This Invited Commentary accompanies the following article:
Hinkelbein J, Schwalbe M, Neuhaus C, et al. Incidents, accidents and fatalities in 40 years of German helicopter emergency medical system operations. Eur J Anaesthesiol 2011; 28:766–773.
Anaesthesia covers a large spectrum of highly specialised disciplines: prehospital emergency medicine, pre-interventional consultation, regional anaesthesia, sedation, general anaesthesia, intensive and intermediate care and acute and chronic pain. Anaesthesia demands knowledge, technical and other skills to deal with elective and urgent interventions. Anaesthesiologists provide a very high quality of professional service daily. Therefore, anaesthesia is attractive and can provide great professional satisfaction.
However, to be an anaesthesiologist is not only a pleasure but also a risk. Particularly, emergency helicopter flights may be dangerous for anaesthesiologists. There is sparse scientific literature on this topic and most information comes from newspapers. In this issue, Hinkelbein et al.1 report on fatalities in the German helicopter emergency medical system. The accident rate was less than six per 100 000 helicopter missions and the fatal accident rate was about one per 100 000 helicopter flights. Landing, often in a ‘hostile’ environment, is the most vulnerable period during helicopter flights. Further risk factors for fatal outcomes are bad weather and darkness.2 In busy emergency helicopter bases, a physician may perform about 1000 missions per year; therefore, theoretically, an anaesthesiologist working in an air-based emergency system will have an accident every 16.5 years and a fatal accident every 100 years. Therefore, working in an emergency helicopter system may be considered as safe even when, rarely and highly regrettably, a colleague dies during a mission.
Even inside a ‘safe’ hospital, anaesthesiologists are exposed to risks from exposure to blood, body fluids and radiation. The risk of transmission of hepatitis B virus infection by a needlestick injury is between 6 and 30% without post-exposure prophylaxis or with insufficient hepatitis B virus vaccination.3 The risk of transmission of hepatitis C virus infection by a needlestick injury is between 3 and 10%, depending on the level of virus load.4 Hepatitis C virus infection even after post-exposure treatment may lead to chronic hepatitis, liver carcinoma and liver failure with, potentially, a fatal outcome. A lower transmission rate is associated with HIV (<0.3%). Independent of the source, anaesthesiologists suffer from significant anxiety and emotional distress following a needlestick injury. Potentially harmful effects of ionising radiation affect increasing numbers of anaesthesiologists because more and more interventions are performed with radiological support. These harmful effects range from lens injuries to genetic or carcinogenic effects. The carcinogenic effects may be particularly hazardous to the thyroid gland. There is no known safe dose below which an induced neoplasm does not occur.5 However, to date, no increased risk of death caused by cancer has been reported in anaesthesiologists compared with internists.6
The greatest risks to which anaesthesiologists are exposed are suicide and drug-related deaths. A figure of about 250 suicides per 100 000 anaesthesiologists has been estimated.6 This suicide rate is 15 times higher than in the normal population7 and statistically significantly higher than among internists.6 Depression and substance abuse are among the most important risk factors for suicide. In our speciality, in common with other healthcare providers, depression is frequently associated with ‘burnout’. Burnout is associated with an increased level of emotional exhaustion and depersonalisation and a low level of personal accomplishment. It is described as an individual experience specific to the context of work.8 Different factors are implicated in the development of burnout in our profession:9,10 job demand (lack of time to complete tasks, work environment); lack of control (increasing production pressure, unrealistic goals); relationships (harassment); fear about change (restructuring of job, operating theatre or hospital); lack of support (poor management, care of extremely ill patients); and difficulties related to the home/work interface. Residents have been shown to have high burnout scores, particularly in personal accomplishment, probably because they are young, often single and less in control of work life.11 Burnout and depression are also strongly correlated with suicidal ideations.12
A rate of about 230 drug-related deaths per 100 000 anaesthesiologists has been reported.6 The rate of drug abuse is higher in residents in anaesthesiology than in senior clinicians (1.6 vs. 1%). The risk of drug-related death among anaesthesiologists is highest in the first few years after graduation, but it remains higher than the risk among other physicians after this period.6 There is a relationship between burnout and drug abuse, due to self-medication for anxiety and depression.13 The proximity to addictive drugs and the relative ease of acquiring them for personal use probably also promote drug abuse.14 A recent theory is that exposure in the work place to drugs present in the exhaled breath of patients may sensitise the reward pathway in the brain of healthcare professionals; however, this hypothesis needs to be confirmed by animal and clinical research.15 Although addiction to opioids remains the most common, other drugs such as propofol, ketamine, nitrous oxide and volatile anaesthetics also have an abuse potential.
Depression and substance abuse are considered as a moral weakness rather than a disease process. Therefore, the clinicians concerned are often reluctant to seek medical advice. Self-diagnosis and self-prescription are common, and psychiatric help is rarely requested.12 The fear of losing employment is also a reason for not seeking treatment. Death – either by suicide or by unintentional overdose – is a common outcome of depression, burnout and drug abuse. Optimisation of workload would probably not be sufficient to escape from this epidemic level of burnout, drug abuse and suicide ideation among clinicians. We also need to change to a culture of individual support, to eliminate the barriers to use of psychiatric resources and to promote professional satisfaction: for instance, with a wonderful, calm helicopter flight over sea, lakes and mountains in the twilight!
P.S. and C.D. received support from the foundation agency of the Ministère de la Santé, France; B.W. received support from the Swiss National Foundation (SNF; K-23K1-122264/1), Swiss Accident Company and the Bangerter-Rhyner Foundation. The funding agencies had no role in the preparation, review or approval of the manuscript.
The authors have no conflicts of interest.
This article was checked and accepted by the editors, but was not sent for external peer review.
1. Hinkelbein J, Schwalbe M, Neuhaus C, et al
. Incidents, accidents and fatalities in 40 years of German helicopter emergency medical system operations. Eur J Anaesthesiol
2. Baker SP, Grabowski JG, Dodd RS, et al. EMS helicopter crashes: what influences fatal outcome? Ann Emerg Med
3. Deisenhammer S, Radon K, Nowak D, Reichert J. Needlestick injuries during medical training. J Hosp Infect
4. Trim JC, Elliott TS. A review of sharps injuries and preventive strategies. J Hosp Infect
5. Bashore TM. Radiation safety in the cardiac catheterization laboratory. Am Heart J
6. Alexander BH, Checkoway H, Nagahama SI, Domino KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology
7. Hepp U, Ring M, Frei A, et al
. Suicide trends diverge by method: Swiss suicide rates 1969–2005. Eur Psychiatry
8. Malasch S, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol
10. Nyssen AS, Hansez I. Stress and burnout in anaesthesia. Curr Opin Anaesthesiol
11. Hyman SA, Michaels DR, Berry JM, et al
. Risk of burnout in perioperative clinicians: a survey study and literature review. Anesthesiology
12. Shanafelt TD, Balch CM, Dyrbye L, et al.
Special report: suicidal ideation among American surgeons. Arch Surg
13. Booth JV, Grossman D, Moore J, et al. Substance abuse among physicians: a survey of academic anesthesiology programs. Anesth Analg
14. Bryson EO, Silverstein JH. Addiction and substance abuse in anesthesiology. Anesthesiology
15. Gold MS, Melker RJ, Dennis DM, et al. Fentanyl abuse and dependence: further evidence for second hand exposure hypothesis. J Addict Dis