Clinical Case: Your lead anesthesia technician reports that three full bottles of sevoflurane have disappeared from three separate operating rooms, despite a light schedule in which all three rooms were finished by noon. What do you do?
Discussion: What if someone stole the bottles of liquid anesthetic? What if they kept them and used them to drug themselves? Does this sound impossible? Not so. In her lecture Substance Abuse in Anesthesia Providers (2003 American Society of Anesthesiologists National Meeting, San Francisco), Roberta Hines, M.D., Professor and Chairperson at Yale, told the following story: A talented, hard-working faculty member of her anesthesia department was found dead. Numerous open bottles of sevoflurane were found in his locker at work. The assessment was that he was abusing the sevoflurane by inhaling its fumes, and overdosed. A similar case report was published (Burrows DL, Distribution of sevoflurane in a sevoflurane induced death, J Forensic Sci. 2004 Mar; 49(2):394-7), describing the following: “The decedent was found lying in a bed with an oxygen mask containing a gauze pad secured to his face. Three empty bottles and one partially full bottle of Ultane (sevoflurane) were found with the body.”
There have been published reports of propofol addiction by anesthesiologists, for example: Iversen-Bermann S, Death after excessive propofol abuse, Int J Legal Med 2001; 114(4-5): 248-51.
The addiction risk with intravenous narcotics is well described and documented. In Dr. Hines’ lecture, she cited the incidence of substance abuse in anesthesia residents as 0.4%, and the incidence in faculty as 0.1%. In 76 – 90% of these cases, the primary abused drug was an opiate. The government has strict rules regarding locking up controlled substances such as narcotics and benzodiazepines, and requiring documentation of all doses given to patients and all doses that are wasted. The amounts of other drugs used, such as inhaled anesthetics or propofol used in infusions, are more difficult to quantitate.
Nobody talks much about addiction risks with non-narcotic anesthetics. Substance abuse among anesthesiologists is something we do not celebrate. People can be seriously harmed or killed by substance abuse of inhalational anesthetics or propofol. Let’s be honest and admit that bottles of these drugs are sitting around operating rooms. If vials of propofol or even half a bottle of sevoflurane were stolen, no one would miss them. Is this a problem? Sure it is. What do we do?
The government makes us carefully document where every drop of narcotic or benzodiazepine goes. If the government regulated the control of these other anesthetic drugs, we would have to come up with a system. Perhaps all inhaled anesthetics bottles would be locked up, and a pharmacist would document the number of milliliters of each liquid at the end of every day. Perhaps only one accountable person would be given the authority to handle the liquid and fill vaporizers. For propofol, perhaps the number of cc’s signed out to each physician would be documented, all patient usage amount quantitated, and all waste returned as we do for narcotics now.
Outstanding training programs now educate their residents and staff on the risks of substance abuse, and offer Physician Well Being Programs for those who are at risk. In addition, let me suggest that we should control the distribution of inhalational anesthetics and propofol. Would this add extra hassles to our day? With inhalational anesthetics, the changes would be a minor inconvenience.
Since Michael Jackson’s death, we are awaiting the American Society of Anesthesiologist’s recommendation on locking up or recording every milligram of propofol that is used or wasted by anesthesia professionals. These changes will require extra paperwork or computer documentation for the pharmacy and for us, involving some elementary school mathematics. I’m not looking to make the duties of an anesthesiologist more complex, but controlling where these life-threatening drugs go is crucial.
If you’re an anesthesia professional, it’s stupid to give yourself an anesthetic, no matter how depressed you get or how much difficulty you are having falling asleep on your own.
In addition to intravenous narcotic abuse and propofol abuse, the cases I’ve referenced above reveal the danger inherent in a stolen bottle of sevoflurane.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: