By David Sherer
The recent diagnoses of pancreatic cancer in three of my anesthesia colleagues have both saddened me and piqued my interest as to the potential causes of this cluster. All three are (or were) male colleagues in their 50s and early 60s, and all of them have been exposed to the physical environment of anesthesia for more than three decades. Two of the said individuals are in treatment now, and one, sadly, passed away. This unfortunate and tragic state of affairs got me to thinking about the risks we in healthcare in general and in anesthesia specifically must endure when we practice what we do. And unlike other professions, there really is no substantial “hazardous duty pay” when it comes to delivering the care we render.
The COVID-19 pandemic has thrown a particularly bright light on the hazards we face and brought no small degree of stress to our lives. Such risks come in three basic forms: physical, emotional and mental. The emotional and mental are well known to us. They come in the form of substance abuse, depression, stress, anxiety, sleep deprivation, burnout and negatively affected personal relationships. The physical risks are also well known, and exact no less of a toll. Decades ago, the main fears were the contracting of communicable diseases from our patients, be they infectious hepatitis, HIV or tuberculosis. Radiation exposure in the environments where we practice has been a consistent threat, as has the inhalation of vaporized virus particles from procedures where aerosolized viral particles permeate the OR and other procedural environments. Even something as simple and basic as wearing a heavy lead apron for hours on end can do a number on your neck and back.
These physical, emotional and mental risks to our well-being, brought on as part and parcel of what we do every day, are well known but not frequently discussed. And that’s too bad. It’s unfortunate because it furthers the misunderstanding both by the general public and even our colleagues as to the tremendous price each of us who practices anesthesiology pays while helping our fellow human beings. And while I am not looking for sympathy here, I am looking for understanding. Understanding and a cultural shift. This shift I refer to can be thought of in different ways. First, there needs to be more respect for those of us who endure these risks. Respect is important for us, as I have written about in past articles, because it enhances our sense of worth. Second—and I harbor no delusions as to the improbability of this—payors need to understand, appreciate and perhaps even compensate us for the risks we take. Although there have been billing unit “modifiers” that have allowed us to request more compensation for our services, there needs to be greater efforts to lobby for more remuneration when the physical risks I’ve mentioned above can be monetized. If we must wear lead for hours on end to protect ourselves from radiation—at the price of the joints and muscles in our necks and backs—we need to be compensated for that. When we are involved in potentially infectious laser procedures, necessitating the use of barely breathable laser masks and hard-to-see-out-of tinted goggles, we need to bill for that and be compensated. During lithotripsy cases to pulverize urinary system stones, we must wear ear protection to spare our hearing from the damaging decibels emitted by the stone-busting machine. The military gives hazardous duty pay, as do other professions. Why not for us?
But getting back to my original point, I reviewed some material from the literature that was illuminating. Writing in Anesthesiology (2000;93[4]:922-930) in the article “Cause-Specific Mortality Risks of Anesthesiologists,” the authors concluded that: “Anesthesiologists had an increased risk of death from suicide, … drug related death, … death from other external causes … and death from cerebrovascular disease. Male anesthesiologists had an increased risk for death from HIV and viral hepatitis. … Substance abuse and suicide represent significant occupational hazards for anesthesiologists.”
Apparently much has been written regarding cancer spread and anesthesia exposure. This can be looked at from differing points of view, but the two approaches are interrelated: Does exposure to anesthetic agents or the OR environment contribute to the development of cancer, or does anesthesia choice merely mitigate the spread or severity of existing cancer? In a paper titled “Pancreatic Cancer and Microenvironments: Implications of Anesthesia,” the authors observed that “evidence shows that perioperative factors, including surgical manipulation, anesthetics, or analgesics, might alter the tumor microenvironment and cancer progression” (Cancers [Basel] 2022;14[11]:2684).
Certainly, with regard to the development of cancer and anesthesia exposure in surgical patients, the data are mixed. Writing in Frontiers of Oncology (2021;11:803266) the authors reported: “In vitro and in vivo studies have shown that when breast, ovarian and renal cell carcinomas cells are exposed to volatile gases there is … an increase in growth, angiogenic and migration factors.” (This effect was not shown, however, to be present in non-small cell lung cancer, where exposure to volatile anesthetic agents appeared to have been somewhat protective.)
And finally, writing in the International Journal of Physiology, Pathophysiology and Pharmacology (2013;5[1]:1-10) in “The Effects of Anesthetics on Tumor Progression,” the authors concluded: “Volatile anesthetics are often protective against hypoxia; however, this very protective mechanism may lead to tumor growth and a poor prognosis. … A good approach is to avoid regimens that are potentially harmful and favor these potentially beneficial. The former includes volatile anesthetics, systemic opioids, and ketamine; while the latter includes regional block, local anesthetics, and propofol. In addition, multidisciplinary strategies need to be implemented to reduce perioperative stress.”
But what of anesthesiologists who, unlike the acute surgical patient, endure long-term and continuous exposure to anesthetic gases? Are the implications for us and the potential for the development of cancer different? The answer is not clear. But if inhalational anesthetics, the vapors of which have been inhaled by anesthesia staff over many years and potentially affect us in ways unlike IV, orally ingested or local anesthetics, can have potentially deleterious consequences for us, one has to ask: Should not more research be done in this area to protect us?
Sherer is a retired anesthesiologist and an author. His book “Into the Ether” was published in 2021. Watch for Sherer’s quarterly column “Wake-up Call” in future issues.
Editor’s note: The views expressed in this commentary belong to the author and do not necessarily reflect those of the publication.
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"The military gives hazardous duty pay, as do other professions. Why not for us?"
I will tell you why. An anesthesiologist doesn't and shouldn't get hazardous duty pay because you don't receive mortar fire sitting in a lounge, you don't have your convoy ambushed driving to work, you don't worry about IED's , you have potable water, the temp in the OR is never above 115 F, your ears aren't exposed 24/7 to the sound of gunfire, jet engines, helicopter rotors, people screaming, soldiers calling for their mamas, sitting on a piece of plywood with a hole cut in it to drop a deuce, watching a camel spider walk across the ceiling of your tent, picking chunks of skin off your feet, going without a shower for months, carrying hundred plus pounds on your back, going without sleep for years, never going anywhere that has more than one person, These are just a couple of things to start the day. If one is lucky to survive, you can become one of the 22 veterans who kill themself every day. I don't know about any other veterans that are reading this, but this sickens me. as a side note Anesthesiologists aren't even placed in the forward area of FST (FAST) Teams Forward Surgical Teams. These are manned by CRNA's all over the world, every day. I know many people say, well you volunteered to go into the military. That is true and so did you. I don't recall an anesthesiologist ever being conscripted to serve their country. This should also sicken anesthesiologists who provide anesthesia and work side by side with CRNA's .
I was an anesthesiologist who served on an MFST team with the Air Force with other anesthesiologists and worked with anesthesiologists assigned to FOBs in Afghanistan, just an FYI
I respect your service as you actually did work and I apologize. Being an anesthesiologist, you should know all too well that many of your cadres don't share the same work ethic and commitment as you do. I can only speak to what I witnessed during the initial invasion in SW Asia and for that my sincere apologies.
Well said...
It is a good idea to however find out what the effects of everything we are exposed is and to see if we can do anything to protect EVERYONE in the OR. Because we are all sitting in one room being exposed to it all. But to Sandman57's point, anesthesiologists should be the least to worry about these as the lounge or the prep area are exempt from most of those hazards!
While I find Dr Sherer's comments interesting and I have many colleagues who have developed a myriad of health issues, asking for hazard pay for being an anesthesia provider, is an insult to my friends who are soldiers, policeman, fireman, etc. The job is the job and we all have a choice as to what we do to earn a living. Don't, want to wear lead for hours, don't do ortho anesthesia. I know its not always that simple, depending upon your practice, but you can limit your exposure. Many jobs have risk and we cannot compensate for everything. Only the woke believe the nonsense of compensating everyone for everything.....
Thank you for your concise accurate reply, Dr. Robles. I find many things interesting, but everyone getting a trophy ain't one of them.
While we certainly respect your service and that of all in the military including my son, he clearly did not mean hazardous duty pay in the same way you do. Dr Sherer simply means that if there is an increased risk of Cancer for us who give anesthesia, AAs, CRNA's and MD's, let's get research done, and then go from there.
Precisely. Thank you.
I thought it was a very good commentary and exploration of the hazard’s anesthesiologists face. I see no issue talking about the harmful substances or enhanced lights or other traumatic experiences when administering care peroperaively. If one is sitting in a lounge or not frequently found in an OR, then you are not doing your job.
At 69, I have been retired one year. I hear the objective aspects of Dr. Shearer’s argument well, but I have little sympathy for them. Like construction workers, who beat their bodies up daily, military folks, who put their lives on the line, pro athletes, firefighters and police, we are in control of our own agency and choose our careers with the good and the bad. Several of the groups have a far greater call to entitlement than we do as anesthesiologists, and I know that my income most years approached the top 1% of those in this country. I do feel, however, that I should be greatly compensated for having to suffer under a hospital system that increasingly imposed DEI and other cultural Marxist dogmas upon my wok environment in my last few years of practice.
Just now read this article, so sorry for the late posting, but read with interest your concern about environmental exposure to carcinogens.
I was diagnosed with breast cancer at the age of 41 and learned at that time that women with significant visual impairment have a lower incidence of breast cancer. This is believed to be due to the protective effect of increased melatonin levels that they have since they live in darkness consistently. There is evidence that light at night decreases melatonin levels associated with the circadian rhythm and can lead to an increased incidence of certain cancers. I can't help but wonder whether the myriad nights on call actually contribute more morbidity to us than any environmental carcinogen exposure in the ORs.