OR-based specialty with MH?

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RdBruce

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Hi Anesthesiology board.

I'm a premed who is interested in surgery and anesthesiology. However, I have malignant hyperthermia. Would OR-based specialties like surgery and anesthesiology be safe for me? If not, are there other specialties I should be wary of as well?

Thanks!
-Rdbruce.
 
With a condition as serious as that, you should probably avoid medicine all together and get yourself some dantrolene.
 
I assume the poster was implying he has the genetic mutation, and not actively in MH (sorry my first post was kind of a joke, not trying be rude). are you saying that giving anesthesia has the same risks for someone with the MH gene mutation??

Btw, I'm wondering if the op got tested for the mutation or if it's just in his FH. How readily available is this testing? Thanks for enlightening a soon to be ca1...
 
RdBruce said:
Hi Anesthesiology board.

I'm a premed who is interested in surgery and anesthesiology. However, I have malignant hyperthermia. Would OR-based specialties like surgery and anesthesiology be safe for me? If not, are there other specialties I should be wary of as well?

Thanks!
-Rdbruce.
Click to expand...

I'm not sure what your background is, so don't be insulted if you already know this. There are 2 classes of drugs that trigger MH: depolarizing neuromuscular blockers, and potent inhaled anesthetics. Of the former class, only succinylcholine is in clinical use. The latter group includes sevoflurane, desflurane and isoflurane (and other older gases that aren't used much in the US anymore).

The risk to you as an anesthesiologist or surgeon comes from breathing in subanesthetic concentrations of gases. You would be at higher risk any time there is a mask induction with a less than perfect seal, and in PACU (patients breathing out gas that's accumulated in tissues - fat, etc.) One of the previous posters mentioned avoiding ENT - this is because you will be working in or near the airway.

You will want to be careful on any OR rotation, since training hospitals are more likely to have new residents or med students bagging with suboptimal mask seals. As far as avoiding any surgical specialty, that is a risk you will have to weigh based on your own risk profile.
 
This topic was discussed several years ago on SDN. A med Student posted the exact same conundrum.

A career outside the opearing room theatre is my recommendation. There are many to choose from including Invasive Cardiology with a sub-specialty in EP.

While it is possible to do Ortho, Optho, Plastics, etc. with a gene for MH why take the additional risk?
 
I think this was discussed a couple of years ago too. So, a search may turn up more info. Tough decision to have several specialties ruled out before you start. But then, I had derm, ophtho, and ortho ruled out for me after my first set of exams in med school 🙂
 
Waste gas exposure in the operating room

While there is a single report of a suspected episode of MH in a nurse attempting to clean up an isoflurane spill, (7) confirmation by muscle biopsy was never performed, and the level of exposure most likely exceeded that which is commonly experienced in hospital operating rooms (OR). The National Institute for Occupational Safety and Health (NIOSH) standard for acceptable OR levels of halothane is 2 parts per million (ppm), which is equivalent to 0.0002%. An abstract published by Maccani reported that MH susceptible swine (a species exquisitely more sensitive than human) did not trigger after exposure to 5 ppm halothane (8). Therefore, in the modern OR with high air turnover, low level exposure is unlikely to trigger MH. There are multiple anecdotal reports of MHS individuals, including anesthesia providers, who have worked and thrived for many years in the OR without adverse incidence (9). Conversely, there are no reports of MH episodes in hospital ORs as a consequence of inhaling waste gases.

Environmental gas exposure outside of the operating room

There are reports of MH-like episodes in biopsy proven individuals from environmental exposures outside of the OR due to the inhalation of halogenated gases from fire extinguishers (10) and gasoline vapors (11). It is not recommended that anyone inhale noxious vapors in a closed, poorly ventilated space, especially MHS individuals. MI-IS laboratory personnel working with vapors should perform such work under a hood. MI-IS veterinary personnel anesthetizing animals should adhere to the same NIOSH requirements for human hospitals, and avoid prolonged exposure to poorly fining, poorly scavenged mask breathing devices.

Summary: There is no evidence to support restricting the professional choices of Mi-IS individuals; however, caution should be exercised regarding the inhalation of any noxious vapor in a poorly ventilated area.


Halsall PJ: Malignant hyperpyrexia and a career in anaesthesia. Anaesth 2002;57:312
 
BLADEMDA said:
This topic was discussed several years ago on SDN. A med Student posted the exact same conundrum.

A career outside the opearing room theatre is my recommendation. There are many to choose from including Invasive Cardiology with a sub-specialty in EP.

While it is possible to do Ortho, Optho, Plastics, etc. with a gene for MH why take the additional risk?
Click to expand...

I provided you with the literature; it appears you may pursue any career you wish.
If you develop MH from exposure in the OR please publish the report as there aren't any I could find.

Still, common sense being what is makes one wonder why pick a career that carries this extra risk to your health?
 
With anesthesia, I would be most concened with spilling volatile on his hands attempting to refill the vaporizer.
 
BobBarker said:
With anesthesia, I would be most concened with spilling volatile on his hands attempting to refill the vaporizer.
Click to expand...


Anesthesia is a poor choice for MH susceptible individuals; it would be the worst career choice he could make except for wind suit flying:

300px-Wingsuit-01.jpg
 
BLADEMDA said:
We have several MH susceptible patients who work in the operating theatre environment, one of whom was an ENT surgeon who spent most of his working life in non-scavenged theatres using Boyle-Davis


http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2002.2520_47.x/full
Click to expand...

Serious question - do they carry around dantrolene? It's so freaking cumbersome and slow to mix. Thankfully, I've never had to give it for real MH, but we mix it up in the sim lab, and also give it for diaphragm pacers as an antispasmodic.
 
BLADEMDA said:
We have several MH susceptible patients who work in the operating theatre environment, one of whom was an ENT surgeon who spent most of his working life in non-scavenged theatres using Boyle-Davis


http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2002.2520_47.x/full
Click to expand...


Also, when I first saw that the ENTs use Boyle-Davis gags, I was like "how do they operate wearing a gag?" I pictured those ball gags that Bruce Willis and Ving Rhames have in Pulp Fiction. I clearly haven't had enough caffeine yet today. The PATIENT. The gags go in the PATIENT.
 
I think the most likely problem he would encounter in ent is death by masking doing pedi tympanostomy tubes.
 
http://youtu.be/yV88pEouZzo?hd=1



One week later he tried the same route, but tried to cross the ridge between Devil's Tooth (the peak to the front,right) and the mountain. His calculations were wrong, and he failed to clear the ridge, resulting in his death at the age of 31.

Geoffrey completed his Master's degree at the University of Stellenbosch, and was a PhD student at the ETH in Switzerland, where he conducted research on wingsuit flying. Here is a recent talk where he describes his research:
http://bit.ly/96Mehj
and newspaper articles on his impressive life and tragic death:
http://bit.ly/dnfHrT ,
http://bit.ly/alCY2L
 
So, what does wing suit flying have to do with this thread? Everything. A career in the O.R. with MH is just like wing suit flying. As long as everything goes like its supposed to you will have a great ride.
But, one big miscalculation as it's GAME OVER.



flyer.jpg
 
Last edited:
BLADEMDA said:
This topic was discussed several years ago on SDN. A med Student posted the exact same conundrum.

A career outside the opearing room theatre is my recommendation. There are many to choose from including Invasive Cardiology with a sub-specialty in EP.

While it is possible to do Ortho, Optho, Plastics, etc. with a gene for MH why take the additional risk?
Click to expand...

They use gas in our EP lab.
 
Thank you for your responses guys! Are all procedural specialties going to be too risky for me? Other than surgery, ENT, and anesthesia (definitely anesthesia), are there any other specialties I should be wary of?
 
RdBruce said:
Thank you for your responses guys! Are all procedural specialties going to be too risky for me? Other than surgery, ENT, and anesthesia (definitely anesthesia), are there any other specialties I should be wary of?
Click to expand...

My first thought is how you will deal with this in medical school during third year, especially surgical rotations.

With regards to specialties, I'm not sure of the true risk but I'd be we wary of any specialty that took me anywhere near volatile anesthetics. For example, interventional radiologists don't generally have to be around volatiles regulary, but we occasionally bring in an anesthesia machine to do a peds case or a case requiring general anesthesia. So there may be some intermittent risks. same thing for interventional cardiology. Any specialty that will involve performing procedures under general anesthesia would be of some risk. For example, pediatric oncology may not come to mind but sometimes we bring kids in and do bone marrow biopsies and LPs with an LMA because they are getting a PICC line. Even if we use a total IV technique or propofol sedation, you will probably have to enter an OR at some point during your fellowship/career. The specialties that in my opinion would be of virtually no risk are:

General pediatrics and subspecialties
General internal medicine and subspecialties (not interventional ones)
Pathology (although pathologists sometimes have to go into the OR)
General cardiology
Family practice
Psychiatry
Emergency Medicine
Radiology (not interventional)

I'm probably missing a bunch, but what comes to the top of my head.
 
RdBruce said:
Thank you for your responses guys! Are all procedural specialties going to be too risky for me? Other than surgery, ENT, and anesthesia (definitely anesthesia), are there any other specialties I should be wary of?
Click to expand...

If you were my kid I would tell you absolutely NO ANESTHESIA OR ENT. The rest you can consider.

For example, Cardiology with EP/Cath Lab your exposure risk is a lot less as many of these cases are TIVA. In fact, you could request TIVA for all your cases.

Your exposure as an Orthopod would again be minimal as I have posted on this thread.

That said, if you can tolerate a specialty without any exposure to Anesthesia Vapors that would be best.
 
As the author of the environmental safety chapter in the upcoming edition of a large anesthesia textbook, I have been reviewing the literature on topics related to this. A few points to consider:

NIOSH sets limits on the ppm of volatile agents in the operating room, but these have not been updated since the 70s, and don't include the two most common agents in use, sevo and des. Some european countries have limits expressed for these agent.

These limits were not set with your scenario in mind. That is, there is not evidence that exposure below these limits = no bystander MH. In fact, no one really knows how many molecules of vapor a person would have to be exposed to in order to trigger. The answer is probably "depends"
and "not very many."

I have reviewed OSHA documents of audits from inspections of ORs all across the country and from a variety of practice settings and, routinely, these centers are not using the "best" of all possible ventilation systems (in terms of the number of times/hr all of the air volume in the room is renewed with outside air). Furthermore, the ppm measurements almost invariably show levels WAY higher than the NIOSH limits.

Lastly, exposure limits are also frequently exceeded in the PACU, where recovering patients are still exhaling anesthetic vapor.

I don't doubt that plenty of people who are susceptible manage to avoid being triggered while working in setting where they are exposed, but given the certainty that you would be exposed to significant amounts of triggering agents, the unknown exposure limit for triggering, and the likelihood that not all susceptible patients are equally susceptible, I will have to agree with the others on this board and suggest a different specialty.

What to do, then, for your rotations? That's tough. I would think that during surgery other than ENT and Peds, once the patient is intubated, your exposure would be virtually zero. Does your medical school have a mandatory anesthesia rotation? Would MH susceptibility be enough to "get out" of the rotation? I can't say for sure.
 
Oh, thanks. I think it's less an honor and more of a way for the current authors to unload a relatively thankless job. But that's what junior faculty are for!
 
PMPMD said:
Serious question - do they carry around dantrolene? It's so freaking cumbersome and slow to mix. Thankfully, I've never had to give it for real MH, but we mix it up in the sim lab, and also give it for diaphragm pacers as an antispasmodic.
Click to expand...

no it isn't.

Newer dantrolene mixes like ancef. Trust me I had to give it last year for MH.
 
JHP Pharmaceuticals Introduces a Dantrium® IV

(
[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]dantrolene sodium for injection..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]..), rapidly mixing at 20 seconds

PARSIPPANY, NJ SEPTEMBER 28 2009
[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]
JHP Pharmaceuticals, LLC ("JHP") announced today that it had developed, and received approval by the FDA for Dantrium
.
.[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV (..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]dantrolene sodium for injection..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]), a rapidly mixing product. Dantrium..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV now reconstitutes in approximately 20 seconds, which is 4 times faster than before, saving valuable time and effort during a malignant hyperthermia (MH) emergency. ..
[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]
Dantrium
.
.[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV, the rapidly mixing product, has the following essential benefits ..
[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]
  1. Reconstitutes in approximately 20 seconds with noticeably less vigorous shaking required to complete the reconstitution process
  2. Easier and faster introduction of diluent into the Dantrium
.
.
  1. [FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV vial ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]..
[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]
JHP has also introduced two new features in the Dantrium
.
.[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV vial; an easy-to-open flip-off vial cap and an easy-to-identify red vial cap and red vial label. ..
[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]
Stuart Hinchen, co-founder and President of JHP said "We are excited about the dramatic enhancements we have been able to make to Dantrium
.
.[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV. The stunning improvement in reconstitution time represents breakthrough innovation that significantly heightens the life-saving characteristics of a drug 30 years after its successful introduction. During fulminant MH, when a patient's core temperature can increase by as much 1º Centigrade every 5 minutes..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]1 ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]and time is obviously a crucial factor, Dantrium..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV can now be reconstituted 4 times faster than before. Taking into account the 36 vials that are recommended by MHAUS (Malignant Hyperthermia Association of the United States) and often needed to stabilize a patient with MH, Dantrium..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV, the rapidly mixing product, saves up to 36 minutes of mixing time." ..
[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]..
 
BLADEMDA said:
JHP Pharmaceuticals Introduces a Dantrium® IV
(
dantrolene sodium for injection), rapidly mixing at 20 seconds
PARSIPPANY, NJ SEPTEMBER 28 2009
JHP Pharmaceuticals, LLC ("JHP") announced today that it had developed, and received approval by the FDA for Dantrium
dantrolene sodium for injection), a rapidly mixing product. Dantrium IV now reconstitutes in approximately 20 seconds, which is 4 times faster than before, saving valuable time and effort during a malignant hyperthermia (MH) emergency. Dantrium
IV, the rapidly mixing product, has the following essential benefits
  1. Reconstitutes in approximately 20 seconds with noticeably less vigorous shaking required to complete the reconstitution process
  2. Easier and faster introduction of diluent into the Dantrium
    1. [FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV vial ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]..
    [FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]
    JHP has also introduced two new features in the Dantrium
    .
    .[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV vial; an easy-to-open flip-off vial cap and an easy-to-identify red vial cap and red vial label. ..
    [FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]
    Stuart Hinchen, co-founder and President of JHP said "We are excited about the dramatic enhancements we have been able to make to Dantrium
    .
    .[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV. The stunning improvement in reconstitution time represents breakthrough innovation that significantly heightens the life-saving characteristics of a drug 30 years after its successful introduction. During fulminant MH, when a patient’s core temperature can increase by as much 1º Centigrade every 5 minutes..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]1 ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]and time is obviously a crucial factor, Dantrium..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV can now be reconstituted 4 times faster than before. Taking into account the 36 vials that are recommended by MHAUS (Malignant Hyperthermia Association of the United States) and often needed to stabilize a patient with MH, Dantrium..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]® ..[FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]IV, the rapidly mixing product, saves up to 36 minutes of mixing time." ..
    [FONT=Times New Roman,Times New Roman][FONT=Times New Roman,Times New Roman]..
Click to expand...


  1. So I bought this Shake Weight for nothing?

    shake%20weight%20for%20men%20pic.jpg
 
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