preoperative tox screening tests Archives - The anesthesia consultant

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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Was Tiger Woods driving under the influence (DUI) on the morning of February 23^rd, 2021 when he was injured in a single car accident?

Perhaps his anesthesiologist knows.

Tiger Woods underwent surgery at Harbor-UCLA Medical Center just hours after his single car rollover vehicle crash. Surgeons performed a pinning of a tibia (shin bone) fracture and pinning of an ankle fracture. Prior to administering an anesthetic, it would be important for the anesthesiologist to know the toxicology screen results in any patient who just survived such an accident. The anesthesiologist needs to know what other drugs, if any, were present in the patient’s system at the time of the crash, because this fact could influence anesthesia management. Drug use could mean central nervous system depressants (opioids, alcohol, sedatives, hypnotics, sleeping pills) or stimulants (cocaine, amphetamines). If sedative drugs were present, there can be a synergistic effect between the drugs and the anesthetic medications. If stimulant drugs were present, the patient may have tolerance and/or increased anesthetic dose requirements.

A 2017 anesthesia study stated that “for optimal patient care through the perioperative period, it is critical to obtain information about patient drug use and other associated treatment in order to construct an appropriate anesthetic plan, including specific considerations during surgery, emergence, and in the post anesthesia care unit.”

In a study from Nature, 1007 consecutive patients undergoing emergency surgery were screened for illicit drug use (IDU). Seventy-five patients (7.45%) were found to be positive for IDU, even though zero patients admitted a positive history of illicit drug use. Of the 75 patients, 50 tested positive for morphine, 22 tested positive for methamphetamine, 13 tested positive for ketamine, 6 tested positive for two drugs, and 2 tested positive for all three drugs. The study concluded, “Knowledge of illicit drug users (IDUs) is important because of the comorbidity related to drug use.”

Miller’s Anesthesia (9^th edition, 2020, Chapter 31, Preoperative Evaluation, authored by Wijeysundera and Finlayson) states, “A patient with a history of current or previous alcohol or drug addiction presents special challenges for the perioperative team. . . . Addictive disease should be considered permanent even in patients who have had long periods of abstinence. . . . Substance abuse disorders are risk factors for poor outcomes in the perioperative setting.”

The 1996 Health Insurance Portability and Accountability Act (HIPAA) prohibits a patient’s doctors from divulging any private healthcare information (PHI) to anyone who is not caring for that patient. The anesthesiologists may know whether a motor vehicle accident patient was part of a DUI incident, but they will not release the results of such a tox screen to the press.

The sheriff who arrived at the Woods crash scene stated there was no evidence that Woods was impaired or intoxicated at the time of the crash in Rolling Hills Estates, California. The police said they “did not issue a citation for Woods . . . To issue a ticket for reckless driving would require evidence that Woods had committed multiple violations before the crash, such as unsafe lane changes, or passing other cars unsafely, according to investigators. . . . Woods had no recollection of the collision, investigators said at the press conference.”

I’m not a lawyer, but I presume that tox screen results could be subpoenaed if a crime had been committed. For example, if an automobile collides with a school bus and kills someone, then I presume the driver’s medical test results would be part of a criminal investigation.

According to the forensic report, Tiger Woods was speeding as fast as 75 miles per hour, or more than 45 mph faster than the legal speed limit before his SUV crashed. Investigators said the accident was “the result of Woods driving in an unsafe manner for road conditions. . . . The evidence suggested the golfer didn’t brake or steer out of the emergency for nearly 400 feet after striking an eight-inch curb in the median.”

Per Golfweek magazine: “forensic experts say the evidence suggests Woods was not conscious when he left his lane and kept going in a straight line before crashing. Instead of staying with the downhill road as it curved right, he went straight over the curb in the median to the left, hit a wooden sign and kept going in a straight line into opposing traffic lanes before leaving the road, hitting a tree and rolling over. Jonathan Cherney, an accident reconstruction expert and former police detective who walked the scene, told USA TODAY Sports it was ‘like a classic case of falling asleep behind the wheel, because the road curves and his vehicle goes straight.’ There were no skid marks on the road, Villanueva said. Instead, Woods’ Genesis SUV kept going straight for several hundred feet. Woods later told sheriff’s deputies he couldn’t remember how the crash occurred and didn’t remember even driving.”

Per USA Today: “’The report doesn’t deal with the underlying cause of the crash,’ said Charles Schack, a former New Hampshire state police trooper who is now president of Crash Experts, which analyzes traffic accidents for law firms and insurance companies. ‘It addresses the data superficially with no apparent curiosity as to why Tiger drove for hundreds of feet without adjusting his steering, braking, or speed. Taking away the high-profile aspect of this crash and looking at the data and roadway, it appears that the driver made no attempt to follow the roadway during the moments leading to the crash. This is typical of a driver who was incapacitated due to a medical issue, falling asleep or being impaired.’”

Can an individual take a sleep medication prescribed by a physician, such as Ambien, at nighttime and still have drowsiness from the medication which impairs their driving ability the next morning? Yes. In 2013 the Food and Drug Administration released the following Safety Communication regarding zolpidem (Ambien):

The U.S. Food and Drug Administration (FDA) is notifying the public of new information about zolpidem, a widely prescribed insomnia drug. FDA recommends that the bedtime dose be lowered because new data show that blood levels in some patients may be high enough the morning after use to impair activities that require alertness, including driving. Today’s announcement focuses on zolpidem products approved for bedtime use, which are marketed as generics and under the brand names Ambien, Ambien CR, Edluar, and Zolpimist.

FDA is also reminding the public that all drugs taken for insomnia can impair driving and activities that require alertness the morning after use. Drowsiness is already listed as a common side effect in the drug labels of all insomnia drugs, along with warnings that patients may still feel drowsy the day after taking these products. Patients who take insomnia drugs can experience impairment of mental alertness the morning after use, even if they feel fully awake.

FDA urges health care professionals to caution all patients (men and women) who use these zolpidem products about the risks of next‐morning impairment for activities that require complete mental alertness, including driving.

There appears to be a public safety concern that individuals who take Ambien for sleep may be impaired when driving a vehicle the following morning.

Was Tiger Woods impaired on the morning of his single car accident? I don’t know, and it’s not my intent to accuse him in any way. I wish him a speedy and complete recovery, and hope we can all watch him play golf at a high level once again. The purpose of this column is to inform readers that: 1) anesthesiologists need to know the results of blood and/or urine toxicology screens before they are administer general anesthesia to an automobile trauma victim; 2) sleeping aids such as Ambien (zolpidem) carry an FDA warning that they can impair activities such as driving the morning after administration; and 3) HIPAA law prevents physicians from disclosing the medical records of patients to the media.