesions o conaminaed blood,PEP will be defined by he volume o blood (drops vs. grea quaniy). Small amounso blood sugges he use o wo classes o drugs or exposure wih blood rom ype1 paiens and recommends he use o 2 drugs or exposure wih blood rom ype 2paiens. When he acciden involves large amouns o conaminaed maerial, herecommendaions include 2 drugs or ype 1 paien maerial and 3 classes o drugsor ype 2 paien maerial. PEP is no recommended when accidens involve paiens wih negaive serolog y, wheher hey be percuaneous or conac wih mucous mem-

branes or skin lesions

10

.e indicaed PEP regime should be iniiaed as quick ly as possible aer he accidenand reassessed 72 hours aer exposure, especially when here is addiional inorma-ion abou he paien. Medicaions should be adminisered or 4 weeks i oleraed,and in he ace o a negaive serology, he regime should be disconinued. Due o heoxiciy o he agens used, one should always weigh he risk/benefi raio o PEP,especially when hree classes o drugs are o be employed.

e exposed proessionals mus be accompanied, advised and submited o medical

evaluaions, especially hose who are receiving prophylaxis. ey mus also undergoserology ess a leas once a six monhs pos-exposure (6 weeks, 12 weeks and 6monhs) or when acing an acue reroviral syndrome.




Occupaional Risk o ransmission o Hepaiis B and C Viruses

Viral hepatitis is a major public health problem worldwide, including Brazil. Accord-ing o esimaes, billions o people have had conac wih hepaiis viruses and mil-lions are chronic carriers. e liver is he primary arge o hese pahogens, bu sys-emic disseminaion o he disease occurs occasionally. Despie he clinical similari-ies beween he various ypes o viral hepaiis, here are undamenal differences inheir eiology, epidemiology and pahophysiology 18.

Viral hepatitis is designated by leers of the alphabet: hepatitis A (HAV), hepatitisB (HBV), hepatitis C (HCV), hepatitis D (HDV) and hepatitis E (HEV). ere areoher hepaoropic pahogens, such as he causaive o non-A, non-E hepaiis , si llunidenified19. Several oher pahogens such as cyomegalovirus, rubella, yellowever, herpes virus, and varicella can inec he liver and resul in hepaiis viruallyindisinguishable o he classic condiions cied above20.

e hepatitis B virus (HBV) can cause acute and chronic infection, cirrhosis, hepato-cellular carcinoma, liver ailure and deah2 3. Mill ions o people are affeced annually,and it is a signicant public health problem worldwide, since HBV is responsible forabou 4,000 o 5,000 deahs a year in he Unied Saes, rom cirrhosis or liver cancer.

Transmission of hepatitis B virus (HBV) is parenteral and sexual, it is considered asexual ly ransmited disease. Hepaiis B can his be acquired hrough cus (skin andmucosa), unproeced sex and parenerally (hrough sharing o needles and syringes,atoos, piercings, denal or surgical procedures, ec...). e magniude o occupa-ional hazard wih he hepaiis B virus is 40 o 60%21.

e hepatitis C virus (HCV), formerly known non-A, non-B hepaiis , was respon-sible or 90% o cases o hepaiis ransmited by blood ransusion wihou a rec-ognized eiologic agen. e causaive agen is an NA virus o he amily Flaviviri-dae, which may presen as asympomaic or sympomaic. On average, 80% o hepeople ineced wih he virus canno eliminae i and evolve ino chronic orms.e remaining 20% eliminae he virus wihin a period six monhs rom he onseo inecion.

When here is exposure o paiens ineced w ih hepaiis C and hose o unknownserology, monioring o he healh proessional is recommended. Occupaionalaccidents involving the hepatitis C virus (HCV) only result in ecient transmissionhrough blood. e average incidence o seroconversion aer percuaneous expo-sure to blood known to be infected with HCV is 1.8% (range 0-7%)21.

Since the incubation period of hepatitis C lasts about 7 weeks and the vast majority (>75%) o acue cases are asympomaic, laboraory invesigaion is necessary or diag-nosis. About 70 to 85% of cases of contamination by HCV progress to chronic disease.

e owchart for Victims of Occupational Accident with Biological Material should be applied and noified. e healh care proessional should sop he procedure and




reques a colleague or replacemen, wash he wound wih waer and soap (skin)or saline soluion (mucosa), ideniy he source and communicae he immediaesupervisor. en assess he individual occupaional hazard22:

Sep 1: Care locaions

• Percuaneous or cuaneous exposure:• Wash exhausively wih soap and waer

• Use antiseptic solution (chlorhexidine or PV P-I)

• Mucosal exposure:

• Wash exhausively wih waer or saline soluion

Conraindicaed measures: procedures ha increase he exposed area suchas cus and local injecions and irrian soluions such as eher, hypochlorie

and gluaraldehyde.Sep 2: Exposure Assessmen

• Biological material with HBV :

Blood is the material with highest titers of HBV. Milk, bile, cerebrospinal uid,eces, nasopharyngeal secreions, saliva, swea and join fluid are no good rans-miers of HBV.

• Biological material with HCV :

Blood is the only ecient transmier of HCV Oher biological maerials pose unquanified risks. ere is significan risk oransmission by conaminaed suraces (omies).

Sep 3: Source Evaluaion

• nown source wih known serologies or available or blood esing

• Source wih unknown serologies and unavailable or esing

• Unknown source

Sep 4: Specific Managemen o Hepaiis B

Risk o ransmission afer accidenal exposure o blood:

a) HBeAg posiive (replicaing):

• 20-30% clinical hepaiis

• 35-60% serological evidence

b) HBeAg negaive (non-replicaing):

• 1-6% clinical hepaiis• 20-35% serological evidence




When aced wih accidens wih HBV risk:

• Unvaccinaed healh care proessional:

• HBV-positive source: immunoglobulin + start vaccination regime

• HBV-negative source: start vaccination regime

• Unknown or unesed source: sar vaccinaion regime

Immunized healh care proessional (Ani-HBs> 10mUI/mL):

• HBV-positive, HBV-negative or unknown source: no specic measures

Carneiro e al. (2003) found a prevalence of HBV infection among anesthesiolo-giss o 8.9% (ani-HBc).

Specific managemen o HBV vaccine:

• Vaccination is very eective (90 to 95%) - (anti-HBs +)

• 10% do no respond o hree doses: repea 3-dose regime

• 40% remain non-responders: orienae

• egime: 0, 1 and 6 monhs

• Vaccinate all health professionals as a PRE-exposure measure

• Pregnan and breaseeding women can be vaccinaed

Specific managemen or HCV

• ere are no posexposure prophylacic measures

• e proessional should be counseled, esed and moniored serologically

• ere is no vaccine

When aced wih accidens wih HCV risk:

• ollow-up wih serology and liver enzyme esing

• ideally, evaluae PC/NA wih sensiive ess

Sep 5: Follow-up clinical and serological

• Lengh: 6 monhs o 1 year

• Guidelines in case o conaminaion: using condoms, no donaing blood orissues, avoiding pregnancy, disconinue breaseeding

While any proessional caegor y may be a risk, surgical healhcare proession-als (including aneshesiologiss), paramedics and emergency care providers are

considered a high-risk group or occupaional exposure o biological maerial.nowledge o saey sandards and heir applicabiliy should be rouine in heclinical pracice o aneshesiologiss.




Reerences

1. Gerberding JL, Litell C, arkingon A, Brown, Schecer WP. isk o exposure o surgicalpersonnel o paiens’ blood During surgery a San Francisco General Hospial. N Engl JMed 1990; 322:1788-93.

2. Jagger J, Perry J. Power in numbers: using EPINe dae o Promoe proecive policies or

healhcare workers. Inusion J Nurs 2002 25: S15-20.3. Lopez R, ayan GM, . Monlux Hand injuries During hand surgery: a survey o inra-

operative sharp injuries of the hand among hand surgeons. J Hand Surg Eur Vol 2008;33:661-6.

4. Greene ES, Berry AJ, Jagger J, e al. Mulicener sudy o conaminaed percuaneousinjuries in aneshesia personnel. Aneshesiology 1998; 89:1362-72.

5. Greene ES, Berry AJ, Arnold WP, 3rd, Jagger J. Percuaneous injuries in aneshesia per-sonnel. Anesh Analg 1996; 83:273-8.

6. Davies CG, han MN, AS Ghauri, anaboldo CJ. Blood and body luid splashesDur ing surger y - he need or eye proecion and masks. An n Coll Surg Engl 200 7;89:770-2.

7. Chak ravarhy M. Enhanced risk o needlesick injuries and exposure o blood and bodyfluids o cardiac aneshesiologiss: need or serious inrospecion. Ann Card Anaesh2010; 13:1-2.

8. Jackson SH, Cheung EC. Hepaiis B and hepaiis C: occupaional consideraions or heaneshesiologis. Aneshesiol Clin Norh America 2004; 22:357-77, v.

9. Matner F, illmann HL. Alleged Proo o ransmission o hepaiis C virus by a conjunc-

ival blood splash. Am J Inec Conrol 2004; 32:375-6.10. Updaed U.S. Public Healh Service Guidelines or he Managemen o Occupaional

Exposures to HBV, HCV, and HIV and Recommendations for Prophylax is postexposure.MMW ecomm ep 2001, 50:1-52.

11. Bell DM. Occupaional risk o human immunodeficiency virus inecion in healhcare workers: an overview. Am J Med 1997, 102:9-15.

12. Filgueiras SL, SF Deslandes. [Evaluaion o counseling aciviies: analysis o a person-cenered prevenion perspecive]. Cad Saude Publica 1999; 15 Suppl 2:121-32.

13. Spira AI, Marx PA, Paterson B, e al. Cellular arges o inecion and roue o viraldisseminaion aer an inravaginal inoculaion o simian immunodeficiency virus inorhesus macaques. J Exp Med 1996, 183:215-25.

14. Oten R, Smih D, Adams D, e al. Efficacy o posexposure prophylaxis aer in-ravaginal exposure o pig-ailed macaques o a human-derived rerovirus (human im-munodeciency virus type 2). J Virol 2000; 74:9771-5.

15. Bötiger D, Johansson NG, B Samuelsson, e al. Prevenion o simian immunodeficiency virus, SIVsm, or HIV-2 infection in cynomolgus monkeys by pre-and postexposure ad-minisraion o BEA-005. Aids 1997; 11:157-62.

16. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversionin healh care workers aer percuaneous exposure. Ceners or Disease Conrol andPrevenion Needlesick Sur veillance Group. N Engl J Med 1997; 337:1485-90.




17. Connor, Sperling S, Gelber , e al. educion o maernal-inan ransmission o hu-man immunodeficiency virus ype 1 wih zidovudine reamen. Pediaric AIDS Clinicalrials Group Proocol 076 Sudy Group. N Engl J Med 1994; 331:1173-80.

18. Aach RD - Viral Hepatitis in: Feigin RD, Cherr y JD - Textbook of Pediatric InfectiousDisease. Philadelphia, WB Saunders, 1981, 513-532.

19. AJ Zukerman - Alphabeo hepaiis viruses. Lance 1996, 341: 558-559.20. Clemens SAC, Fonseca JC, Azevedo e al - Seroprevalence or hepaiis A and hepaiis

B in our ceners in Brazil. ropical ev Soc Bras Med 2000; 33:1-10.

21. MS. Procedure manual or occupaional exposure o biological maerial, 2004. Gerberd-ing, N Engl J Med 2003, 348 (9): 826-33.

22. MS, ecommendaions or care and monioring o occupaional exposure o biologicalmaterial: HIV and Hepatitis B and C, 2004. MS, Recommendations for ART, 2002/2003.

23. Ram AF, Daher RR. Seroprevalence of Hepatitis B Virus in Anesthesiologists. RBA

2003; 53: 5: 672 -679.



3.5 - Ex posure o inhaled anesheics | 231

Exposure o Inhaled Anesheics

Maria Angela ardelli Associae Proessor, Deparmen o Aneshesiology, Pain and Inensive Care,

School o Medicine - UNIFESPCo-Edior o he Brazilian Journal o Aneshesiology

Carlos Rogério Degrandi OliveiraCo-responsible o he CE o he Sana Casa de Sanos

esponsible or Cardiac Aneshesia Service o Sana Casa de Sanos Maser in Clinical Medicine Foundaion Lusiada, Sanos

Edno Magalhães Maser and Docor Pauli sa School o Medicine - UNIFESP

Full esearch Proessor - Universiy o Brasiliaesponsible or CE 9103/SBA - Universiy o Brasilia

Hisory

e eraogenic effecs o inhaled anesheics were iniially sudied in 1910 by Sock-ard 1 , bu concerns abou he consequences o prolonged exposure o is residues onlyarose in he lae 1960s in he Sovie Union, Denmark, England and he Unied Saes. Aricles published in he Brazilian Journal o Aneshesiology over he 1970s revealedgrowing concern over he issue in our counry 2, 3.

In 1967, healh examinaions were perormed in 198 male and 110 emale aneshesi-ologiss rom he ormer Sovie Union, all o whom used eher, N2O and halohane in

heir daily pracice4. High levels o headache, aigue and irriabiliy were repored,as well as he firs published cases o adverse effecs on human reproducion: 18 ouo 31 pregnancies resuled in sponaneous aborion and congenial malormaion.Laer ha year, Fink demonsraed he adverse effecs o N

2O on he reproducion

o ras by showing ha high blood concenraions o ha gas resuled in increasedincidence o skeleal abnormaliies5.

Also in 1967, Parbrook repored cases o previously healhy paiens who developed bone marrow depression aer chronic exposure o N2O6.

In 1968, a sudy on he cause-speciic moraliy o 411 American aneshesiolo-giss over a 20-year period ound low incidence o lung cancer, normal incidenceo leukemia and higher incidence o lymphaic malignancies compared wih hegeneral populaion7.

Anoher research in 1973 showed ha he incidence o cancer among Americannurse anesheiss was 1.33% higher han he conrol group (0.4%)8.

Laer, in 1981, he American Sociey o Aneshesiologiss published a bookle called“Wase anesheic gases in operaing room air: A Suggesed program o reduce per-sonnel exposure”9.



3.5 - Exposure o inhaled anesheics | 233

Cyochrome sysems P450 2E1 and 3A conribue o he meabolism o isoflurane, which is approximaely 0.3%. rifluoroaceic acid is a lso ormed as an inermediaecompound15. Likewise, 0.02% o desflurane is meabolized ino inorganic fluorideand rifluoroaceic acid16.

e degree o meabolism o mehylehyl ehers is lower han ha o halohane. Con-sequenly, liver damage ascribed o hese anesheics is very rare.

Sevolurane is meabolized by cyochrome P450 2E1 a a rae o 2%15 , bu unl ikeoher halogenaed agens, i does no resul in riluoroaceic acid ormaion.he byproducs o sevolurane meabolism are inorganic luorides and hexa-luoroisopropranolol. he laer is rapidly conjugaed wih glucuronid acid andexcreed in he urine. Inorganic luorides are produced a higher raes han hoseproduced by enlurane meabolism, bu sevolurane’s low solubiliy and rapideliminaion make oal exposure o inorganic luorides aer sevolurane lesshan aer enlurane17.

Byproducs o he reacion wih CO2 absorbers

All halogenaed anesheics may reac wih componens o CO2 absorbers. Poassium

hydroxide (OH) and sodium hydroxide (NaOH) are he main reacive componens.High emperaure and desiccaion o he absorber caalyze degradaion reacions.

Conac o deslurane wih desiccaed absorbens conaining OH and NaOHresuls in he ormaion o high concenraions o carbon monoxide (CO). hisalso occurs wih oher halogenaed anesheics, bu in smaller quaniies han wih des lurane18.

Compound A is he byproduc o he ineracion o sevoflurane wih OH andNaOH. I occurs mos in low-flow and closed-circui anesheic sysems and cor-relaes direcly wih emperaure, desiccaion and concenraions o CO

2 , OH and

NaOH in he absorber19.

Exposure o desiccaed soda lime o sevoflurane has resuled in significan amounso mehanol and ormaldehyde in he breahing circui20.

oxiciy in Specific Organs

Hepaooxiciy Abou 20% o halohane undergo bioransormaion in he liver. e firs largererospecive sudy on he associaion o halohane wih liver damage repored anincidence o aal liver necrosis in 1:35.000 anesheic procedures21.

epeaed anes-

hesia was shown o be a risk acor or his relaively rare and aal complicaion. Inconras, a moderae orm o hepaocellular damage was observed in 20% o paiens

exposed o halohane22. is sudy provided evidence ha ulminan hepaiisinduced by halohane is an immune response o hapens, which are he combinaiono inermediae compounds wih macromolecules.




her immediae nor complee: concenraions end o be higher near he aneshesiadelivery machine, where he aneshesiologis says.

In operaing rooms devoid o venilaion and air condiioning sysems, he concen-raion o N

2O is 1000-3000 ppm, while hose urnished wih his kind o sysem

show N2O concenraions o 200-500 ppm. Insallaion o air exhaus sysems inhese rooms reduces his concenraion o 100-300 ppm and 15-35, respecively 28.

Governmen agencies have recommended maximum exposure sandards. e maximumN

2O concenraion in Europe is 100 ppm or 8 working hours/day. In he Unied Saes,

or he same workload, he maximum level is 50 ppm (as deermined by he AmericanConerence o Governmenal and Indusrial Hygieniss - ACGIH) and 25 ppm whenN

2O is used as a single agen (as deermined by he Naional Insiue or Occupaional

Saey and Healh - NIOSH). e concenraion limi or oher inhaled agens in Europe,considering 8 working hours/day, is 10 ppm o 50 ppm or enflurane and isoflurane. In heU.S., he ACGIH considers 50 ppm or halohane and 75 ppm or enflurane28. In France,he limi or occupaional exposure is 25 ppm or N

2O and 2 ppm or oher volaile agens.

In general, maximum values range rom 25 o 100 ppm or N2O and 0.5 o 20 ppm or

volaile anesheics, depending on specific agen, exposure ime and counry 29.

Monioring Occupaional exposure o inhaled anesheics has been quanified by chromaogra-phy and inrared specromery o room air colleced in dosimeers27.

Direc measuremens in exposed workers have been carried ou by chromaogra-phy o urine samples. Anoher mehod o analyze real ime exposure is analysis oexhaled gas hrough proon-ranser-reacion mass specromery 30.

Polluion conrolEffors should always be made o minimize sources o conaminaion. Operaingrooms should be equipped wih air-condiioning, non-rebreahing exhaus sysems wih high sucion flow. ecommendaions or operaing room air renovaion are 15o 21 exchanges per hour, wih a minimum inpu o 50m3 per person per hour.

Poenial Hazards

Organ oxiciy As previously menioned, he organs mos affeced by volai le anesheics are hekidneys and liver. Bea-lyases presen in he kidney ac upon compound A o ormolefins ha are oxic o he proximal ubule, and oxiciy on he collecing ducis caused by fluoride ion. e hreshold or nephrooxiciy o compound A is 300ppm/h in ras and 600 o 800 ppm/h in monkeys, animals wih bea-lyase aciviy30 and 1.5 greaer han ha o men, respecively. During sevoflurane aneshesia wih

resh gas flow o 1L/min, he concenraion o compound A in soda lime does noexceed 20 ppm. Given ha here was no renal damage wih fluoride levels o less han50 μM/L, his was posulaed o be a hreshold or inorganic fluoride nephrooxic-




iy 31. And as or hepaooxiciy, evidence suggess ha he ulminan orm is immunomediaed and resuls rom rifluoroaceic acid acion, while he less severe orm ohepaiis occurs by direc acion o volaile anesheics on hepaocyes.

Wih respec o chronic exposure, a sudy ha evaluaed he serum and urine concen-

raions o inorganic fluoride in 10 aneshesiologiss over a 2-year period ound haserum levels ranged rom 0.2 o 7.9 μM/L. ese proessionals worked in operaingsuies wih non-rebreahing air condiioning and exhaus sysems wih 12 exchanges/hour32. In Brazil, a cohor sudy perormed serial measuremens o serum inorganicfluoride or a period o 18 monhs in ASA I anesheiss aged beween 28 and 43 years, who had been working or 6 o 17 years wih a daily exposure beween 8 and 12 hoursin operaing suies wihou ani-polluion sysems. Average serum fluoride levels were7.24 μM/L, ranging rom 6.17 o 12.95 μM/L, wih peak concenraions up o 40.82μM/L. Average serum fluoride in inhabians o he ciies where hese physicians

worked was 2.74 μM/L. Serum fluoride levels did no reurn o normal in hese proes-sionals, even when hey were away rom work or periods o hiry days33. eevaluaiono he same aneshesiologiss aer 5 years evidenced unchanged plasma concenra-ions o fluoride (7.48 μM/L), bu laboraory ess showed no ubular dysuncion34.

GenooxiciyGenooxiciy resuling rom occupaional exposure o inhaled anesheics is silldebaable. Markers o genooxiciy include chromosomal aberraions and micro-nuclei ormaion, as well as siser chromaid exchange. Increased micronuclei in

lymphocyes have predicive value or cancer risks and siser chromaid exchangeis associaed wih eal malormaions and requen miscarriages. Sudies showincrease in hese markers especially aer exposure above he recommended levels.Exposure o low levels o sevoflurane (0.2 ppm) or isoflurane (0.5 ppm) increasessiser chromaid exchange raes, bu doesn’ influence he ormaion o micronuclei.ese changes disappear wihin 2 monhs o deachmen rom he operaing suie.Oher acors such as sress, smoking and exposure o ehylene oxide also generaehese ypes o changes 29. Chromosome aleraions are ound more requenly in non-smokers exposed o inhaled anesheics. Among smokers, however, he incidence o

hese changes is already high and does no depend on exposure o anesheics 35.

CarcinogenesisSudies show unchanged incidence o cancer among aneshesiologiss. In animals,carcinogenic risks were demonsraed aer 2 years o exposure o low concenraionso N

2O and halohane28. Some sudies conclude ha only older anesheics such as

richlorehylene, chloroorm and fluroxene exhibi carcinogenic poenial in rodens when adminisered in high concenraions27,28.

Reproducive oxiciyFeriliy: ecen mea-analyses have shown increased risk o sponaneous aborionand congenial malormaions in nurses exposed o inhaled anesheics. However,




his associaion was no as eviden in well conduced sudies and he significance ohese findings was limied by he number and heerogeneiy o he included sudies36.

Muageniciy: oxic effecs during eal ormaion. Scienific evidence suggess hahe inhaled anesheics currenly used are no muagenic28.

eraogeniciy: oxic effecs during eal developmen. N2O is he only anesheicexperimenally proven o be eraogenic. Adminisraion o concenraions o 50%or 2.4 o 6 days or 70% or 24 hours in pregnan ras during he period o organo-genesis resuled in an increase in visceral and skeleal abnormaliies, as well as headminisraion o low concenraions (0.1%) hroughou pregnancy in ras. How-ever, hese condiions would be unlikely o be reproduced in humans27,37.

wo o he main acors associaed wih N2O eraogeniciy are is inhibiory effec

on mehionine synhase and is sympahomimeic effecs. In humans, however, he

eraogenic poenial has no been well esablished37

.

Psychophysiological Effecs

Mos sudies ailed o show significan change in cogniive or moor uncion aerexposure o various concenraions o N

2O, wih or wihou halohane, when com-

pared o baseline or conrol cases28.

ypes o Sudy and Inerpreaion o Cause and Effec

Epidemiological sudies evaluae cause-effec relaionships. e indicaed epide-miological sudy design depends on he hypohesis o be esed. In occupaionalmedicine, sequenial measures are essenial, as well as cause-effec relaionships. Acause is denominaed sufficien when i ineviably produces or iniiaes an oucome,and i is called required when he oucome canno occur in is absence38. Alhoughresearch almos always deecs a disease o hen search is causes, i is also possible oideniy a poenial cause, such as air polluion, and invesigae is effecs.

In order o sudy occupaional diseases, research is necessary and mandaory andshould ocus primarily on chronic exposure.

e majoriy o sudies ha assess chronic exposure o operaing suie air are qual-iaive raher han qua niaive, based on inerviews and readings. Purely descrip-ive sudies ai l o analyze possible associaions beween exposure and is effecs.I is also worh noing ha operaing suie proessionals are no only exposed oinha led anesheic wase, bu also o oher chemical, physical and biological agensha can inerere wih sudy resuls. Oher bias sources o be considered are expo-sure magniude variance, age, nuriional saus, obseric hisory, smoking andalcohol consumpion.

Quaniaive sudies are, hereore, he mos appropriae sudy design or analysiso inhaled anesheic exposure in operaing suie air. Observaional sudies such asanalyical surveys and case-conrol cohors are good examples. Cohor sudies are




less suscepible o bias and have he abiliy o assess causaliy. In hese sudies, heresearcher idenifies a poenial risk acor (cause) and moniors or disease develop-men in he ollow-up. ese are usually prospecive sudies and require a long imeo be compleed38.

Considering ha inhaled anesheic oxiciy is relaed o is byproducs rom heirmeabolism or degradaion in CO

2 absorbers, he ocus o research mus be he

inensiy and mechanisms o meabolism o hese drugs. Exposure o human kid-ney collecing duc cells o inorganic fluoride concluded ha miochondria are hearge o acion o he nephrooxiciy responsible or sodium and waer disurbancesin hese paiens. Modern fluorinaed anesheics are meabolized by cyochromeP450, which is no significanly presen in he human kidney. Mehoxyfluorane, onhe oher hand, underwen significan inrarenal defluorinaion. enal damage sud-ies have shown ha exposure ime, i.e. he area under he curve o serum inorganic

fluoride levels, is more imporan han isolaed peak concenraions o his ion39

.e assessmen o renal ubular uncion should include sensiive and specific markers40.

Conribuion o Pharmacogenomics

Drug oxiciy is an adverse effec o he ineracion beween a drug and organ sysems.

DNA sequencing sudies have highlighed he imporance o pharmacogenomics inideniying he influence o geneic variaions on drug response, hrough correla-ions beween gene expression or polymorphisms and efficacy and/or adverse effec

profiles o subsances.Environmenal exposure aecs people dierenly according o individual cha r-acerisics, among which are geneic acors ha may augmen vulnerabiliy.here is usually a combinaion o geneic componens and environmenal issuesin disease mechanisms.

Possible genooxiciy o inhaled anesheics remains conroversial. e sudiespublished so ar ace echnical difficuly in measuring oucomes and he bias o noknowing he subjecs’ pre-exposure geneic profiles.

Geneic polymorphisms influence he effec o anesheics. e possibiliy ogeneic predisposiion or N

2O oxiciy is corroboraed by he case repor o a

paien who developed diffuse myelopahy, upper limb paresis, paraplegia and neu-rogenic bladder dysuncion aer 2 hours o 50% N

2O aneshesia. e sympoms

disappeared aer olic acid and viamin B12 use. DNA analysis showed a polymor-phism o he 5,10-mehyleneerahydroolae reducase isoorm41. Oher problemsalso linked o his polymorphism include hyroid cancer, ovarian and prosaecancers, congenial malormaions, he incidence o Down syndrome, hrombosis

and leukemia.us, in addiion o environmenal acors, geneic polymorphism o proessionalscan inerere wih he effecs o occupaional exposure o inhaled anesheic wase.




Reerences

1. Sockard C - e influence o alcohol and oher anesheics on embryonic developmen. Am J Anes 1910; 10:369-392.

2. Magellan E - isk proessional aneshesiologis. ev Bras Anesesiol 1976, 26:136-147.

3. eis Jr - Exercise o Aneshesiology, chronic inhalaion anesheics and proessional risk:carcinogenesis. ev Bras Aneshesiol 1978; 28:439-447.

4. Vaisman A I - Working conditions in the operating room and eir eect on the health ofanesheiss. Eksperimenalnaia hirurgiia I Aneseziologiia 1967, 12:44-49.

5. Fink B, Shepard H, J Blandau - eraogenic aciv iy o nirous oxide. Naure 1967,214:146-148.

6. Parbrook GD - Leucopenic effecs o prolonged nirous oxide reamen. Br J Anaesh1967, 39:119.

7. Bruce DL, Eide K, Linde HW e al - Causes o deah among aneshesiologiss: a 20-year

survey. Aneshesiology 1968; 29:565.8. Corbet H, Cornell G, e al Lieding - Incidence o cancer among Michigan Nurse-

Anesheiss. Aneshesiolog y 1973; 38:260.

9. Wase anesheic gases in operaing room air: A Suggesed program o reduce personnelexposure. Park idge, IL: American Sociey o Aneshesiologiss 1981.

10. eichle FM, Conzen PF - Halogenaed inhalaional anesheics. Bes Pracice & e-search Clinical Anaeshesiology 2003; 17:29-46.

11. andel L, Laser MJ, Eger EI e al - Nefrooxiciy in ras Undergoing a one-hour expose

o compound A. Anesh Analg 1995, 81:559-563.12. Nunn JF - Clinical aspecs o he ineracion beween nirous oxide and viamin B12. Br J Anaesh 1987; 59:3-13.

13. Gourlay G, Adams JF, Cousins MJ e al - ime-course o ormaion o volaile re-ducive meabolies o halohane in humans and an Animal model. Br J Anaesh 1980,52:331-336.

14. Chris DD, enna JG, ammerer W e al - Enflurane meabolism produces covalenly bound liver adducs ecognized by anibodies rom pacienes wih halohane hepaiis. Aneshesiology 1988; 69:833-838.

15. harasch ED, ummel E - Idenificaion o cyochrome P450 2E1 o he predominanenzyme caalyzing human liver microsomal defluorinaion o sevoflurane, isoflurane, andmehoxyflurane. Aneshesiology 1993, 79:795-807.

16. oblin DD - Characerisics and implicaions o Desflurane meabolism and oxiciy. Anesh Analg 1992, 75: S10-S16.

17. Shiraishi Y, Ikeda - Upake and bioransormaion o sevoflurane in humans: a com-paraive sudy o sevoflurane wih halohane, enflurane, and isoflurane. J Clin Anesh1990, 2:381-386.

18. Fang ZX, Eger EI, Laster MJ et al - Carbon monoxide production from degradation of

Desflurane, enflurane, isoflurane, halohane, and sevoflurane by soda lime and Baralyme. Anesh Analg 1995; 80:1187-1193.




19. Higuchi H, Adachi Y, Arimura S e al - Compound A concenraions During low-owsevoflurane aneshesia correlae direcly wih he concenraion o monovalen bases incarbon dioxide absorbens. Anesh Analg 2000, 91:434-439.

20. Funk W, Gruber M, Wild e al - Dry soda lime degrades markedly During simulaedsevoflurane inhalaion inducion. Br J Anaesh 1999, 82:193-198.

21. JP Bunker, WH Forres, Moseler F e al - e Naional Halohane Sudy: a Sudy o hePossible Associaion Beween Halohane Aneshesia and Posoperaive Hepaic Necro-sis. Behesda, Maryland: U.S. Governmen Prining Office, 1969.

22. Wrigh , Eade OE, M Chisholm e al - Conrolled prospecive sudy o he effec on liveruncion o muliple exposures o halohane. 19751:817-820 Lance.

23. Carrigan W, Sraughen WJ - A repor o hepaic necrosis and deah Following isofluraneaneshesia. Aneshesiology 1987, 67:581-583.

24. Joel Marin, Plevak DJ, Flannery D - Hepaooxiciy aer Desflurane aneshesia. Anes-hesiology 1995; 83:1125-1129.

25. Cook L, Beppu WJ, Hit BA e al - A comparison o renal effecs and meabolism o sevo-flurane and mehoxyflurane in enzyme-induced ras. Anesh Analg 1975, 54:829-835.

26. Sun L, Suzuki Y, akaa M e al - epeaed low-flow sevoflurane aneshesia: effecs onhepaic and renal uncion in beagles. Masui 1997, 46:351-357.

27. Oliveira CD - Occupaional Exposure o Wase Anesheic Gases. ev Bras Aneshesiol2009; 59: 110-124.

28. Burm AGL - Occupaional hazards o inhalaional anesheics. Bes Prac es Clin An-aeshesiol 2003, 17:147-161.

29. Wiesner G, Schiewe LANGGÄNE-F, Lindner , e al -. Increased ormaion o sis-er chromaid exchanges, bu no o micronuclei, in anesheiss exposed o low levels osevoflurane. Anaeshesia, 2008, 63: 861-864.

30. Summer G, P Lirk, Hoerau , e al - Sevoflurane in exhaled air o operaing room person-nel. Anesh Analg 2003; 97:1070-1073.

31. Cianova ML Ielongt B Verpont MC, et al. - Fluoride ion toxicity in human kidney col-lecing duc cells. Aneshesiology 1996, 84: 428-435.

32. PH osenberg, M. Oikkonen - Effecs o working environmen on he liver in 10 aneshe-iss. Aca Anaesh Scand 1983, 27:131-134.

33. Magellan E. - Behavior o serum inorganic fluoride in workers exposed chronically ofluorinaed anesheics. esis - Maser - Paulisa Medical School - São Paulo, 1993.

34. Magellan E. - Evaluaion o renal ubular uncion in workers exposed chronically o fluo-rinaed anesheics. esis submited o he School o Medicine o he Federal Universiyo São Paulo o obain he i le o Docor o Medicine. São Paulo, 1998.

35. Nilsson , Bjordal C, Andersson M, e al. - Healh isks and occupaional exposure o volaile anesheics - a review wih a sysemaic approach Journal o Clinical Nursing,2005, 14: 173-186.

36. Quansah , Jaakkola JJ - Occupaional exposures and adverse pregnancy oucomesamong nurses: A sysemaic review and mea-analysis. Womens’s Healh J 2010;19:1851-1862.




37. Fujinaga M. - eraogeniciy o nirous oxide. Bes Prac es Clin Anaeshesiol 2001;15:363-375.

38. Bonia , Beaglehole , jalbisran - Basic Epidemiology-2nd Ed - Sanos - SP, 2011.

39. Goldberg ME, Canillo J, Larijani GE, e al. - Sevoflurane versus isoflurane or maine-nance o aneshesia: are serum inorganic fluoride ion concenraions o concern?Anesh

Analg 1996, 82:1268-1272.40. harasch ED, Frink EJ, Zager , e al. - Assessmen o low-flow sevoflurane and isoflu-

rane effecs on renal uncion using sensiive markers o ubular oxiciy.Aneshesiology1997; 86:1238-1253.

41. Lacassie HJ, Nazar C B Yonish, e al. eversible nirous oxide myelopahy and polymor-phism in he gene encoding 5, 10-mehyleneerahydroolae reducase. Br J Anaesh2006, 96: 222-225.



3.6 - Exposure o chemical agens | 243

Exposure o Chemical Agens

Rogean Rodrigues NunesSA/SBA, Maser and Docor in Aneshesiology, Proessor o Medicine a Fachrisus,

Pos-graduae in clinical engineering -UNIFO, Co-responsible insrucor a he HospialGeral de Foraleza raining Cener in Aneshesiology, Brazil

Crisiane Gurgel Lopes Farias Aneshesiologis o Hospial Cesar Cals and o he Hospial Universiário Waler Canídio

Head O he Service o Aneshesiology Insiuo do Câncer-CE , Brazil

Inroducion

e pracice o aneshesia enails exposure o physical, biological, ergonomic and

chemical hazards1

. Forunaely, in recen years, echnical advancemens and guide-lines have helped minimize he adverse effecs o occupaional exposure, alhoughsill ar rom eliminaing hem enirely 2.

Regulaory Sandards

e Brazilian Minisry o Labor aims o eliminae or conrol occupaional hazards by issuing regulaory sandards (S) abou urban work. ere are 32 o hem and S32 is especially relevan o healh care providers3,4:

• S 1 – General provisions;• S 4 – Specialized services in Saey Engineering and Occupaional Medicine;

• S 5 – Inernal Commission or he Prevenion o Accidens;

• S 6 – Personal proecion equipmen;

• S 7 – Occupaional healh conrol program;

• S 9 – Environmenal risk prevenion program;

• S 15 – Insalubrious aciviies;

• S 16 – Hazardous aciviies;• S 17 - Ergonomics;

• S 24 – Saniary and comor condiions a he workplace;

• S 26 – Saey signs a he workplace;

• S 31 – Healh and saey in confined spaces;

• S 32 – Healh and saey a he workplace in healh care insiuions.

Hazard Maps

According o Brazilian sandards, occupaional hazards can be classified in five ca-egories, each represened by a differen color (able 1)5. Hazard maps are graphicrepresenaions o occupaional risks wih he inenion o a) Gahering inormaion o




esablish he Healh and Saey diagnosis o he workplace, and b) Promoing aware-ness among employees and simulaing prevenion sraegies. ey are designed by heInernal Commission or he Prevenion o Accidens (ICPA) under he guidance ohe company’s Specialized Services in Saey Engineering and Occupaional Medicine(SEOM) and should ideally include a simplified floor plan o he workplace.

able 1 - Classificaion o he main occupaional risks in groups, according o heir naureand he sandardizaion o corresponding colors.

Group 1Green

Group 2ed

Group 3Brown

Group 4 Yellow

Group 5Blue

Physical Chemical Biological Ergonomic Mishaps

Noise Dus Viruses Physical srainInadequae

physical seting

Vibration Smoke Baceria Weigh liingUnproecedmachines and

equipmen

adiaion Mis ProozoaInadequae

posureInadequae

lighing

Cold Fog FungiExcessive workload

Elecriciy

Hea Gases ParasiesShi and

nightime work Probabiliy o fire

and explosion

Pressure Vapors Bacilli

Long working

hours

Inadequae

sorage

Humidiy ChemicalsMonoony and

repeaabiliy

Exposure opoisonous

animals

Greaer occupaional risks mus be represened by circles o increasing size (Figure 1).

Figure 1 - Inensiy o risks

Circles mus be drawn or posed in he area o he floor plan where he associaedrisks ex is. In case here are several hazards o he same caegory, which are harmulo he same exen (i.e. vibraion, hea and noise – physical risks), a single circle can




be chosen in he appropriae color and size. When here are differen risk caegoriesin he same area, he circle can be divided in up o 5 differenly colored pars, asshown in Figure 2. is procedure is called inciden crierion6.

Figure 2 – Inciden crierion

Chemical hazards in he surgical environmen may be ound in solid, liquid or gas-eous orm and classified ino6:

• Dus

• Smoke

• Mis

•

Gas

• Vapors

ese chemicals come in conac wih he human body hrough he skin, airways ordigesive sysem. Several acors influence heir oxiciy 6:

• Concenraion: he higher he concenraion o an agen, he aser andmore harmul is effecs;

• espiraory Index: represens he average amoun o air inhaled by a

proessional in a workday;• Individual sensiiviy: variaion in sensiiviy o harmul agens beweenindividuals;

• oxiciy

• Exposure ime

Upon enering he body, hese chemicals can cause a variey o oxic effecs o imme-diae (acue) or delayed (chronic) onse, depending on he naure o and he roue oexposure o he chemical. Effecs can, hereore, be classified as ollows7:

• Irr iaing and/or corrosive: aleraions in skin and mucous membranes (cemen,acids and alkali);




• Hypersensitivity reactions (nickel, chrome);

• Asphyxia: impairment of oxygen metabolism (carbon monoxide);

• Narcosis: unconsciousness (chloroform, ether, alcohol);

• Neurotoxicity: central nervous system alterations (benzene solvents in general);

• Carcinogenicity: leading to malignant tumors (benzene, formaldehyde);• Mutagenicity: leading to mutations;

• Teratogenicity: leading to fetal malformations.

Volaile anesheics

Even hough eher, chloroorm and nirous oxide were discovered in he 19 h cen-ur y, he associaed occupaional risks were no repored unil 19602. Since hen, hechronic effecs o environmenal exposure o anesheics have been sudied hrough

epidemiological surveys, in viro sudies, cellular research and experimenal sudies.ese works invesigae he poenial influences o wase anesheic gas on he inci-dence o ineriliy, miscarriages, liver disease, psychomoor and behavioral changes,neurological disease and deah.

An increased incidence o aborion was repor ed among ema le aneshesiolo-giss in 19672. Several sudies since hen have revealed he associaion beweenexposure o volaile anesheics and sponaneous aborions, congenial abnor-maliies and premaure birhs. However, mos o hese indings have been chal-

lenged due o mehodological laws and sources o bias such as nuriional saus,obseric hisory, alcohol inake, smoking and exposure o mehylmehacrylaeand radiaion2.

e American Sociey o Aneshesiologiss (ASA) considers curren evidence on hesubjec o be inconclusive and recommends common sense in limiing he exposureo proessionals o hese agens2.

ürkan e al demonsraed ha even brie exposure o wase anesheic gas maycause headache, irriabiliy, nausea, drowsiness, aigue, impaired coordinaion and

judgmen and increase he r isk o l iver and kidney disease8

. Volatile anesthetics seem to increase the imbalance between production of reactiveoxygen species and anioxidan deense mechanisms. is condiion is called oxida-ive sress and may damage cellular srucures such as DNA, plasmaic membranesand organelles8,9. According o Akbar e al, even small concenraions o gas increaselipid peroxidaion and producion o reacive oxygen species, poenially leading olong-erm damage o issues and organs10.

Lieraure shows conradicory daa regarding poenial muagenic effecs induced

by inhaled anesheics. ere is no evidence o clinical or pahological consequenceso inhaled anesheic use in humans, even when exposure is above curren limis.Only nirous oxide has proven eraogenic in animals. e exposure o pregnan ras




o high N2O concenraions (50% o 75%) or 24-hour periods during organogenesis

and low concenraions o i (0.1%) hroughou he whole pregnancy increased heincidence o visceral and skeleal abnormaliies11.

is effec is hough o originae in he inhibiion o mehionine synhase and con-

sequen reducion o erahydroolae in developing embryos, which would impairDNA producion and resul in morphological abnormaliies. Even so, he reproduc-ive effecs o N

2O in ras occur only aer prolonged exposure o high concenraions

unlikely o be encounered in clinical pracice12.

Saey limis or inhaled anesheic exposure have been esablished by some gov-ernmenal organizaions (able 2), bu some clinical siuaions ineviably enailincreased exposure, such as inhalaional inducion echniques15 , il l-fiting acemasks, uncuffed racheal ubes, pediaric respiraory sysems, sidesream gas ana-lyzers, lar yngeal masks, accidenal disconnecion o circuis, rigid bronchoscopyand ohers.

he Naional Ins iue or Occupaional Saey and Healh (NIOSH) saes ha iis impossible o deine a sae level o exposure o volaile anesheic wase andrecommends he greaes possible reducion, wih upper limis o 2 ppm (parsper mil lion) in operaing room air or halogenaed agens and 25 ppm or nirousoxide. When boh ypes o anesheics are used in combinaion, he limi orhalogenaed agens is reduced o 0.5 ppm. he ma ximum concenraion o halo-hane vapor recommended by he NIOSH is many imes lower han he lowes

concenraion recognized by he human olacory sysem - ew people are ableo perceive concenraions o 33 ppm. hereore, i anesheics can be smelledin he operaing room (O), heir concenraion is well above recommendedlevels. he occupaional risk exends o he pos-aneshesia care uni (PACU),since paiens coninue o ex hale volaile anesheics or 5-8 hours aer he endo aneshesia2.

According o he American Insiue o Archiecs, medical aciliies mus be designedo allow, on average, 15 exchanges o operaing room air per hour. Air inpu mus

be hrough he cener o he ceil ing and he oupu mus be hrough ducs near heground in he laeral walls, in order o conrol he flow o dus and conaminans andhus mainain he surgical field serile13.

ecommendaions or mini mizing occ upaional exposure o volaile anesheicagens include promoion o awareness among exposed proessionals, provisiono eecive air exhaus sysems in Os and PACUs, adequae mainenance oaneshesia delivery machines and heir wase sucion devices and a monioringsysem o keep records o air sampling resuls and liver and uncion screening

ess o employees14

.




able 2 - Occupaional exposure levels recommended or anesheic vapors in severalcounries in ppm.

N2O Halohane Enflurane Isoflurane Sevoflurane Desflurane

Ausria 5

Denmark 100 5 2

France 2

Germany 100 5 20

Unied ingdom 100 10 50 50

Ialy 100

Norway 100 5 2 2

Sweden 100 5 10 10

Swizerland 100 5 10 10

USA – NIOSH* 25 2 2 2 2 2

USA – ACGIH** 50 75

* NIOSH: Naional Ins iue or Occupaional Sae y and Healh** ACGIH: American conerence o governmenal indusrial hygieniss and

Gluaraldehyde

is clear liquid wih a srong odor was widely employed in hospials or seril izaiono hea-sensiive maerials. oxiciy due o unproeced handling is one o is maindrawbacks and is also he reason why i has been replaced wih oher maerials. Ismain oxic effecs are16:

• roat irritation and soreness;

• Asthma and respiratory distress symptoms;

• Nosebleed;

• Eye burning and conjunctivitis;

• Contact or atopic dermatitis rashes;

• Brown blemishes on hands;

• Urticaria;

• Headache and nausea.

Ehyl eher

Ehyl eher, also known as suluric eher, is a highly volaile clear liquid wih acharacerisic odor ha is poenially flammable/explosive. Adverse effecs o acueinoxicaion include narcosis, wih an iniial exciemen phase ollowed by numb-ness. Vomiting, facial pallor, bradycardia and salivation can also be present. It ismoderaely irriaing on upper airways, bu aspiraion o lower airways can resul

in chemical pneumoniis. Skin conac causes dehydraion and mild local irriaion, which can lead o skin fissures. Chronic exposure o high concenraions o his sub-sance may manies as aigue, nausea, vomiing, headache17.




Ehylene oxide

Due o is anibacerial effecs, his clear gas has been widely employed in he ser-ilizaion o hea-sensiive medical maerials. I is poenially explosive and remainsimpregnaed on he surace o maerials, which mus hereore be aired aer seril-izaion in order or ehylene oxide residue o be removed.

Sympoms o poisoning may arise several hours aer exposure. Conac wih skinand mucous membranes may cause irriaion, skin lesions, conjunciviis, cornealabrasion and caaracs i concenraion o he subsance is high. Chronic exposuremay lead o allergic sensiizaion, nausea, vomiing, hroa irriaion, drowsiness,headache, weakness and seizures18.

Laex

Laex is one o he producs o which aneshesiologiss are exposed mos requenly.

Naural or processed laex proeins consiue he mos common allergens o causereacions. ere are wo ypes o laex reacions: allergic or immunologic (ype I andIV hy persensitivity reactions) and non-allergic (irritant). Type I reactions may rangefrom localized edema to anaphylactic shock and death. Type IV reactions present asconac dermaiis. Non-allergic laex reacions, on he oher hand, presen as skinirriaion by consan conac wih laex derivaives, mos commonly laex gloves19.

Laex is conveyed by glove alc paricles and can be absorbed hrough mucous membranes, airways and even inac skin.

Prevenive measures include20:

• Avoiding gloves wih alc and producs wih high anigenic load;

• Ideniying laex producs in he O;

• Searching or alernaive producs;

• eaffirming insiuional responsibiliy o offer suppor and guidance oraffeced proessionals.

Surgical smoke

Elecric, harmonic and argon scalpels generae aerosols. Since 1920, when elecrocaueri-zaion was popularized in operaing rooms by he neurosurgeon Harvey Cushing, inha-laion o aerosols (smoke) has become a rouine par o he proessional lives o surgeons,aneshesiologiss and oher surgical eam members. e amoun and conen o inhaledsmoke vary depending on he naure and pahology o he reaed issue, surgical ech-nique, energy ype and applicaion ime. Analyzes o his maerial has shown significanamouns o inac viruses, viable umor cells and oxic chemical subsances. rones21 eal have shown ha boh cuting and coagulaion echniques wih various ypes o cauery

were able o produce poenially harmul smoke. Cuting a high emperaures can pro-duce even more oxic compounds, such as acealdehyde, ormaldehyde, benzene, carbonmonoxide, hydrogen cyanide and acrylamide. Some o hese subsances are carcinogenic




and may also precipiae ischemic hear disease. e NIOSH and he Associaion o peri-operaive regisered nurses recommend he use o sucion devices or scalpel-generaedsmoke, since sandard surgical masks do no provide adequae proecion.

Formaldehyde

Formaldehyde is commonly used in an aqueous soluion o preserve issue samplesdestined for histopathological examination. Brazil, ANVISA issued a resolution (RDC37/2008) o prohibi he use o ables conaining ormaldehyde or paraormaldehydein he disinecion and serilizaion o suraces and equipmen. e average concenra-ion during exposure is 0.5 ppm and, due o is waer solubiliy, ormaldehyde is rapidlyabsorbed rom he gasroinesinal and respiraory racs and meabolized. Dermalabsorpion is minimal, bu ormaldehyde and is meabolies are able o penerae hehuman skin and may induce conac dermaiis. Adverse effecs are dose-relaed and rangerom eye, nose and hroa irriaion o pulmonary edema, pneumonia and even deah.

e IAC - Inernaional Agency or esearch on Cancer classified ormaldehyde, rom2004, as carcinogenic and eraogenic. Nasopharyngeal neoplasms and leukemiasare associaed wih exposure o his subsance22.

Mehyl mehacrylae

2-mehylpropenoae (MM A) is colorless, flammable and volaile a room emperaure.I is an organic monomer widely used in denisry, neurosurgery and orhopedics as“bone cemen”. e main roue or occupaional exposure o healh care providers is

by inhalaion. e nasal caviy and he lungs are responsible or he iniial clearance oMMA by he enzyme carboxyleserase, which convers mehyl mehacrylae o meh-acrylic acid, an irrian and corrosive chemical. ere organs are, hereore, he mainocus o research on MMA oxiciy. Pulmonary findings are emphysema, pneumonia,hemorrhage, aelecasis, edema and hyperplasia o he bronchial epihelium. An exper-imenal sudy by Nai G.A. e al23 , showed poenial damage in chronic inhalaion oMMA vapors. Significan clinical aleraions repored o dae were pulmonary emphy-sema and liver seaosis o early deecion, wihin five days o exposure o he agen.ese daa imply imporan occupaional hazards and indicae he need or adequae

ume exhaus sysems while using he MMA. Alcohol (60% o 90%)

Alcohol, in paricular ehanol and isopropanol, has been used as an animicrobial agenor many years and as carrier-soluions or waer insoluble agens such as iodine and phe-nols. I acs by denauring proeins, has minimal oxiciy and can cause skin dryness 24.

Chlorhexidine gluconae (0.5 alcohol, 2%, 4%)

Chlorhexidine was approved or use in surgical scrubs in he mid 1970s, and as a

mouhwash a 0.12% a he end o he 1980s. In surgical washes, 4% chlorhexidinesoluions are as-acing, highly effecive agains Gram-posiive microorganismsand is less effecive agains Gram-negaive ones. oxiciy can occur by direc con-




ac wih eyes and ears o newborns. I does no cause respiraory sympoms and isslighly irriaing o skin. Harmul effecs are dose- and ime-dependen25.

Chemoherapy

Inroducion and handling o chemoherapeuic agens in he operaing room came

wih he adven o HIPEC (Hyperhermic Inraperioneal Chemoherapy), which isperormed aer cyoreducive surgery. Cyoreducive surgery involves long periodso perioneal and visceral resecion, using high volage elecrocauery, which gener-aes a significan amoun o aerosolized paricles in he operaing room. e ulrafineparicles and oxic subsances released are associaed wih pulmonary dysuncion,cardiovascular aleraions and increased moraliy. Cyooxic agens commonly usedin his echnique are: miomycin C, cisplain, oxaliplain, doxorubicin, which areadminisered in a dilued orm. Alhough he oxiciy o hese agens is well describedin herapeuic dosages, long-erm effecs o occupaional exposure o low, repeaeddoses remain unknown. Hence, all proecive measures should be adoped.

e roues o drug exposure during HIPEC are mosly direc conac and inhalaion.Proessional proecion measures include26:

• Surgical field: using impermeable and disposable drapes;

• Operaing room: closed doors, resricion o circulaion o people, absorbendrapes on he floor in case here is spillage;

• Personal proecion: disposable long-sleeved scrub capes, impermeable shoes,

ocular proecion, high-proecion mask (FFP3);• Environmenal measures: adequae air venilaion and exhaus sysems;

• Handling residue: leak-proo conainers labeled “cyooxic agens”.

Conclusion

Exposure o aneshesiologiss o chemical agens can resul in severe illnesses.ankully, he increased vigilance by governmen and proessionals has diminishedhe raes o adverse evens due o occupaional exposure o chemical agens. Preven-ion sraegies and idenificaion o occupaional illnesses caused by chemical agens will coninue o be undamenally based on exernal evaluaion, since no specific andsensiive biological markers have been validaed.

Reerences

1. Volquind D Bagatini A GMC Monteiro et al . - R isks and illnesses related to the exerciseo aneshesiology. ev Bras Anesesiol, 2013; 63:227-232.

2. Nicholau D, Arnold WP III-Environmenal saey including chemical dependency, in:Miller D e al. - Miller’s Aneshesia, 7 h ed., 2010, Philadelphia, Churchill LivingsoneElsevier, 3053-3073.

3. Mauro MYC, Mazi CD, M Guimarães e al. - Occupaional healh hazards. ev EnermUEJ, 2004; 12:338-345.

4. Segurança and Occupaional Medicine. 67h ed. Sao Paulo: Alas; 2011:610-642.




5. Segurança and Occupaional Medicine. 11h ed. updaed. Sao Paulo: Saraiva; 2013:936-937.6. Sanos J-Inroducion o saey engineering. isk map-FSA. Universiy Cener FAENG.

Producion engineering. Available a:htp://www3.sa.br/localuser/Producao/arquivos/mapaderisco.pd. Accessed on: May 26, 2013.

7. Med & Mon - Chemical risks. Available a: htp://medeseg.com.br/acidenes.php? aci-

dene=16. Accessed on: May 18, 2013.8. ürkan H, Aydin A, Sayal A-Effec volaile anesheics on oxidaive sress due o occupa-ional exposure. World J Surg 2005, 29:540-542.

9. Baysal Z Cengiz M Ozgonul A e al. - Oxidaive DNA damage saus and room personnel.Clin Biochem 2009, 42:189-193.

10. Akbar Malekirad A, anjbar A, ahzani e al. - Oxidaive sress in operaing room per-sonel: occupaional exposure o anesheic gases. Hum Exp oxicol, 2005, 24:597-601.

11. Oliveira CD-Occupaional exposure o wase anesheic gases. ev Bras Anesesiol,2009; 59:110-124.

12. Fujinaga M, Mazzi , Baden JM e al a whole embryo culure: an in viro model oresing nirous oxide eraogeniciy. Aneshesiology 1988; 69:401-404.

13. Pere M - Enviromenal sae in: DE Longnecker, Brown DL, Newman, MF e al. Aneshe-siology, 2 nd ed., New York, McGraw-Hil l Companies, 2012; 371-388.

14. Naional Ocupaional Insiue or Saey and Healh (NIOSH) - Wase anesheic gases:occupaional hazards in hospials. DSSH (NIOSH). Publicaion No. 2007-151.Availablea: htp://www.cdc.gov/niosh/docs/2001-115/. Accessed: May 26, 2013

15. Hoerau H, Waller , e al e Akça-Exposure o sevoflurane and nirous oxide Duringour differen mehods o anesheic inducion. Anesh Analg 1999, 88:925-929.

16. Naional Ocupaional Insiue or Saey and Healh (NIOSH): Gluaraldehyde-Occu-

paional Hazards in Hospials. DHHS (NIOSH). Publicaion No. 20 01-11517. Ocupaional Naional Insiue or Saey and Healh (NIOSH) - Pocke guide o chemi-

cal hazards: ehyl eher. Available a: htp://www.cdc.gov/niosh/npg/npgd0277.hml. Accessed on: May 26, 2013.

18. Gesal JJ-Occupaional hazards in hospial accidens, radiaion, exposure o noxious che-micals, drug addicion and psychic problems and assaul. Br J Ind Med 1987, 44:510-520.

19. Mahias LAS, MFP Boelho, LM Oliveira e al Prevalence o signs / sympoms sugges-ive o laex sensiizaion in healh care workers. ev Bras Anesesiol, 2006; 58:137-146.

20. Bati MACSB-Laex Allergy-Anesesiol Bras, 2003; 53:5:555-560.

21. rones CJ, Conze J, Hoelze F e al. - Chemical composiion o surgical smoke produced byelecrocauery and harmonic scalpel argon beaming i shor sudy. Eur Surg 2007; 39:118-121.22. Insiuo Naional Cancer Insiue (INCA) - Formaldehyde or ormaldehyde. Available

a: htp://www.inca.gov.br/coneudo_view.asp?!d=795_ormolouormaldeído- INCA. Accessed: May 26, 2013.

23. Nai GA, Parizi JLS, Batle CF e al. - Pulmonary and hepaic oxiciy o vapors o mehylmehacrylae: an experimenal sudy in ras. oxic Bras, 2007; 20:47-53.

24. Phmb.ino - Anisepsis and anisepics - Available in: htp://phmb.ino/anissepsia_e_ anissepicos.hml. Accessed on May 26, 2013.

25. Pino LP, LB Souza, Lagrange MBS-sudy o he effecs o chlorhexidine gluconae 0.5%

and 5% in he oral mucosa o ras. ev Fac Odonol, 2002; 43:3-7.26. Moreno SG, Gonzalez-Bayon L, Orega-Perez G-Hyperhermic Chemoherapy, Meho-

dology and Saey Consideraions. Surg Oncol Clin N Am, 2012, 21: 543-557.




able 2 - Basic precauions or he use o PPE

ProcedureHand

washingGloves Aprons

Mask andGoggles

Examinaion o he paien wihouconac wih blood, secreions, mucous

membranes or non-inac skin areas

X

Examinaion o paien conac wih blood, secreions, mucous membranes ornon-inac skin areas

X X *

Sampling o blood, sool and urineexaminaion

X X

Execuion o dressings X X * **Pareneral adminisraion o drugs X X **Cannulaion or cu-down or deep vein

access X X X X Airway sucion and racheal inubaion X X X X

Endoscopy and bronchoscopy X X X X

Denal procedures X X X X

Procedures wih he risk o splatering blood and secreions

X X X X

* Use in dressings large (large surgical wounds, burns and pressure sores).** Use i risk o blood fluid splatering or during preparaion and adminisraion o chemoherapy.

Measures afer an acciden involving percuaneous exposure

Care should be iniiaed immediaely, including careul local cleaning wih soap and waer. Anisepic soluions, like iodine-povidone or chlorhexidine may be useul, bu no evidence exiss o heir superioriy in relaion o soap and waer cleansing. Inconjuncival conaminaion, rinsing wih saline soluion is indicaed3.

e local Commission or Inecion Conrol should be consuled or a careul reviewo he vaccinaion saus o he source paien and o he exposed proessional,according o esablished norms (ables 3 and 4)3.

able 3 - Serological Conduc or he source paien

• Anti - HIV (rapid test).

• Anti - HCV and HBsAg (waived if the contaminated person is anti - HBs positive).

able 4 - Serological Conduc adoped or he conaminaed proessional

• Anti-HIV I and II (ELISA) and anti- HCV.

• HBsAg (or unvaccinaed vicims or or hose wih incomplee vaccinaion schedule, i.e.,

< 3 doses).• Ani - HBs (or vicims who received ull vaccinaion schedule, bu has no provenimmunizaion or is ani - HBs negaive)



3.7 - Sharps injuries: Guidance or he aneshesiologis | 255

In severe accidens prophylaxis should sar o he vicim and subsequenly re-evalu-aed or changes or mainenance o reamen. I a he rapid serology es he paienis positive for HIV, the victim should start chemoprophylaxis for a period of threedays, aer which you should be re-evaluaed by an inecologis 3.

A negaive rapid es resul in he source paien avoids saring chemoprophylaxisor healh proessionals. However, is no definiive o exclude he diagnosis o inec-ion in he paien3.

In accidents involving HIV patients or infected material unknown patients, theexposed proessional should be ollowed or six monhs. Monioring o he exposedprofessional is indicated if the source patient has been exposed to HIV in the previ -ous hree o six monhs, given he risk o conversion3.

All healh care proessionals should be vaccinaed agains hepaiis B. However,

wih regard o hepaiis C, here is no specific effecive measure o reduce he risk oinecion ollowing occupaional exposure, excep he prevenion o percuaneous ormucous membrane exposure o blood or oher biological maerial.

* e auhor is esponsible or he raining Cener in Aneshesiology o MunicipalHospial o São José dos Campos, PhD in Aneshesiology, MBS in pharmacologyand assisan proessor a he aubaé Universiy, direcor o he Scienific Depar-men – Brazilian Sociey o Aneshesiology.

Reerences

1. apparini C, einhard EL. Manual de implemenação: programa de prevenção de aci-denes com maeriais perurocoranes em serviços de saúde. São Paulo: Fundacenro,2010, 161p.

2. Alexandre BH. Checkoway H, Nagahama SI, Domino B. Cause-specific Moraliyisks o Aneshesiologiss. Aneshesiology 200 0; 93; 922-930.

3. BRSIL. Minisério da Saúde. Secrearia de Políicas de Saúde. Coordenação Nacionalde DS e AIDS. Manual de conduas: exposição ocupacional ao maerial biológico: he-patite e HIV. Brasília: MS, 1999, 22p.



- Part 4 -Interdisciplinary aspects of

occupational health



4.1 - Addicion among aneshesiologiss: rom diagnosis o inervenion | 259

Addicion Among Aneshesiologiss: rom diagnosiso inervenion

Hamer Nasasy Palhares Alves

Psychiaris, Docor o Sciences UNIFESP,esearcher UNIAD / UNIFESP

Luiz Anônio Nogueira-MarinsFull Proessor, reired associae proessor o he Deparmen

o Psychiary, UNIFESP

Daniel Sócraes Psychiaris, PhD suden , Depar men o Psychiary

UNIFESP. esearcher UNIAD / UNIFESP

Ronaldo Laranjeira Proessor o Psychiary, UNIFESP, Uni coordinaor

esearch on Alcohol and Drugs (Uniad-Inpad/Uniesp)

Inroducion:

Why is i imporan or physicians o know he Dependence Syndrome?

Docors ge sick as oen as he general populaion1 , bu menal healh issues andaddicion are no easily recognized, even hough hey are he mos requen cause olabor problems and early reiremen.

ese disease processes cause physicians and heir amilies grea emoional sufferingand resul in diminished perormance, wih poenial consequences o heir paiens.

us, chemical dependence consiues a disorder whose naure is bio (involvinggeneics and emperamen) psycho (psychiaric comorbidiies, expecaions, copingmechanisms) social (amily environmen, peer pressure, drug availabiliy).

Lieraure daa on physician addicion sugges an epidemiologic profile similar oha o he general populaion, only wih a higher prevalence o drugs whose access isaciliaed by proessional aciviy, such as benzodiazepines and opioids2, 3.

Te diagnosis o dependence:

I is imporan ha proessionals know how o correcly recognize subsance abuse. According o medical lieraure, i is an ehical duy o care or he healh o col-leagues, hereore i is up o physicians o aler heir colleagues as soon as hey noice behavioral changes ha sugges menal healh problems, addicion or he need orspecialis consulaion.

Subsance dependence occurs insidiously in mos cases, here is usually a progression

rom experimenal use o a subsance o a sae o harmul consumpion. In he earlysages, biopsychological consequences already exis, bu ypical sympoms o depen-dence such as olerance, wihdrawal or oher dependency elemens are no eviden ye.




e concep o addicion as i is currenly undersood was ormulaed more hanhree decades4 ago and remains virually unchanged in various inernaional clas-sificaion sysems, as exemplified by he Inernaional Classificaion o Diseases(ICD-10) crieria below:

e diagnosis o subsance dependence syndrome should be considered only i hreeor more requiremens are presen during he las year:

a) A srong desire or sense o compulsion o ake he subsance;

b) Difficulies in conrolling subsance-ak ing behavior in erms o is onse, er-minaion and levels o use;

c) A psychological wihdrawal sae when subsance use has ceased or has beenreduced, as evidenced by: he characerisic wihdrawal syndrome or he sub-sance; or use o he same (or closely relaed) subsance wih he inenion o

relieving or avoiding wihdrawal sympoms;d) Evidence o olerance, such ha increased doses o he psychoacive subsanceare required o achieve effecs originally produced by lower doses (clear exam-ples o his are ound in alcohol- and opiae-dependen individuals who may akedaily doses sufficien o incapaciae or kill nonoleran users);

e) Progressive neglec o alernaive pleasures or ineress because o psychoac-ive subsance use, increased amoun o ime necessary o obain or ake hesubsance or o recover rom is effecs;

) Persising wih subsance use despie clear evidence o overly harmul conse-quences, such as harm o he liver hrough excessive drinking, depressive moodsaes consequen o periods o heavy subsance use, or drug-relaed impairmeno cogniive uncioning; effors should be made o deermine ha he user wasacually, or could be expeced o be, aware o he naure and exen o he harm.

Source: ICD-10, 2008

e mesolimbic-corical dopaminergic sysem is hypohesized o be he primary pahway in he acquisiion, mainenance and reinsallaion o subsance-seeking behaviors.

I coordinaes behavioral reinorcemen, i.e. he srenghening o a specific behavior which makes i likely o be repeaed in he uure5 , and is hereore a cenral pahwayin he pahophysiology o addicion and compulsive behaviors. Neuroadapaions inhese sysems avor he perpeuaion o consumpion in dependen individuals.

Despie growing evidence o pahological mechanisms involved in he repeiive behavior ha characerizes addicion, he sigma o subsance abuse sil l prevails andmay hinder he search or care. Moreover, individuals affeced by dependence syn-drome or menal illnesses suffer rom sel-sigma as well6.

Besides srong sigma, here is a conspiracy o silence regarding he issue o alcoholand drug abuse among physicians, i.e. no one wans o raise he quesion or ear oharming colleagues affeced by he condiion. e problem is much more complex




Environmenal Exposure o Volaile Drugs

Exposure o volailized subsances in he operaing room has been a concern in hemedical lieraure or ory years24,25.

Fenanyl and suenanil are highly poen drugs, 80-800 imes sronger han

morphine26

. Exposure o aerossol paricles o anesheic drugs like Propool andFenanyl has been heorized as a risk acor or subsance dependence among anes-hesiologiss. One sudy ound small concenraions o hese subsances in oper-aing room air, especially in he air exhaled by he paien, i.e. in he area whereaneshesiologiss work or hours over he years. is hypohesis migh provide anexplanaion or he high raes o drug experimenaion and addicion among hesephysicians, even when compared o oher specialies wih easy access o opioids,such as oncology 26,27. I can also aler o higher risks o relapse, hrough he phe-nomenon o neurobiological sensiizaion21.

Alhough medical lieraure reveals ha abou 70% o aneshesiologiss seeking spe-cialized reamen are dependen on enanyl, aneshesiologiss use various classeso drugs. e medicaions mos requenly aken are opioids, ollowed by benzodiaz-epines, illici drugs, propool and keamine28.

An American sudy compared cause-specific moraliy risks o aneshesiologiss wih ha o inernal medicine praciioners beween 1979 and 1995 and reporedrelaive risks o approximaely 2 or deah by suicide and nearly 3 or drug-relaeddeath. Moreover, deaths related to Hepatitis C and HIV were also signicantly

higher among aneshesiologiss29. ese differences beween he wo specialies aregreaes in he firs five years aer medical school graduaion, which corroboraesoher findings o increased vulnerabiliy during his period.

Suicide is highly prevalen among aneshesiologiss when compared o ohermedical specialies30. his moraliy proile subsaniaes concerns abou heoccupaional healh o anesheiss and he higher prevalence o drug addicionin his populaion. his issue sar ed o gain aenion in he medical lieraureory years ago31.

Since hen, ineress have grown over he menal healh o aneshesiologiss,especially regarding addicion and suicide. A Briish sudy evaluaed 304deparmens o aneshesiology and noed ha alcohol and drug misuse arecommon and ha mos colleagues do no eel comorable or able o deal wihhese siuaions13.

Aneshesiology Residency and Menal Healh

Medical residency was developed in he USA in 1889 and has since been adoped in

mos medical schools in he world as he gold sandard o raining. In Brazil, i wasesablished in 1944-45. Bu alhough his is considered one o he mos sophisicaededucaional sysems or proessional raining, i is also a very sressul period in a




However, criicisms o i were based on is being rerospecive, which may haveavored memory bias and made bad oucomes more likely o be repored.

A sudy ha evaluaed he firs 1000 cases reerred o he Impaired Physicians Pro-gram in Georgia noed ha docors are a populaion a risk or addicion and ha,

among hese, anesheiss are clearly overrepresened

10

. Moreover, compared ooher docors, aneshesiologiss were more likely o abuse drugs han alcohol, o useopioids and o adminiser drugs mainly inravenously 11. e auhors emphasize heneed or more awareness abou he issue, as well as early deecion and reamenaiming or rehabiliaion.

Anoher invesigaion abou he reamen oucomes o aneshesiology residensanalyzed daa rom 180 rainees, 26 o which died o overdose41. 113 ou o he 180residens were allowed reener aneshesiology raining. ose previously dependenon opioids (79 cases) had a success rae o 34% (27 cases). ere were 14 deahs rom

suicide or overdose among residens who were allowed reenry ino he proession(17%). Among rainees who abused oher drugs (non-opioids), he success raein resuming proessional aciviy was 70% (16 o 23 cases). e auhors hereoresugges ha aneshesiologiss who have aced opioid-dependence be relocaed oanoher medical specialy.

Based on sudies reporing poor resuls in atemps o resume aneshesiology prac-ice by residens who abused opioids, an aricle suggesed, as a sandard procedure,he idea “One srike, you’re ou”14 , i.e., “used injecion drugs once, you’re ou o anes-

hesiology.” is has moivaed grea debae in he American Sociey o Aneshesiol-ogy, since oher sudies have repored beter oucomes regarding reenry. Anoherlieraure review suppors he heory ha i is bes no o resume aneshesiologypracice aer a course o dependence, even aer reamen or addicion42. However,hese auhors commen ha some smaller sudies ound beter oucomes, oen a heexpense o more sysemaic monioring programs, and possibly using he long-acingopioid anagonis nalrexone.

Lieraure reveals ha aneshesiologiss who coninue pracicing aneshesiologyhave an increased risk o relapse compared o he ones who changed specialy 43. Analysis o 292 physicians reaed a a special ized cener in Washingon showedha, aer successul iniial reamen or deoxificaion, acors relaed o high risko relapse were: a amily hisory o addicion (nearly riples he risk o relapse), psy-chiaric comorbidiy alone and opioid dependence in he presence o psychiariccomorbidiy (nearly six imes greaer risk o relapse). When all hree acors werepresen, he risk o relapse was almos 14 imes higher43.

I is hereore suggesed ha he decision o reenry he pracice o aneshesiology bemade on a case-by-case basis, considering local variables as he insiuion’s capaciy

o absorb a docor in a reenry program, he presence o amily hisory and psychi-aric comorbidiy as well as compliance wih a specialized care program involvingconinued monioring42.




One sudy noed slighly beter resuls regarding recoverabiliy and even reurn oproessional aciviy o anesheiss wih greaer securiy han previously repored44.

Analysis o 16 U.S. programs or alcohol- and drug-dependen physicians showedha anesheiss, when engaged in he reamen and closely moniored, had similar

raes o successul resumpion o work as oher specialiss, even when he abuseddrugs were opioids, conradicing previous publicaions45. ere was no differencein erms o relapse rae, moraliy or proessional problems when compared o ohermedical specialies.

eenry ino proessional pracice by aneshesiologiss who abused opioids andoher injecable drugs remains highly conroversial, especially because o difficuliesin he ollow-up o idenified cases due o high raes o geographical changes46,47.

How o deal wih colleagues acing drug abuse issues

Many physicians experience siuaions when here is robus evidence o subsanceabuse by colleagues.

Alhough here are no pahognomonic signs, some changes may be suggesive odrug problems, especially when many o hese coexis, such as sudden and unpre-dicable behavioral changes, reusal o meals and snack breaks, desire o workalone, willingness o work exra ime, requen breakage o vials o anesheic,requen rips o he bahroom or on-call room48. Some sudies sugges ha sais-ical programs ha are sensiive o changes in prescribing paterns can help deecpoenial abusers49,50.

A physician who is addiced o opioids or oher anesheic drugs may seek exra working ime in order o be close o he source o he subsance abused. is, combined wih muliple jobs, litle conac wih he amily and he usually independen way o working, oen complicaes he diagnosis o dependence.

Hence he need or an approach ha is a he same ime firm and compassionae. Awareness o labor laws and roues o reerral o reamen, which differ grealy romregion o region, is essenial. egardless o differences in laws, some componens oappropriae approach involve:

• Showing ineres in lisening o he problems he physician wan o express;

• Avoiding conronaion and encouraging him o seek specialized evaluaion;

• eerring him o proessionals rained in dependence reamen;

• rying o reassure him ha, once reaed, his job and wages will be main-ained, as well as anonymiy. I he affeced docor canno resume work as ananeshesiologis, he insiuion should ideally assis him in he ransiion o

anoher specialy;• equesing ha he physician responsible or he colleague’s reamen provideregular repors regarding compliance wih reamen;




• In cerain insances, according o local policies o confidenialiy and involve-men o medical pracice regulaors, samples o hair or drug-esing are requiredin order o allow reurn o aciviy in he operaing suie. is seems o be hemos reliable way o monioring cessaion o subsance abuse.

Alhough is i no he drug ha mos moivaes reamen-seeking, alcohol is prob-ably he one ha mos requenly causes problems or aneshesiologiss.

e majoriy o aneshesiologiss reaed or subsance abuse have a “dependenprofile dependen”. Many o hem show ype A behavior: compeiive, proacive,exremely dedicaed o work and, oen, devoid o obvious signs o psychopahology.us, sraegies ha ocus on all aneshesiologiss (universal prevenion) may makemore sense and deliver beter resuls han selecive prevenion sraegies ocusedonly on more vulnerable groups.

I is recommendable ha programs aimed a he healh o aneshesiologiss have a wide range o acion and don’ ocus exclusively on subsance abuse, which couldeven impair he disseminaion sraegy o he campaign. Programs aiming or phy-sician healh and qualiy o lie may be more welcome and suffer less resisance oimplemenaion and mainenance.

Wha works and how reamen should be

Despie being a chronic disease, here is a endency on he par o mos physicians operceive addicion as an acue condiion, such as a racure or pneumococcal pneu-

monia, so ha he reamen is hough o according o ha viewpoin, and deoxi-ficaion is considered he ideal reamen. elapse is seen as a ailure o reamenraher han a condiion inheren o he disease isel 51.

Neuroransmission pahways remain alered or long periods aer cessaion o druguse and manies again quickly aer resumpion, which leads o he phenomenon orelapse and reinsallaion o dependence syndrome.

ere is no inernaional consensus on how he reamen o chemically dependenaneshesiologiss should be, bu some sraegies have been ormulaed in he dedi-caed lieraure.

In he firs place, i is imporan ha employers have a definie and compassionaeapproach wih a colleague who is acing drug-relaed problems. I is also clear hareamen mus be made by saff experienced in he care o addiced physicians 52.

I is no usually necessary or he affeced physician o be suspended rom his jobas long as he’s being reaed, alhough an iniial period o deachmen is essenial incases o dependence on drugs such as opioids and propool.

Daa rom a long ollow-up program sugges ha he iniial deachmen period oropioid-dependen residens should las a leas welve monhs in order or he physi-cian o ocus solely on recovery 53. Aer his, here should be a gradual reurn o prac-




ice, saring wih aciviies involving less exposure o drugs and wih close monior-ing. e reamen o associaed psychiaric comorbidiies is essenial 54 , since heyare imporan risk acors or relapse43.

An imporan guide produced by NIDA (Naional Insiue on Drug Abuse), “Prin-

ciples o effecive reamen o addicion”, enumeraes useul ools in clinical man-agemen whose validiy has been suppored by mea-analyses55. I is worh noingha reamen is usually long and hospializaion may be necessary, in addiion o behavioral/counseling herapies. reamen o psychiaric comorbidiies, presen inabou 50% o hese individuals, is also essenial.

Managemen o wihdrawal:

Alhough wihdrawal syndrome resuls in grea physical and menal suffering, i israrely lie-hreaening. When opioid subsiuion is necessary, he drug mos recom-

mended by medical lieraure is mehadone. Iniial mehadone dosing ranges rom20 o 120 mg per day bu, in mos cases, he dose lies beween 30 and 60 mg per day.

e atending physician mus provide a phone number or quick conac in case herecovering proessional needs suppor during difficulies.

e affeced aneshesiologis should be deached rom any medical aciviy or aniniial period.

Hospializaion is no necessary as long as he aneshesiologis is adheren o rea-

men and does no presen severe comorbidiies. I is usually cosly and gives riseo a eeling ha “now he problem is solved”, in addiion o sigmaizing he paien.

e amily should monior compliance wih reamen and conribue o he variousreamen approaches: engaging he paien’s amily in reamen plays a key role inis mainenance o over he years.

Mehadone adminisraion should be resriced o he period o ransiion rom wihdrawal o complee absinence and, aer a leas wo weeks wihou mehadone,i is recommended o inroduce he use o an opioid anagonis (nalrexone).

Relapse Prevenion Sraegies: Using Nalrexone

Nalrexone is an opioid anagonis ha has been used o reduce he incidence orelapse and o aid in he “behavioral exincion” o opioid abuse. I has also been usedsaely and wih litle side effecs in he reamen o alcoholism 56.

A sudy compared he relapse requency o 11 aneshesiologiss who underwenmandaory nalrexone reamen wih ha o 11 aneshesiologiss who didn’ receivehis drug. In he group ha didn’ receive nalrexone reamen, 8 ou o 11 proes-

sionals relapsed and only one could resume anesheic pracice. On he oher hand,only one nalrexone-reaed aneshesiologis relapsed, and 9 o he 11 docors in hisgroup were successul in reurning o aneshesiology 57.




A ew consideraions mus be made:

• Nalrexone mus no be adminisered on he firs days o absinence (or dur-ing he firs wo weeks o mehadone removal) due o he risk o “super wih-drawal syndrome”;

•

Paiens mus sign an inormed consen or using his medicaion. e suspen-sion o is use ollowed by opioid relapse grealy increases overdose risks, due ohypersensiizaion o recepors;

• e amily should be engaged in reamen and help he paien ake his medica-ions. Ideally, he amily should reain medicaions and supervise is adminisra-ion, and alernaively, medicaions can be aken upon arrival a he workplace.Nalrexone can be adminisered wice a week, aer an adjusmen period ohree ables wice a week.

Lieraure has shown superior resuls wih deposi nalrexone once a monh han

wih oral nalrexone, alhough his sraegy has no ye been documened or opioid-dependen physicians58-60. e key difference is greaer adherence o his orm oadminisraion (one decision a monh, versus 30 decisions a monh).

Reurn o Aneshesiology pracice:

ere is no consensus on how reenry o aneshesiologiss ino proessional aciviyshould be. I is recommended ha here be collaboraion o all sakeholders: depar-men chairmen, amily, affeced physician and atending proessionals - psychia-ris and clinical saff. e physician mus sign an inormed consen orm, providesamples o hair, avoid working excessively, a nigh or during weekends. A period oa leas a year away rom he operaing suie is also recommendable, in order or hepaien o ponder his proessional choice54.

Many environmenal cues o relapse in operaing suie populaions (no only anes-hesiologiss) have no been well described ye, bu probably involve olacory simulisuch as alcohol swabs and elecrocauery smoke, environmenal simuli (he acualoperaing suie) and inerpersonal ones61. ese elemens conribue o higher raeso relapse among aneshesiologiss, since here is no way o avoiding hose acors

upon reurning o proessional aciviy.

elocaing o anoher specialy has shown good resuls. However, his ype o pro-cedure enails collaboraion o he physician. Legal, financial and amily suppor areessenial during he recovery process, which can oen require reraining in anoherarea o medical pracice.

reamen ceners or docors:

Ceners specialized in dependence reamen or physicians ake ino accoun vari-

ous financial, legal and culural aspecs. I is recommended ha recepion be as brieas possible, ha here be sric confidenialiy policies and ha hese insiuions work independenly o medical pracice regulaory insances.




Providing guidance o amily members and colleagues o he affeced physician is akey issue. Making his colleagues aware ha he needs help and financial assisance ihe needs o sop working o ge reamen is very imporan. Guaraneed job and/or compensaion o colleagues who commi o reamen is essenial, because ac-ing oherwise can preven uure cases rom seeking reamen or make colleagues

uncomorable by recommending ha an aneshesiologis wih problems seek help.

Adverising o special ized care services should be made or docors exclusively inorder o avoid alarmism in he general populaion, which could lead o resisance byphysicians hemselves .

Approaches should be wide-ocused and muliproessional, argeing no only chemicaldependence, bu also menal and occupaional healh issues. Experimenaion o anes-heic drugs may be prevened by early idenificaion o menal healh disrupions62.

Suppor services o physicians should be well publicized and have he suppor o medi-cal regulaory insiuions. Such services shall rely on specific raining o deal wih hepeculiariies o chemical dependency among physicians, especially in he case o useo injecable subsances, in addiion o general knowledge regarding addicion. eesablishmen o a elephone holine is a possible sraegy o aciliae access.

Screening ess:

Hair examinaions have been repored as he bes alernaive, since hey are difficulo amper and cover a broader ime period48. Saliva samples are pending validaion63.In opioid-dependen individuals (general non-medical populaion), random screen-ing ess and observance o behavioral progress are relaed o beter oucomes64.

Muual help groups:

Groups o muual help have been highlighed as an imporan sraegy or dealing wih addicion among physicians. In many counries, here are groups specific orphysicians or or all healh care proessionals. Such groups operae independenly omedical care ceners.

Prevenion

Efficien approach sraegies involve prevenion (hrough improving working condi-ions), promoion o awareness o hese diseases by medical praciioners and efforsor early deecion8.

Effecive measures o preven he consumpion o alcohol and drugs among anes-heiss have no ye been esablished. I appears ha imporan sraegies includechanging he culure o sel-medicaion, since his may be a risk acor or drug

dependence3

. Ideally, every docor should have heir rused physician.Beter drug dispensaion conrol and monioring o anesheic records have beenunderlined as poenially useul sraegies in dealing wih prescripion drug diver-




ere is wide percepion ha propool addicion is increasing: a survey evidencedha, in 10-year period, approximaely 18% o American residency programs had aleas one repored case o abuse o his drug80. Moraliy among propool-dependenaneshesiology praciioners was 28%, mos which were residens. Likelihood oabuse ere showed correlaion wih lack o drug-dispensaion conrol by he hospi-

al pharmacy (p 0.048). e increase in keamine and propool abuse among anes-hesiologiss can be explained by he easier access when compared o opioids28.

A sudy o 16 propool-dependen residens showed ha six o hem died, and ou ohe remaining en, hree abandoned medicine, five changed medical specialy andonly wo remained in aneshesiology 80.

An American case series o propool addicion showed rapidly progressive anddescending clinical courses. I also discussed he increased prevalence o propoolabuse in recen years, according o he percepion o proessionals specialized in car-ing or addiced physicians. e firs sympom o propool abuse was deah in 28%o cases81.

Final Toughs

Besides being more prevalen han in oher medical specialies, subsance dependenceamong aneshesiologiss involves acors ha se i apar rom oher orms o illness -he person who suffers rom his condiion usually canno seek help or ear o losinghis proession39 , and requires very compassionae and firm pos-reamen care.

Unlike oher docors, he search or reamen is mainly by sel-demand or indicaiono colleagues or heads o deparmen3. is suggess ha he problem can be barely visible by he physician’s amily, hence he need or colleagues and he physicianhimsel o be aware o menal healh issues and consumpion paterns o any psycho-acive subsance. is approach has he poenial o proec he affeced physician as well as his paiens, and should be seen no only as a careaking gesure, bu also assandard ehical conduc.

Reerences

1. Nogueira-Marins LA, Sella C,Nogueira HE.A pioneering experience in Brazil:he creaion o a cener or assisance and research or medical residens (Napreme)a he Escola Paulisa de Medicina, Federal Universiy o Sao Paulo. Sao Paulo Méd J,1997;115(6):1570-4.

2. Jungerman FS e al. Anesheic drug abuse by aneshesiologiss. ev Bras Anesesiol.2012;62(3):375-86.

3. Palhares-Alves HN e al. Clinical and demographic profile o aneshesiologiss usingalcohol and oher drugs under reamen in a pioneering program in Brazil. ev Bras

Anesesiol. 2012;62(3):356-64.4. Edwards G, Gross MM. Alcohol dependence: provisional descripion o a clinical syn-

drome. Br Med J. 1976;1(6017):1058-61.




5. Johnson BA e al. Effecs o acue opiramae dosing on mehampheamine-induced subjecive mood. In J Neuropsychopharmacol. 2007;10(1):85-98.

6. Corrigan PW, ao D. On he sel-sigma o menal illness: sages, disclosure, and srae-gies or change. Can J Psychiar y. 2012;57(8):464 -9.

7. Cohen S.e conspiracy o silence. Can Fam Physician.1980;26:847-9.

8. Mera F, Mera S. Occupaional hazards relaed o he pracice o anaeshesia. Ann Fr Anesh eanim. 2008;27(1):63-73.

9. Alves HN e al. Clinical and demographical aspecs o alcohol and drug dependen phy-sicians. ev Assoc Med Bras.2005;51(3):139-43.

10. albo GD e al. he Medical Associaion o Georgia’s Impaired PhysiciansProgram. eview o he irs 1000 physicians: analysis o specialy. JAMA.1987;257(21):2927-30.

11. Gallegos KV et a l. Addiction in anesthesiologists: drug access and paerns of substance

abuse. QB Qual ev Bull. 1988;14(4):116-22.12. Lusky I e al. Subsance abuse by aneshesiology residens. Acad Med. 1991;66(3):164-6.

13. Baird WL, Morgan M. Subsance misuse amongs anaesheiss. A naeshesia.2000;55(10):943-5.

14. Berge H, Seppala MD, Lanier WL. e aneshesiology communiy’s approacho opioid-and anesheic-abusing personnel: ime o change course. Aneshesiolo-gy.2008;109(5):762-4.

15. ezlaff J e al. A sraegy o preven subsance abuse in an academic aneshesiology de-parmen. J Clin Anesh. 2010;22(2):143-50.

16. Gravensein JS, ory WP, Marks G. Drug abuse by aneshesia personnel.AneshAnalg.1983;62(5):467-72.

17. Bruce DL. Alcoholism and aneshesia. Anesh Analg. 1983;62(1):84-96.

18. Beaujouan L e al. Prevalence and risk acors or subsance abuse and dependence amonganaesheiss: a naional survey. Ann Fr Anesh eanim. 2005;24(5):471-9.

19. enna GA, Lewis DC. isk acors or alcohol and oher drug use by healhcare proes-sionals. Subs Abuse rea Prev Policy. 2008;3:3.

20. Voltmer E et al. Psychosocial health risk factors and resources of medical students and

physicians: a cross-secional sudy. BMC Med Educ. 2008;8:46.21. Merlo LJ e al. Fenanyl and propool exposure in he operaing room: sensiizaion hypo-

heses and urher daa. J Addic Dis. 2008;27(3):67-76.

22. Gold MS, GrahamNA, Goldberger BA. Second-hand and hird-hand drug exposures inhe operaing room: a acor in aneshesiologiss’ dependency on enanyl. J Addic Dis.2010;29(3):280-1.

23. Nyssen AS e al. Occupaional sress and burnou in anaeshesia. Br J Anaesh.2003;90(3):333-7.

24. Goell P, Sundell L. Anaesheiss’ exposure o halohane. Lance. 1972;2(7774):424.

25. Jenkins LC. Chronic exposure o anaesheics: a oxiciy problem? Can Anaesh Soc J.1973;20(1):104-20.




26. Gold MS e al. Fenanyl abuse and dependence: urher evidence or second hand expo-sure hypohesis. J Addic Dis. 2006;25(1):15-21.

27. McAuliffe PF e al. Second-hand exposure o aerosolized inravenous anesheics propo-ol and enanyl may cause sensiizaion and subsequen opiae addicion among aneshe-siologiss and surgeons. Med Hypoheses. 2006;66(5):874-82.

28. Maier C e al. Addiced anaesheiss. Anashesiol Inensiv med Noallmed Schmer-zher. 2010;45(10):648-54, 655.

29. Alexander BH e al. Cause-specific moral iy risks o aneshesiologiss. Aneshesiology.2000;93(4):922-30.

30. Waterson DJ. Psychiaric illness in he medical proession: incidence in relaion o sexand field o pracice. Can Med Assoc J. 1976;115(4):311-7.

31. Occupaional disease among operaing room personnel: a naional sudy. epor o an Ad Hoc Commitee on he Effec o race Anesheics on he Healh o Operaing oomPersonnel, American Sociey o Aneshesiologiss. A neshesiology. 1974;41(4):321-40.

32. Cook DJ e al. esidens’ experiences o abuse, discriminaion and sexual harassmenduring residency raining. McMaser Universiy esidency raining Programs.CMAJ.1996;154(11):1657-65.

33. Asaiag PE, PerotaB, Marins MA, empski P. Avaliacao da qualidade de vida, sonolenciadiurna e burnou em medicos residenes. ev Bras Educ Med. 2010;34(3):423-9.

34. Immerman I, ubiak EN, Zuckerman JD. esiden work-hour rules: a survey o resi-dens’ and program direcors’ opinions and atiudes. Am J Orhop (Belle Mead NJ).2007;36(12):E172-9; discussion E179.

35. Heller F. esricion o duy hours or residens in inernal medicine: a quesion o qualiyo lie bu wha abou educaion and paien saey? Aca Clin Belg. 2008;63(6):363-71.

36. Macedo PC e al. Healh-relaed qualiy o lie predicors during medical residency in arandom, sraified sample o residens. ev Bras Psiquiar. 2009;31(2):119-24.

37. Booth JV et al. Substance abuse among physicians: a survey of academic anesthesiologyprograms. Anesh Analg. 2002;95(4):1024-30.

38. Weeks AM e al. Chemical dependence in anaesheic regisrars in Ausralia and NewZealand. Anaesh Inensive Care. 1993;21(2):151-5.

39. Farley WJ. Addicion and he anaeshesia residen. Can J Anaesh. 1992;39(5 P 2):p.11-7.

40. Ward CF, Ward GC, Saidman LJ. Drug abuse in aneshesia raining programs. A survey:1970 hrough 1980. JAMA. 1983;250(7):922-5.

41. Menk EJ e al. Success o reenry ino aneshesiology raining programs by residens wiha hisory o subsance abuse. JAMA. 1990;263(22):3060-2.

42. Oreskovich M, Caldeiro M. Aneshesiologiss recovering rom chemical dependency:can hey saely reurn o he operaing room? Mayo Clin Proc. 2009;84(7):576-80.

43. Domino B e al. isk acors or relapse in healh care proessionals wih subsance use

disorders. JAMA. 2005;293(12):1453-60.44. Pelon C, Ikeda M. e Caliornia Physicians Diversion Program’s experience wih

recovering aneshesiologiss. J Psychoacive Drugs. 1991;23(4):427-31.




45. Skipper GE, Campbell MD, Dupon L. Aneshesiologiss wih subsance use disor-ders: a 5-year oucome sudy rom 16 sae physician healh programs. Anesh Analg.2009;109(3):891-6.

46. Bryson EO. Should aneshesia residens wih a hisory o subsance abuse be allowed oconinue raining in clinical aneshesia? e resuls o a survey o aneshesia residency

program direcors. J Clin Anesh. 2009;21(7):508-13.47. ezlaff JE, Collins JB. eenry o aneshesiology residens aer reamen o chemical

dependency--is i raional?J Clin Anesh. 2008;20(5):325-7.

48. inz P e al. Evidence o addicion by aneshesiologiss as documened by hair analysis.Forensic Sci In. 2005;153(1):81-4.

49. Chisholm AB, Harrison MJ. Opioid abuse amongs anaesheiss: a sysem o deecpersonal usage. A naesh Inensive Care. 2009;37(2):267-71.

50. Epsein H, GrachDM, Grunwald Z. Developmen o a scheduled drug diversionsurveillance sysem based on an analysis o aypical drug ransacions. Anesh Analg,2007;105(4):1053-60.

51. O’Brien CP, McLellan A. Myhs abou he reamen o addicion. Lance.1996;347(8996):237-40.

52. Saunders D. Subsance abuse and dependence in anaesheiss. Bes Prac es Clin Ana-eshesiol. 2006;20(4):637-43.

53. Bryson EO, Levine A. One approach o he reurn o residency or aneshesia residensrecovering rom opioid addicion. J Clin Anesh. 2008;20(5):397-400.

54. Bryson EO, Silversein JH. Addicion and subsance abuse in aneshesiology. Aneshe-

siology. 2008;109(5):905-17.55. Pearson FS e al. Mea-analyses o seven o he Naional Insiue on Drug Abuse’s princi-

ples o drug addicion reamen. J Subs Abuse rea. 2012;43(1):1-11.

56. illeen e al. Effeciveness o nalrexone in a communiy reamen program. AlcoholClin Exp es. 2004;28(11):1710-7.

57. Merlo LJ, Greene WM, Pomm . Mandaory nalrexone reamen prevens relap-se among opiae-dependen aneshesiologiss reurning o pracice. J Addic Med.2011;5(4):279-83.

58. Miller PM, Book SW, Sewar SH. Medical reamen o alcohol dependence: a sysema-ic review.In J Psychiary Med. 2011;42(3):227-66.

59. Brooks AC e al. Long-acing injecable versus oral nalrexone mainenance herapy wihpsychosocial inervenion or heroin dependence: a quasi-experimen. J Clin Psychiary.2010;71(10):1371-8.

60. rupisky EM, Blokhina EA. Long-acing depo ormulaions o nalrexone or heroindependence: a review. Curr Opin Psychiary. 2010;23(3):210-4.

61. Wilson H. Environmenal cues and relapse: an old idea ha is new or reenry o recoveringaneshesia care proessionals. Mayo Clin Proc. 2009;84(11):1040-1; auhor reply 1041.

62. Brown SD, Goske MJ, Johnson CM. Beyond subsance abuse: sress, burnou, and de-pression as causes o physician impairmen and disrupive behavior. J Am Colladiol.2009;6(7):479-85.




63. Pil K,Verstraete A. Current developments in drug testing in oral uid.er Drug Monit.2008;30(2):196-202.

64. az NP e al. Behavioral monioring and urine oxicology esing in paiens receivinglong-erm opioid herapy. Anesh Analg. 2003;97(4):1097-102.

65. Moleski J e al. Conrol and accounabiliy o conrolled subsance adminisraion in

he operaing room. Anesh A nalg. 1985;64(10):989-95.66. lein L, Sevens WC, ingson HG. Conrolled subsance dispensing and accounabiliy

in Unied Saes aneshesiology residency programs. Aneshesiology. 1992;77(4):806-11.

67. Dexer F. Deecing diversion o anesheic drugs by providers. Anesh Analg.2007;105(4):897-8.

68. Lecky JH e al. A deparmenal policy addressing chemical subsance abuse. Aneshesio-logy. 1986;65(4):414-7.

69. Saada H e al. Wellness program or aneshesiology residens: a randomized, conrolled

rial. Aca Anaeshesiol Scand. 2012;56(9):1130-8.70. Nogueira-Marins LA, Jorge M. Sress naure and magniude during medical residency

raining. ev Assoc Med Bras. 1998;44(1):28-34.

71. Suozzo AC e al. Atenion and memory o medical residens aer a nigh on call: a cross--secional sudy. Clinics (São Paulo). 2011;66(3):505-8.

72. Fizsimons MG e al. andom drug esing o reduce he incidence o addicion in anes-hesia residens: preliminary resuls rom one program. Anesh Analg. 2008;107(2):630-5.

73. Brock MF, oy C. andom urine drug esing. Anesh Analg. 2009;108(2):676; auhorreply 676-7.

74. Jaffee WB e al. Is his urine really negaive? A sysemaic review o ampering mehods inurine drug screening and esing. J Subs Abuse rea. 2007;33(1):33-42.

75. Cummings SM, Merlo L, Cotler L. Mechanisms o prescripion drug diversion amongimpaired physicians. J Addic Dis. 2011;30(3):195-202.

76. Wilson JE e al. A survey o inhalaional anaesheic abuse in anaeshesia raining pro-grammes. Anaeshesia. 2008;63(6):616-20.

77. Moore NN, Boswick JM. eamine dependence in aneshesia providers. Psychosoma-ics. 1999;40(4):356-9.

78. Follete J W, Farley W J. Aneshesiologis addiced o propool. Aneshesiology.1992;77(4):817-8.

79. Zacny JP e al. Propool a a subanesheic dose may have abuse poenial in healhy vo-luneers. Anesh Analg. 1993;77(3):544-52.

80. Wischmeyer PE e al. A survey o propool abuse in academic aneshesia programs. Anes-h Analg. 2007;105(4):1066-71.

81. Earley PH, Finver . Addicion o propool: a sudy o 22 reamen cases. J Addic Med.2013;7(3):169-76.



4.2 - Ehical and legal aspecs o medical malpracice | 277

Ehical and legal aspecs o medical malpracice

Desiré Carlos Callegari Member o he Medical Fees Commitee and Firs-Secreary

o he Federal Council o Medicine, Brazil

Inroducion

Aneshesiologiss are exposed o several occupaional risks as a consequence ohe working environmen and heir proessional aciviies. One can cie physicaldamage, like inhalaional anesheic-induced oxiciy, exposiion o ineced bloodand secreions, ionizing radiaion. Oher risks are relaed o psychological damage,including drug addiion and burnou syndrome, which are he ocus o his chaper.

Aneshesiology in paricular is considered an exremely sressing specialy preseningseveral occupaional hazard acors, like inadequae working condiions; long workinghours, requenly associaed wih sleep deprivaion; overwhelming responsibiliy; lowincome; and he need or consan updaing effors. As a consequence o hese acors,aneshesiologiss are a risk o developing several psychological morbidiies.

Te problem rom he psychological and physical sandpoins

e commones problems are sress, crises o anxiey, humor changes, and he conse-

quences o he consumpion o psychoacive subsances. Suicidal behavior, somai-zaion o depressive saes (he developmen o physical maniesaions o he diseaseha causes early or permanen sick leaves rom work), and burnou syndrome mayalso occur.

Burnou syndrome is a work-relaed psychological nosology. I is a ype o prolongedresponse o chronic emoional and inerpersonal sressors a work. Clinical mani-esaions are usually nonspecific and include aigue, eaing and sleep disorders,headaches and emoional insabiliy. I may evolve o emoional exhausion, wihconused menal sae, low personal accomplishmen, proessional rusraion andulimaely depersonalizaion. I diagnosed, emporary leave rom work, psychiaricreamen and rehabiliaion are required.

Drug addicion (biochemical addicion) is defined as he abuse and repeaed useo a subsance, which leads o a clinical condiion characerized by significanadverse effecs. Among hem, we highligh wihdrawal sympoms, he need orprogressively larger amouns o he drug, which enails increasing demand or hedrug and ruiless atemps or sel-conrol. Numerous acors may induce proes-sionals o sar using addicing subsances: psychological aggression as a resul o

daily ac iviies, ease o obaining psychoacive drugs, desire o experimen, geneicpredisposiion, low sel-eseem and ohers associaed wih pre-exising psychiaricdisorders. e mos prevalen subsances are alcohol, opioids (enanyl, suenani l,




pehidine and morphine), cannabis, cocaine, benzodiazepines and propool (insub-anesheic doses).

In drug addicion, here are differen ways o esablish dependency. One is psycho-logical, in which he body has he need o use he subsance or a sense o well being

and relie rom everyday sress. I is generally characerized by a repeiive searchor sensaions he addic used o experimen during he early days o drug abuse,maniesed by brain effecs such as reducion o sympoms o anxiey, eelings oeuphoria, pleasan mood swings, alered percepion o senses and sense o increasedphysical and menal capaciies.

Anoher orm is physical dependence in which he body adaps o cerain subsance.us, when he use o he subsance is inerruped, he user undergoes physicalsympoms and signals and eners a sae o anxiey. Facors such as geneic profile,physical consiuion o he user and usage patern are variables ha can influencehe ime o drug abuse, which is also an aspec o physical dependence.

When he body adaps o a subsance ha is i used regularly and in large quani-ies, mechanisms o deense are creaed. When he use o he drug is inerruped,he user presens wihdrawal sympoms. Once deeced he sae o drug addicion, which is oen di fficul o be idenified, he proessional should be removed romhis/her clinical aciviies and reerred o psychiaric reamen. I is noeworhyha reamen is difficul o conrol, as well as he reinegraion o he proessionalo he specialy.

A sudy abou chemical dependence among aneshesiologiss

e esearch Uni in Alcohol and Drugs (UNIAD, rom he Poruguese Unidadede Pesquisa em Álcool e Drogas), rom he Escola Paulisa de Medicina, perormeda sudy o he clinical and demographic profile o a sample o physicians underak-ing reamen or subsance abuse. is sudy colleced daa rom 198 docors underambulaory reamen or subsance abuse hrough a orm. e orm included psy-chiaric comorbidiies and he consequences o drug addicion.

e majoriy o paricipans were male (87,8%), married (60,1%), o an average age o39,4 years (sandard deviaion 10,7 years). Sixy-six percen o hem had already beenhospialized or alcohol/drug abuse. Seveny-nine percen had been hrough medi-cal residency programs and he mos requen specialies were inernal medicine,aneshesiology and general surgery.

Psychiatric comorbidities of the axis I of DSM-IV were diagnosed in 27,7% of thesample , while diseases o he axis II o he same manual were presen in 6%. e sub-sances mos requenly abused were a combinaion o alcohol and drugs (36,8%),

ollowed by alcohol alone (34,3%) and drugs (28,3%). ere was an average 3,7-yearinerval beween idenificaion o subsance abuse and he reach or reamen.iry percen o paiens looked or reamen volunari ly.




egarding social and medico legal issues associaed wih drug addicion, he sudyshowed a prevalence o unemploymen during he previous year in one hird o hesample, divorce in 52%, involvemen in raffic accidens in 42%, legal issues in 19%,proessional issues in 84,8% and issues wih local medical pracice regulaory boardsin 8,5% o he sur veyed physicians.

1. Increasing knowledge abou chemical dependence and osering awareness oi during medical school can increase raes o early diagnosis as well as spona-neous reach or reamen. Physicians’ oulook on subsance abuse, combined wih insufficien inormaion, leads o he common impression o hopelessnessassociaed wih unreaable diseases. Docors ear sigma, lack o confidenialiy,loss o repuaion and unemploymen. e resul is a “silence conspiracy”: amilymembers and colleagues end o deny or choose no o approach he issue, earingis consequences. us, diagnosis is oen sudden and lae.

2. Educaional and healhcare measures mus be underaken in order o reducesel-medicaion, which can delay diagnosis and reamen.

3. raining healhcare eams o recognize, advise and conron addiced proession-als is essenial. Advising and reerring here individuals or appropriae reamenis an ehical duy - inervenion in hese cases can save lives, boh o he addicedphysician and ha o his paiens. Alhough he iniial reacion may be anger, ioen urns ino proound graiude a he end o a successul reamen course.

4. Specific services or he reamen o addiced physicians mus be imple-

mened, which conribues o screening or new cases and enhances compliance wih he reamen while proecing docors and he general public. Accordingo he English Medical Associaion, here mus be specific services or addicedphysicians, since radiional models are inefficien. ree componens are essen-ial or he effeciveness o hese services: firsly, reamen enry mus be simple,quick and well-publicized. Secondly, care is beter when provided by oher physi-cians, and lasly, long-erm suppor mus be offered, including monioring andsupervision, ocusing on he prevenion o relapse. e exisence o specializedservices is an addiional line o reasoning o convince addiced proessionals o

look or reamen.5. eenry ino medical pracice, i.e., changing o anoher medical specialy dueo subsance abuse happened in 4,5% o he sample in he UNIAD sudy. issubjec warrans urher invesigaion, since i allows docors o change roma high-risk specialy o one associaed wih lesser risks o subsance abuse, orinsance, aneshesiology o amily medicine.

6. e rae o non-medical legal issues (19%) shows ha hese individuals needlegal suppor raher requenly, which shall no be negleced in care programs or

addiced physicians.7. Follow-up sudies are necessary o evaluae he long-erm effecs o reamen.e sudy o physicians who deny reamen may help build knowledge abou




he naural hisory and clinical course o chemical dependence among docors. Well-designed prevalence sudies are also warraned.

8. Screening ess or subsance abuse (urine and hair samples) may be useul inenhancing he reliabiliy o sel-reporing as well as amelioraing he perormanceo affeced physicians and offering legal proecion rom unounded accusaions.

Chemical Dependence: acing he problem

egarding precauionary suspension o proessional pracice and he reamen ophysicians wih psychic disorders, he egional Council o Medicine o he sae oSão Paulo (CEMESP) innovaed in adoping permanenly he successul experi-ence perormed a he beginning o he decade. In May 6h 2002, he Suppor Sys-em or Physicians wih Chemical Dependence was consolidaed.

is pioneer iniiaive in Brazil resuled rom an alliance beween he regional coun-cil o medicine and he UNIAD wih he goal o aciliaing access o reamen,preserving physicians’ healh and heir righ o pracice Medicine.

is projec originaed in he need o approach drug abuse in a maure, conscien-ious and acive manner. Addiced physicians need he help o heir colleagues, sincehey may disance hemselves rom riends and amily.

ere is no single recipe or he approach o such individuals. Personal and conex-ual characerisics mus be aken ino accoun. However, experience shows heimporance o decisive and empaheic acion by offering alernaives while priori-izing atiude changes.

Access o he suppor sysem occurs iniially via a call cener. Aer ha, an in-personapproach is atemped wihin he shores possible ime inerval rom he iniial call,ideally up o 24 o 48 hours. In his inerview, diagnosic plans and reamen reer-rals are made.

When psychological and/or psychiaric suppor are indicaed, i he paien so wishes, he firs sessions (usually he firs our sessions) are offered by UNIAD or

ree. Aer his sage, he affeced physician will be reerred o a cas o psychiarissin he sae wih whom hey will discuss he need or psychoherapy, wihdrawalrom proessional aciviy and occupaional herapy.

Wih he help o social services, C EMESP develops welcoming sraegies or pro-essionals under adminisraive inquiries whose illness is severe enough o warran wihdrawal rom medical pracice. One o hese sraegies is reerral o he abovemenioned suppor sysem.

A undamenal principle in his process l ies in he ac ha proessionals engaged

in hese aciviies do i volunarily. Since he majoriy o illnesses are relaed ochemical dependence, psychiariss who have a background in dealing wih suchissues are preerred.




One o he challenges or he consolidaion o his suppor sysem is obaining betercoverage inland; or ha reason, psychiariss are needed in smaller ciies urheraway rom he capial o he sae. In many cases, physicians who work wih UNI AD/CEMESP say on perorming ollow-up or clinical supervision aciviies. oseineresed in joining he iniiaive can send heir curricula o he medical educaion

insiuions which are par o he program.

Ehical and legal aspecs

Medical malpracice poses he duy o answer or he consequences o proessionalaciviy. According o law, physicians can be penalized or breaching ohers’ righs,eiher by individual or collecive acions.

In hose cases, here will be an adminisraive or legal inquiry. On ehical erms,he moive o violaion is o adminisraive concern and responsibiliy or i belongs

exclusively o he proessional who perormed i. Aneshesiologiss’ ehics com-mandmens are condiioned o he Medical Ehical Code, as well as o he normsdesigned and published by he egional and Federal Councils o Medicine.

On he civil jurisdicion, he moive o violaion is o privae concern and he goal is oenable someone whose righs were violaed o be compensaed or he damage infliced.Civil acion is condiioned o he Civil Code as well as he Consumer’s Proecion Code.

On he penal jurisdicion, he moive o violaion is o collecive concern and raises arial or elucidaion o he ac and is auorship. Upon confirmaion, a sancion will

be made. e penal acion is condiioned o he Penal Code.

Te ehical aspecs

In Brazil, he Councils o Medicine were creaed by ederal law nº 3.268 rom30/08/1957, signed by Presiden Juscelino ubischek. e decree nº 44.045 rom19/07/1958 approved he auhoriy o he Federal Council o Medicine (CFM) andha o he egional Councils, o which his ederal law applies.

e Medical Ehical Code was las updaed in 2009 under he norm nº 1.931 rom

he Federal Council o Medicine. is code includes he norms o be respeced byphysicians in medical pracice: 25 undamenal principles, 10 norms relaed o pro-essional righs and 118 norms regarding duies o be ollowed by docors and whoseransgression warrans penal sancions.

Aneshesiologiss, due o he peculiariies o heir specialy, are also subjec o henorms and resoluions o he CFM. ose rules aim o proec he lives o paiensundergoing anesheics acs in or ou o he hospial environmen.

CFM norms can be alered and improved in consonance wih he evoluion o medi-

cine or aleraions in law and sociey. e echnical Commitee o Aneshesiologyrom he FCM reevaluaes proposals o aleraions in norms and ollows up on he viabiliy o hese changes. I a lso issues appraisals o specific qualms.




One o he mos imporan regulaions or echnical and ehical aspecs o he prac-ice o aneshesiology is norm 1.802/2006 rom he FCM. Given he imporance ohis documen, i is available in ull a he end o his chaper.

Anoher impor an norm, number 1.990/2012, which regulaes admin israive

inquiries abou he exisence o illnesses ha disable parially or compleely aphysician or proessional pracice. his norm addresses precauionary suspen-sions o proessional pracice, which enables physicians aeced by psychic ill-nesses (or insance burnou syndrome or chemical dependence, among ohers)o be wihdrawn rom medical pracice while being reaed. his helps prevenproessional malpracice.

Civil responsibiliy

Civil responsibiliy inquiries aim or inegral compensaion o any damage su-

ered by he vicim. I can be ascribed o he causaive agen in one o wo manners,depending on he assumpions made. From a subjecive poin o view, i is necessaryo deermine wheher he ac was inenional or uninenional in order o jusiy herigh o compensaion. From an objecive poin o view, his characerisic is noaken ino accoun.

Inculpaion occurs when he agen ignored esablished cauion sandards, aced ina heedless manner which can be classified as impruden, negligen or inexperience.Imprudence consiss in recklessness, lack o cauion in perorming a given ask. Neg-

ligence consiss in omission and inexperience is characerized by lack o experise.Inculpaion occurs when he auhor acs deliberaely, ha is, he perormed a givenac ou o his own ree will .

In boh cases (subjecive and objecive responsibiliy), damage and moive mus be presen. ereore, in civ il responsibiliy inquiries, a disincion mus be made beween objecive and subjecive based on culpabiliy, which is a prerequisie orobligaory compensaion. is elemen is presen when he mater is subjeciveresponsibiliy, whereas i is discarded when he mater is objecive responsibiliy.

Medical liabiliy is regulaed by Ar. 14, § 4 o Brazilian law 8.078/1990, which esab-lished he Consumer’s Proecion Code. According o his law, he liabiliy o anysel-employed proessional will be evaluaed according o he exisence o culpabil-iy, hrough subjecive responsibiliy.

Civil responsibiliy, once esablished and adjudicaed, pressuposes setling o damage.Quaniying maerial damage does no enail grea difficuly. Indenizaion or maerialdamage is raher predicable, since i reers o exisen and measurable parimony.

Besides, in case o physical damage, a reund can be offered o cover expenses wih

medicaions, hospial say and urher surgery. In case he paien canno work ora cerain period, his daily income mus also be reunded. When here is permanendamage, he income ha he paien would receive, be i rom wages or any oher




source o income, should also be included. When deah occurs, financial compensa-ion mus include 2/3 o he vicim’s income, o be paid o his amily.

Penal Responsibiliy

Physicians and especially aneshesiologiss canno offer paiens cerainy o suc-

cess. Several exraneous acors can change he course o acs, or insance, peoplereac differenly o he same reamen. e same procedure ha resuls in recoveryor one paien can lead o adverse effecs or anoher.

In order or criminal as well as civil accounabiliy o aneshesiologis o occur,he mus commi an ac specified in law as a crime. Inenion mus be proven, hais, he perperaor mus have desired he resul o his acion or acceped he risko causing i. Proessionals may also be ascribed uninenional culpabiliy whendamage resuls rom imprudence, negligence or inexperience (Ar. 18, II o he

Penal Code). Anoher characerisic o concern is he exisence o an oucome (wih some excep-ions) and a causal relaionship ha links conduc o resuls. I mus be ascerainedha he ac was, in ac, illici, and a breach o law, since here are condiions in which he Penal Code isel esablished he exclusion o wrongulness. Jusifiedsel-deense, compliance wih legal duy and acs perormed in he name o law areypical examples o his.

Usually, penal liabiliy o aneshesiologiss occurs hrough uninenional acs –

imprudence, negligence or inexperience. Imprudence happens when a physicianmakes rushed, reckless decisions. Negligence is an ac o omission by an apaheic,indifferen proessional who chooses no o ac upon a siuaion. Inexperience is helack o heoreical and pracical medical knowledge.

I is difficul o characerize hese modaliies o culpabiliy in a cr iminal responsibil-iy process, especially inexperience in he case o a physician who can prove parici-paion in specific courses and has a license o pracice issued by he specialy socieyregisered wih he egional Council o Medicine. However, in any o hese modali-

ies, i damage, a causal relaionship and culpabiliy are presen, he aneshesiologis will be sancioned accordingly.

A proessional can commi a common crime, which can be perperaed by anyperson, or a crime resulan rom proessional pracice. e penal process is inii-aed by sociey and he sae mus penalize he physician who, volunarily or no,engenders damage o ohers. Presumpion o innocence mus always guide penalresponsibiliy inquiries.

Once adjudicaed rom he proessional sandpoin, an ac may also qualiy as invol-

unary manslaugher. ereore, medical negligence can resul no only in subsan-ial resiuions bu also in one o hree years o confinemen. I a physician has akenexceedingly reckless acions, he may even be prosecued or homicide.




Inenion reers no only o malice bu also o acceping he risk o causing damage.Imprudence and negligence all ino he later caegory, since hey are so immeasur-ably severe ha i would be unair o allow hem he reduced punishmen ha resulsrom being caegorized “uninenional”. Confinemen ime or homicide varies rom6 o 20 years.

Lesser crimes wih a maximal seclusion ime o 2 years, excep or homicide and seri-ous bodily harm, only lead o confinemen in case o recurrence. Some perperaorsmay be punished wih a fine and all o hem are allowed a simplified process ha may be resolved by an indenizaion agreemen, by condiional suspension o he inquiryor by issuing an alernaive punishmen.

Te aneshesiologis’s aciviy

e naure o he obligaion o he aneshesiologis depends on here being a conrac

beween docor and paien. In he case o privae or healh insurance services, hereis a conracual aspec o his relaionship. On he oher hand, in he case o he pub-lic service, he docor-paien relaionship does no include ha aspec.

egarding ehics, he naure o he obligaion o any physician o his paien is oneo means (i.e. canno promise resuls), whereas in law here are conflicing heories. Wih respec o aneshesiologiss’ aciviies and malpracice, here is a se o obliga-ions ha, i unobserved, may lead o liabiliy.

In order o evaluae his responsibiliy, i is essenial o caegorize echnically he

obligaions o he aneshesiologis. Classificaion o hese aciviies may be dividedin preanesheic, anesheic and posanesheic.

Preanesheic acions mus be underaken in order o gaher inormaion abou hepaien’s condiion and creae a saer anesheic plan, hereby decreasing he inci-dence o adverse effecs. e anesheic acions are he mos crucial momens in ananeshesiologis’s pracice and also he momens in which mos accidens occur.Care mus be aken o veriy correc applicaion o drugs and echniques.

e responsibiliy o he aneshesiologis finishes in he posanesheic period, aer

complee recovery o he paien’s consciousness. Filling pre, rans and posanesheicregisries correcly and readably helps proec physicians agains liabiliy inquiries.

Inormed Consen Forms

Offering paiens a writen inormed consen orm is a way o respecing sel-deer-minaion, ha is, he ree wil l o individuals. I is essenial or he physician o inormhe perinen deails o he case o enable paiens or auonomous and consciousdecision-making.

Physicians, hereore, have a duy o inorm he paien as broadly and clearly aspossible o available opions and deails o his case. e writen inormed consenorm mus include a descripion o he proposed procedures, associaed risks and




benefis, he possibiliy o requiring urher inormaion and i should also ascerainhe paien’s righ o desis rom he procedure a any ime.

According o curren regulaions, i is no mandaor y ha he inormed consen be writen. However, documening he paien’s agreemen is imporan or he anes-

hesiologis o deend himsel in case o a uure inquiry.

Conclusion

Medical sudies and pracice have suggesed ha aneshesiology enails subsanialexposure o physical and psychic illness. Sress, anxiey and chemical dependenceoccur raher requenly.

Moreover, due o he naure o proessional aciv iy, aneshesiologiss are suscepibleo suicidal ideaion, somaizaion o depressive saes and burnou syndrome. ese

are complex issues, since hey are relaed o he sel-percepion o perormance andexer an impac on docor-paien relaionships and on he likelihood o medicalmalpracice claims.

Aneshesiologiss have o answer or he consequences o heir proessional praciceand also or acs ha affec he righs o hird paries. a means o say ha heyare liable o civil, criminal and ehical inquiries which may resul in penalies orinenional or uninenional acs.

e Civil Code and he Consumer’s Proecion Code are beacons o he civil realm.

e penal sphere is based on he Penal Code, whereas he ehical sphere is he com-peence o Medicine Councils based on he Medical Ehical Code.

In order o address his issue, sudies have emphasized he need or pracical mea-sures. A beter undersanding o chemical dependence and educaion abou i inmedical schools can enhance early recogniion. Simulaing sponaneous reach orreamen, opposing prejudice and educaing physicians can help hem rerain romsel-medicaing. raining medical eams o recognize, advise and conron addicedphysicians, as well as creaing specialized services or heir reamen may help

screen and deec cases, enhancing compliance o reamen and proecing physi-cians and paiens alike.

e groundbreaking experience o CEMESP wih precauionary suspensions oproessional pracice and he reamen o physicians wih psychiaric illnesses sug-gess i is perinen o expand his iniiaive o oher saes and creae a naional sup-por sysem or physicians wih chemical dependence.

Acknowledging he releva nce o h is issue, he Federal Council o Medicine(CFM), suppored by he Brazil ian Socie y o Aneshesiology (SBA), has creaed

a speciic commiee or he creaion o a naional suppor sysem which will aidin he recovery and reenry o physicians ino social, amilial and proessionallie. his comm iee includes members o he echnical Commiee o Aneshe-




siology and he echnical Commiee o Psychiary. I is a pilo projec, iniiallyocused on aneshesiologiss, ha shall be expanded in he uure o assis allBrazilian physicians.

Reerences

1. Posso IP, Callegari DC. esoluções do Conselho Federal de Medicina de Ineresse para o Anesesiologisa. In: Cangiani LM, Posso IP, Poério GMB, Nogueira CS, Cal legari DCediores. raado de anesesiologia SAESP. 7a ed. São Paulo: Aheneu; 2011. p. 31-60.

2. Posso IP, Lima OS. esponsabilidade Éica e Legal do Anesesiologisa. In: CangianiLM, Posso IP, Poério GMB, Nogueira CS, Cal legari DC ediores. raado de anesesio-logia SAESP. 7a ed. São Paulo: Aheneu; 2011. p. 61-73.

3. Braz JRC, Vane LA, Silva AE. Risco prossional do anestesiologista. In: Cangiani LM,Posso IP, Poério GMB, Nogueira CS, Callegari DC ediores. raado de anesesiologiaSAESP. 7a ed. São Paulo: Aheneu; 2011. p. 75-84.

4. Duval Neto GF. Dependência Química e os Anestesiologistas. In: Cavalcanti IL, Cantin-ho FAF, Assad A ediores. Medicina Perioperaória SAEJ.1ª ed. io de Janeiro:

5. Sociedade de Anesesiologia do Esado do io de Janeiro; 2006. p. 981 - 989

6. Collins GB, McAlliser MS, Jensen M, Gooden A. Chemical dependency reamenoucomes o residens in aneshesiology: resuls o a survey. Anesh Analg. 2005 Nov;101(5):1457-62.

7. Alves HNP, Surjan JC, Marins LAN, Marques ACP, amos SP, Laranjeira, . PerfilClínico e Demográco de Médicos com Dependência Química, Uniad, Unifesp; art.

pub. na Rev. Bras. Med. Trab., Belo Horizonte , out-dez, 2004, Vol. 2, Nº 4: p. 310-316, eev. Assoc. Med. Bras., São Paulo, 2005, 51(3) : p. 139-143

8. Serralheiro FC, Braga A LF, Garcia MLB, Grigio T, Martins LC. Prevalência da síndromede Burnou em anesesiologisas de Insiuição de Ensino Superior em Medicina; ar.pub. na Arquivos Brasileiros de Ciências da Saúde, São Paulo, set-out, 2011, V.36, n. 3,p. 140-143

occupational well-being

Documents