Miscellaneous

Operating Room Humidity

Some ORs experience rises in humidity in summer. This APSF free answer to a query discusses the rationale and impact of working outside the generally recommended humidity levels 20 – 60%.

Low humidity could affect shelf life or generate electrostatic sparks. High humidity is uncomfortable for staff and could increase wound infection or cause mildew or mild in the longer term. The evidence on both fronts is sparse but equipment and supplies often specify ranges that prudent organizations adhere to, which may involve suspending operations.

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Vitamin C, Steroids and Thiamine for Sepsis

One might be forgiven for assuming that this is a “revolutionary” and “astounding” treatment for sepsis – the cocktail of steroids, high dose vitamin C and Thiamine propounded almost by a single person, Dr. Paul Marik, based on tiny observational personal studies.

This is an important commentary on the state of wild claims not supported by a single randomized trial in Sepsis.

It is dubbed “science by press release” in this JAMA article. While everyone hopes for a new effective treatment for Sepsis, hype ahead of the evidence is not the way of science.

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Suicide in Anesthesiologists

Light is shed upon this once taboo subject in this Association of Anaesthetists survey. The entire spectrum of stress, depression, burnout, sleep deprivation, etc. is now a pressing issue in healthcare professionals. Anesthesiologists have ready access to potent medications, posing addiction risks as well as intentional or accidental fatal overdose.

This survey looked at experiences of colleague suicide as well as the support schemes in place, and awareness of same.

Most respondents were unaware of the existence of policies/guidance on mental illness, addiction or suicide, or of welfare leads. Deficiencies were noted in the support available and in the way the deaths were handled.

The authors summarize their paper: “emphasizes the need for continued work in promoting discussion, awareness and support of mental health issues, including work‐related stress and alcohol/drug misuse, throughout healthcare systems and anaesthetic departments. We hope that the Association of Anaesthetists guidance, currently in preparation, will provide a useful resource for individuals and departments in this area.”

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Unprofessional Behavior by Surgeons and Surgical Complications

Unprofessional or what is known as disruptive behaviour has been shown to be rife in hospitals. This retrospective study tested the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications.

The conclusion: “Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient’s operation appeared to be at increased risk of surgical and medical complications. ”

The authors point out that “optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications.”

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OR Waiting Lists

Many organizations face issues of surgery waiting lists which interact with issues of OR start tines, late endings and surgical volume.

A report from the NHS in the UK sought to analyze this but a commentary on their efforts is not over complimentary, and highlights the complexity of the issues as well as the influence of politics for those with an interest in these matters.

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Stress, burnout, depression and work satisfaction among UK anaesthetic trainees

There is increasing awareness of mental health and well-being in physicians. This full text article studies some of the worrisome statistics in UK trainees in Anesthesia.

The authors “observed a high prevalence of perceived stress; 37% (95%CI 32–42%), burnout risk 25% (21–29%) and depression risk 18% (15–23%), and found that these issues frequently co‐exist. Having no children, > 3 days sickness absence in the previous year, ≤ 1 h.week−1of exercise and > 7.5 h.week−1 of additional non‐clinical work were independant predictors of negative psychological outcomes”.

Hopefully these results will help inform the identification and management of risk factors. However this should not substitute for improving safe workplaces and work scheduling, workload and practice.

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Caring for the mental health of the medical workforce

The title from the BMA survey into doctors’ and medical students’ mental health applies to all specialties but Anesthesia has ranked in the top in many surveys.

40% reported symptoms of depression, anxiety, burnout, stress, emotional distress or a mental health condition that is impacting on their work/training/study.

27% of respondents reported being diagnosed with a mental health condition at some point in their life.

Doctors work when they know they are unwell and are reluctant to take sick leave.
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Most participants, if they could avoid it, did not disclose their illness to their educational supervisor or anybody else who might have any influence over their career progression. D

Access to appropriate support was impeded for the interviewees in a number of ways including cultural barriers.G

Returning from sick leave was difficult for a number of respondents. Experiences varied with regards to support from their line managers and occupational health services. 

The paper emphasizes building a supportive culture, enhancing access to support, and encouraging self-support and peer-support.

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Abusive behaviour in Canadian and US operating rooms

Some 23% of clinicians experienced abuse and 39% witnessed abuse in the previous year, physical or psychological. Studies have demonstrated negative effect of abusive behaviour on team-work, clinical decision-making, staff health, institutions, and patient outcomes, as well as anxiety disorders and post-traumatic stress disorder, with staffing and legal implications.

Abusive behaviour was more egregious than ‘disruptive’ behaviour – one in ten clinicians were exposed to a physical assault, one in four were exposed to verbal threats, and one in three were exposed to a personal space invasion.

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The wider study on disruptive behaviour reached 97%, almost all had experienced! Four out of the five most common disruptive behaviours involved making inappropriate comments about other people, be they colleagues, patients, or unspecified groups.

More vulnerable groups included females, nurses, and junior or younger doctors.

Institutions clearly have still much work to do in promoting – or enforcing – professional and respectful behaviours in the Operating Room.

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Achieving unconsciousness in assisted dying

This review article from Anaesthesia does not wade into the contentious ethics of assisted dying but seeks to determine the optimal method of guaranteeing humane unconsciousness, drawing analogies from the evidence on accidental awareness under anesthesia and capital punishment, while not equating such practices.

The authors discuss methods ranging from oral barbiturates to the more common intravenous anesthetic + neuromuscular blocking agents (+ Potassium). Variously propofol or midazolam, tubocurarine, succinylcholine, vecuronium or rocuronium have been employed.

Debate exists as to how unconsciousness can be guaranteed to a plane of surgical anesthesia, particularly with Midazolam. Ample cases exist that show failure, and even reawakening from intended assisted death. EEG monitoring is not routine but may be ideal; Bispectral Index (BIS) is fraught with uncertainty.

To ensure unconsciousness, the authors propose continuous infusion of supramaximal anesthetic to burst suppression or isoelectric EEG followed by confirmation of anesthesia, and only then neuromuscular blockade/Potassium.

Much as many medical organizations oppose it, assisted death where legal should be accompanied by measures to assure optimal and humane death. “Canadian colleagues are facing this reality post‐hoc, without having first been involved in framing the law‘.

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