Occupational safety in anesthesiology

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jrsteves

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I'm a current medical student who loved my anesthesiology rotation and am thinking of going into it. More recently, I've become a little worried about the occupational safety aspects of the job, specifically the exposure to gas and radiation.

The NIOSH guidelines limit exposure to less than 2 ppm of sevo or des, but there is a quite bit of literature that finds significantly (2-3 fold) higher levels of DNA damage markers in individuals exposed to lower levels of anesthestic gases (~0.2-0.5 ppm)
Sci-Hub | Exposure to anesthetic gases among operating room personnel and risk of genotoxicity: A systematic review of the human biomonitoring studies. Journal of Clinical Anesthesia, 35, 326–331 | 10.1016/j.jclinane.2016.08.029
Error - Cookies Turned Off
SAGE Journals: Your gateway to world-class research journals
Sci-Hub | Genotoxic effects of anaesthetics in operating theatre personnel evaluated by the comet assay and micronucleus test. International Journal of Hygiene and Environmental Health, 212(1), 11–17 | 10.1016/j.ijheh.2007.09.001

For those of you who have worn sniffers, how many ppm of sevo/des are you exposed to? How would you feel about a resident who wanted to do TIVA for most patients (unless contraindicated, maybe because of hypotension/carotid stenosis, morbidly obese, etc)? How would you feel about an anesthesiologist who wore a respirator in the OR? (Amazon product ASIN B000NJ90CM, Amazon product ASIN B085Y2PK26 there's an international version of the first that looks like the second)

I'm less worried about the radiation. A study of Stanford residents found that they average annual dose was ~0.4 mSv surface, ~0.2 mSv deep (https://sci-hub.se/10.1177/1089253217692110) less than the difference between living in CA and CO (Calculate Your Radiation Dose | US EPA). But, those are residents at one particular institution. Folks who have worn dosimeters, what are your actual annual exposure levels?
 
If a resident wanted to do tivas for most of the cases (I think I would avoid in cardiac or anything that ischemic preconditioning might be more beneficial) I would be ok with that. I'd probably do it for more cases except for the fact that it is extra work ...

Regarding volatile exposure (outside of peds) I think much of it can be avoided by not turning on volatile while bmv (which on most iv inductions isn't necessary) and remembering to pause gas flows (an option on most modern machines) when disconnecting the circuit from ett/lma.

Edit: I think the occupational hazards that are more worrisome are night work (as above) and infectious exposure
 
Hork Bajir said:
Not as good as benzoin
Click to expand...

Not as good as Vi-drape spray adhesive. It smelled so good and worked so well they had to take it off the market.

4D156829-6EDC-405F-8389-5ACFF668D2E3.jpeg
 
Are you a female and planning to have children?

I’d actually be more worried about radiation, had a few attendings in their early 50s to get cataract surgeries.

If you’re worried now, as a student with very limited exposure to everything, because you’re “protected” perhaps anesthesia is not for you. Think about covid, think about blood borne pathogens. Those may be harder to avoid than using sevo/dex/iso.

Part of not doing Tiva for every case is also cost. Sevo is cheap and reliable. Doubt your future employer, especially in PP, will want to bear that cost.

On the other hand, you can stay in academia and be the expert for TIVA.
 
SaltyDog said:
But sevo smells sooooooooo good.
Click to expand...
There was a resident in my program who was on call one night in the unit and nurses said he wasn’t responding to any calls. No response after banging on his call room door. Was found lying on the bed with sevo soaked cotton balls jammed up his nostrils. Needless to say, he was kicked out. I think he eventually made it back into some sort of program in a different specialty and might have even graduated but last I heard he died not too long after. OP, don’t get high on ur own supply and you’ll be fine lol.
 
Ezekiel2517 said:
There was a resident in my program who was on call one night in the unit and nurses said he wasn’t responding to any calls. No response after banging on his call room door. Was found lying on the bed with sevo soaked cotton balls jammed up his nostrils. Needless to say, he was kicked out. I think he eventually made it back into some sort of program in a different specialty and might have even graduated but last I heard he died not too long after. OP, don’t get high on ur own supply and you’ll be fine lol.
Click to expand...

Was there a sevo bottle nearby? Did they test the cotton balls? Being so volatile, I wouldn’t expect the sevo to hang out on the cotton balls for long. Also, how was he monitoring his etSevo? Strange story.
 
Ezekiel2517 said:
There was a resident in my program who was on call one night in the unit and nurses said he wasn’t responding to any calls. No response after banging on his call room door. Was found lying on the bed with sevo soaked cotton balls jammed up his nostrils. Needless to say, he was kicked out. I think he eventually made it back into some sort of program in a different specialty and might have even graduated but last I heard he died not too long after. OP, don’t get high on ur own supply and you’ll be fine lol.
Click to expand...

Was his favorite pickup line “Hey, does this rag smell like sevo to you?”
 
As your attending, I would not be ok with you doing a TIVA for every case.

You need to learn the breadth of anesthesia, and a lot of it includes using the anesthetic gas.

Actual exposure to the gas is minimal, except on peds or other inhalation inductions, and even then it is pretty low overall.

We had an ortho PA who was pregnant that demanded TIVAs when she was going to be in the room, due to concerns for her baby. After an exhausting and exhaustive literature search I got to have a tearful conversation telling her “no.”
She decided she would be in clinic for 9 months rather than going to the OR, which almost made her Ortho MD fire her, but he let her stay away.

Your gas based concerns are unfounded.

Radiation is very low level, as the anesthesia person you can wear lead, lead glasses, and pull a radiation shield in front of you in almost every situation.

Real risks to anesthesia include blood borne pathogens, covid type aerosols, and dealing with dickhead surgeons and clipboard happy nurses all day.

If you are concerned about gas exposure to the degree you sound here, don’t do anesthesia, or educate yourself on the actual risk and exposure levels.
 
ButterButter said:
Was there a sevo bottle nearby? Did they test the cotton balls? Being so volatile, I wouldn’t expect the sevo to hang out on the cotton balls for long. Also, how was he monitoring his etSevo? Strange story.
Click to expand...


Maybe it’s being so volatile actually saved his life?

Heard of stories that people use a rag and hold it with their hands, just so when lights out, the hand would fall and they won’t be getting 15% (or whatever it is) sevo.

Why do you think they would care how to “monitor” when the goal is NOT being monitored?
 
There was a case a number of years ago of an anesthesiologist committing suicide at home (intentionally) by huffing sevo soaked cotton balls.
 
jrsteves said:
I'm a current medical student who loved my anesthesiology rotation and am thinking of going into it. More recently, I've become a little worried about the occupational safety aspects of the job, specifically the exposure to gas and radiation.

The NIOSH guidelines limit exposure to less than 2 ppm of sevo or des, but there is a quite bit of literature that finds significantly (2-3 fold) higher levels of DNA damage markers in individuals exposed to lower levels of anesthestic gases (~0.2-0.5 ppm)
Sci-Hub | Exposure to anesthetic gases among operating room personnel and risk of genotoxicity: A systematic review of the human biomonitoring studies. Journal of Clinical Anesthesia, 35, 326–331 | 10.1016/j.jclinane.2016.08.029
Error - Cookies Turned Off
SAGE Journals: Your gateway to world-class research journals
Sci-Hub | Genotoxic effects of anaesthetics in operating theatre personnel evaluated by the comet assay and micronucleus test. International Journal of Hygiene and Environmental Health, 212(1), 11–17 | 10.1016/j.ijheh.2007.09.001

For those of you who have worn sniffers, how many ppm of sevo/des are you exposed to? How would you feel about a resident who wanted to do TIVA for most patients (unless contraindicated, maybe because of hypotension/carotid stenosis, morbidly obese, etc)? How would you feel about an anesthesiologist who wore a respirator in the OR? (Amazon product ASIN B000NJ90CM, Amazon product ASIN B085Y2PK26 there's an international version of the first that looks like the second)

I'm less worried about the radiation. A study of Stanford residents found that they average annual dose was ~0.4 mSv surface, ~0.2 mSv deep (Sci-Hub | Occupational Radiation Exposure of Anesthesia Providers: A Summary of Key Learning Points and Resident-Led Radiation Safety Projects. Seminars in Cardiothoracic and Vascular Anesthesia, 21(2), 165–171 | 10.1177/1089253217692110) less than the difference between living in CA and CO (Calculate Your Radiation Dose | US EPA). But, those are residents at one particular institution. Folks who have worn dosimeters, what are your actual annual exposure levels?
Click to expand...
Fluro etiquette is important. Gotta be careful with the ortho resident who is doing an unannounced tap dance on the fluro pedal when your back is turned.
 
pjl said:
As your attending, I would not be ok with you doing a TIVA for every case.

You need to learn the breadth of anesthesia, and a lot of it includes using the anesthetic gas.

Actual exposure to the gas is minimal, except on peds or other inhalation inductions, and even then it is pretty low overall.

We had an ortho PA who was pregnant that demanded TIVAs when she was going to be in the room, due to concerns for her baby. After an exhausting and exhaustive literature search I got to have a tearful conversation telling her “no.”
She decided she would be in clinic for 9 months rather than going to the OR, which almost made her Ortho MD fire her, but he let her stay away.

Your gas based concerns are unfounded.

Radiation is very low level, as the anesthesia person you can wear lead, lead glasses, and pull a radiation shield in front of you in almost every situation.

Real risks to anesthesia include blood borne pathogens, covid type aerosols, and dealing with dickhead surgeons and clipboard happy nurses all day.

If you are concerned about gas exposure to the degree you sound here, don’t do anesthesia, or educate yourself on the actual risk and exposure levels.
Click to expand...
I'm sure her lawyers would've absolutelyLOVED for her to get fired by that ortho doc. lol
 
Angus Avagadro said:
Fluro etiquette is important. Gotta be careful with the ortho resident who is doing an unannounced tap dance on the fluro pedal when your back is turned.
Click to expand...
That's mostly what I'm concerned about. Majority of the lead we have is strictly the front facing kind and I frequently am turned around prepping stuff, drawing up more ancef etc etc. That plus the cataracts I'll develop when I'm 70+ although admittedly, that might be sun damage from surfing away my teen years.
 
BHM1 said:
I'd say the greatest anesthesia related occupational hazard would be sympathetic discharge secondary to 2 AM obstetric related calls.
Click to expand...
My favorite was the 0600 Sat call for an epidural during an elective induction that had arrived a whole 2 hrs earlier while I had a hospital board member with a dissecting thoracic aneurysm in the OR.
 
IMGASMD said:
Maybe it’s being so volatile actually saved his life?

Heard of stories that people use a rag and hold it with their hands, just so when lights out, the hand would fall and they won’t be getting 15% (or whatever it is) sevo.

Why do you think they would care how to “monitor” when the goal is NOT being monitored?
Click to expand...

Lol, the monitoring thing was a joke. He’s obviously just tryna get hiiiiiiiiiigghh.
 
pjl said:
As your attending, I would not be ok with you doing a TIVA for every case.

You need to learn the breadth of anesthesia, and a lot of it includes using the anesthetic gas.

Actual exposure to the gas is minimal, except on peds or other inhalation inductions, and even then it is pretty low overall.

We had an ortho PA who was pregnant that demanded TIVAs when she was going to be in the room, due to concerns for her baby. After an exhausting and exhaustive literature search I got to have a tearful conversation telling her “no.”
She decided she would be in clinic for 9 months rather than going to the OR, which almost made her Ortho MD fire her, but he let her stay away.

Your gas based concerns are unfounded.

Radiation is very low level, as the anesthesia person you can wear lead, lead glasses, and pull a radiation shield in front of you in almost every situation.

Real risks to anesthesia include blood borne pathogens, covid type aerosols, and dealing with dickhead surgeons and clipboard happy nurses all day.

If you are concerned about gas exposure to the degree you sound here, don’t do anesthesia, or educate yourself on the actual risk and exposure levels.
Click to expand...
Thanks! I was definitely was interested to see if this perspective was out there and also to what degree it is shared (if you could speculate about your fellow attendings?) I am of course absolutely invested in first becoming comfortable with delivering gas, so the majority TIVA practice was geared more towards the CA-3 or latter half of CA-2 years. How do you think that would fly?

I'd also be super grateful if you could help me with that education and tell me about any resources (publications or reasoning) that would suggest the minimal risk. I could happily go full steam ahead with my future field. I've been looking pretty hard for those things, and all I am able to find are conclusions that say risk is unknown (only thirty year history, so unable to see long-term data) and reviews/original papers that state these markers of genetic damage are pretty routinely found at ~0.2-0.5 ppm levels which are below the NIOSH guidelines. I've been trying to learn if the actual levels are substantially lower (like the minimal exposure argument you make) but I can't really find those numbers anywhere. Do you happen to know where I could find them or what they are at your institution?
 
We have something like that over here. Beats sevo by a mile. Also useful for microscopic lacerations from opening amps (we had a bad batch of betamethasone, breaking them by gentle touch alone). .
nimbus said:
Not as good as Vi-drape spray adhesive. It smelled so good and worked so well they had to take it off the market.

View attachment 331406
Click to expand...
 
jrsteves said:
I'm a current medical student who loved my anesthesiology rotation and am thinking of going into it. More recently, I've become a little worried about the occupational safety aspects of the job, specifically the exposure to gas and radiation.

The NIOSH guidelines limit exposure to less than 2 ppm of sevo or des, but there is a quite bit of literature that finds significantly (2-3 fold) higher levels of DNA damage markers in individuals exposed to lower levels of anesthestic gases (~0.2-0.5 ppm)
Sci-Hub | Exposure to anesthetic gases among operating room personnel and risk of genotoxicity: A systematic review of the human biomonitoring studies. Journal of Clinical Anesthesia, 35, 326–331 | 10.1016/j.jclinane.2016.08.029
Error - Cookies Turned Off
SAGE Journals: Your gateway to world-class research journals
Sci-Hub | Genotoxic effects of anaesthetics in operating theatre personnel evaluated by the comet assay and micronucleus test. International Journal of Hygiene and Environmental Health, 212(1), 11–17 | 10.1016/j.ijheh.2007.09.001

For those of you who have worn sniffers, how many ppm of sevo/des are you exposed to? How would you feel about a resident who wanted to do TIVA for most patients (unless contraindicated, maybe because of hypotension/carotid stenosis, morbidly obese, etc)? How would you feel about an anesthesiologist who wore a respirator in the OR? (Amazon product ASIN B000NJ90CM, Amazon product ASIN B085Y2PK26 there's an international version of the first that looks like the second)

I'm less worried about the radiation. A study of Stanford residents found that they average annual dose was ~0.4 mSv surface, ~0.2 mSv deep (Sci-Hub | Occupational Radiation Exposure of Anesthesia Providers: A Summary of Key Learning Points and Resident-Led Radiation Safety Projects. Seminars in Cardiothoracic and Vascular Anesthesia, 21(2), 165–171 | 10.1177/1089253217692110) less than the difference between living in CA and CO (Calculate Your Radiation Dose | US EPA). But, those are residents at one particular institution. Folks who have worn dosimeters, what are your actual annual exposure levels?
Click to expand...

oh my...

Some attendings wore p-100 respirators during peak COVID but have since stopped and switched to regular n-95s.

I think if you wore one of these on a regular basis, as a resident, for the purpose of minimizing gas exposure during a pediatric inhalational induction, people would probably talk about you...
 
One of the forum members wrote the Miller chapter on occupational safety. Maybe he’ll chime in.

Don’t mind if I do...

It is true that a number of studies show that working in an OR is associated with a handful of negative health outcomes and, more recently, a number of surrogate genetic/DNA breaks or replication errors. These studies are often published under the guise of “exposure to waste gas,” and they choose their population based on likelihood of exposure. Thing is, they never actually measure exposure or control for the 100 other things that occur in an OR and are stressful, many of which have been mentioned here, but I’ll add stress, noise, other chemical vapors like surgical smoke and MMA.

At the end of the day, whether it’s the waste gas other the other factors, working in an OR may be bad for your health in ways that aren’t controllable no matter how you conduct your anesthetic.
 
cchoukal said:
One of the forum members wrote the Miller chapter on occupational safety. Maybe he’ll chime in.

Don’t mind if I do...

It is true that a number of studies show that working in an OR is associated with a handful of negative health outcomes and, more recently, a number of surrogate genetic/DNA breaks or replication errors. These studies are often published under the guise of “exposure to waste gas,” and they choose their population based on likelihood of exposure. Thing is, they never actually measure exposure or control for the 100 other things that occur in an OR and are stressful, many of which have been mentioned here, but I’ll add stress, noise, other chemical vapors like surgical smoke and MMA.

At the end of the day, whether it’s the waste gas other the other factors, working in an OR may be bad for your health in ways that aren’t controllable no matter how you conduct your anesthetic.
Click to expand...
Thanks! This is reasoning I hadn't thought about previously (especially the control parts, I think the exposure is often measured, sometimes just ppm, sometimes urinary sevo). I really appreciate it!
 
ButterButter said:
Was there a sevo bottle nearby? Did they test the cotton balls? Being so volatile, I wouldn’t expect the sevo to hang out on the cotton balls for long. Also, how was he monitoring his etSevo? Strange story.
Click to expand...
Yes. Iso too. No need to test, smell is obvious.
 
pjl said:
Radiation is very low level, as the anesthesia person you can wear lead, lead glasses, and pull a radiation shield in front of you in almost every situation.
Click to expand...
I think all residency programs should pay for individualized lead. Most of the lead laying around are old af, dirty af or made to fit only the morbidly obese.
 
okayplayer said:
Lately I’ve been worried about noise exposure over thousands of hours of totals and spine cases. I’m sure I’ll have hearing loss, which, if severe enough, may be grounds for disability from the specialty in my 50s...
Click to expand...


I agree. I worry more about ambient noise (Neptune sucks!) and cold temperatures than anything else.
 
jrsteves said:
I'm a current medical student who loved my anesthesiology rotation and am thinking of going into it. More recently, I've become a little worried about the occupational safety aspects of the job, specifically the exposure to gas and radiation.

The NIOSH guidelines limit exposure to less than 2 ppm of sevo or des, but there is a quite bit of literature that finds significantly (2-3 fold) higher levels of DNA damage markers in individuals exposed to lower levels of anesthestic gases (~0.2-0.5 ppm)
Sci-Hub | Exposure to anesthetic gases among operating room personnel and risk of genotoxicity: A systematic review of the human biomonitoring studies. Journal of Clinical Anesthesia, 35, 326–331 | 10.1016/j.jclinane.2016.08.029
Error - Cookies Turned Off
SAGE Journals: Your gateway to world-class research journals
Sci-Hub | Genotoxic effects of anaesthetics in operating theatre personnel evaluated by the comet assay and micronucleus test. International Journal of Hygiene and Environmental Health, 212(1), 11–17 | 10.1016/j.ijheh.2007.09.001

For those of you who have worn sniffers, how many ppm of sevo/des are you exposed to? How would you feel about a resident who wanted to do TIVA for most patients (unless contraindicated, maybe because of hypotension/carotid stenosis, morbidly obese, etc)? How would you feel about an anesthesiologist who wore a respirator in the OR? (Amazon product ASIN B000NJ90CM, Amazon product ASIN B085Y2PK26 there's an international version of the first that looks like the second)

I'm less worried about the radiation. A study of Stanford residents found that they average annual dose was ~0.4 mSv surface, ~0.2 mSv deep (Sci-Hub | Occupational Radiation Exposure of Anesthesia Providers: A Summary of Key Learning Points and Resident-Led Radiation Safety Projects. Seminars in Cardiothoracic and Vascular Anesthesia, 21(2), 165–171 | 10.1177/1089253217692110) less than the difference between living in CA and CO (Calculate Your Radiation Dose | US EPA). But, those are residents at one particular institution. Folks who have worn dosimeters, what are your actual annual exposure levels?
Click to expand...
Honestly, the question to me is, is there any CLINICAL significance to all this? Just because they showed "statistically significant" differences in genetics in those with higher exposure to volatile anesthetics.

Are we seeing higher rates of malignancy or other disorders/diseases (other than substance abuse) in anesthesiologists and crnas than other areas of healthcare? Not that I'm aware of.

And it's certainly not difficult to ensure that you have adequate lead when around radiation. For good measure I also distance myself significantly from any imaging even when I have lead on.
 
For imaging I move to a far corner or leave the room for a bit. I also started to use earplugs cause it is just too loud.
 
This is on Reddit too, and I saw a comment there talking about the ppm patients are experiencing. 1% is 10,000ppm for iso and 6% is 60,000ppm.

Though on a semi-related note, I am aware of a few studies going on right now that are trying to look at Volatile vs TIVA outcomes for cancer surgery .
 
I'm just imagining a resident rocking up to work with a full respirator on trying to pre-oxygenate a patient.

"BREATHE IN THIS PERFECTLY SAFE NON-POISONOUS GAS. YOU ARE SAFE. THIS IS NOT POISON. THERE IS NOTHING TO WORRY ABOUT. BREATHE THE GAS."
 
okayplayer said:
Lately I’ve been worried about noise exposure over thousands of hours of totals and spine cases. I’m sure I’ll have hearing loss, which, if severe enough, may be grounds for disability from the specialty in my 50s...
Click to expand...
Just tell ortho joint and ortho spine to turn down the Linkin Park and Green Day
 
God I love this thread. If OP has this kind of risk tolerance for himself (I loled at respirator for inhaled induction), I imagine he'd be the "every patient gets an AFOI" oral board candidate.

I don't mean to tease you too much, OP. This kind of attention to detail and thoughtful concern can be very useful in our field provided you don't let it get too OCD out of control.

Also, I need to look into the lumbar brace thing because my clinical experience thus far has shown me that spine surgery is probably the biggest scam known to mankind. "Oh man that third revision T2-Pelvis PSF totally fixed all my chronic back pain" said no one ever
 
Also I don't really get the whole getting high on pure amnestic anesthetics things. Shortly after I started residency one of the non-clinical OR staff was found shooting up propofol in the bathroom. Is the point just to go unconscious? Hope it was worth it, because it turned propofol into a controlled substance that we had to waste.
 
Airway said:
And practicing 'soft skills' (Trying to not let mid-levels hurt patients while worrying about their feelings).
Click to expand...

Some of the more seasoned supervising anesthesiologists will cry foul. Then say, I’ve always prescribed a plan that’s sound and all my nurses follow my plans. I don’t understand why this should be a concern.

Is it really though. Or people will start chiming in, you should find a job you can do your own cases for at least five years before you start supervising.... are we for real? Gaswork and all the recruit emails I get now are happily announcing that it’s a 100% supervising job, as if that should be celebrated. Or I love this one, 99% supervising. What? I get to stand in a GI case, while my 3pm nurse coming late?! GTFOH.

Yes that ship already sailed, I am not saying I have a solution, just merely frustrated.
 
Yeah I mean the solution offered on here is often to just move out west and just get that 600-800K/16 weeks vacation job doing your own cases.
 
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