The occupational hazards of emergency physicians

The Occupational Hazards of Emergency Physicians

SAMUEL DOREVITCH, MD AND LINDA FORST, MD, MPH, MS

Emergency physicians are exposed to a variety of occupational hazards. Among these are infectious diseases, such the human immunodeficiency virus, hepatitis B and C viruses, and tuberculosis. Hepatitis G virus is transmissible but may not be a cause of illness. The likelihood of being exposed to these agents appears to be higher in the ED than other medical settings but estimates of the prevalence of these diseases in the ED vary, depending on the patient population served. Estimates of risk for contracting these infections are reviewed. Measures to prevent these exposures can reduce risk, but compliance is low, particularly for those involving changes in the behavior of emergency physicians (such as not recapping needles). Latex allergy is a hazard of health care workers. Its prevalence is reported to be quite high, but these findings are difficult to interpret in the absence of a universally accepted definition of the condition. Its prevalence in emergency physicians is not known. Other noninfec- tious hazards include workplace violence and exposure to nitrous oxide. The health effects of rotating shift work may put emergency physicians at increased risk of coronary artery disease and impaired reproductive health. Emotional stress is another hazard of emergency physicians, and may lead to burnout. (Am J Emerg Med 2000;18:300-311. Copyright © 2000 by W.B. Saunders Company)

Like all health care workers (HCWs), emergency physicians (EPs) are exposed to a wide range of physical, chemical, and biological hazards in the workplace (see Table 1). Unlike the majority of HCWs, EPs are the first point of hospital contact for patients with traumatic injury and high acuity illness. Because of the emergent nature of their conditions, the emergency department (ED) environment may be less controlled than other clinical settings. In the chaos of evaluating and treating life-threatening conditions, well-established preventive procedures may not be followed by EPs. In addition, the rapid turnover of patients during a single shift in a busy ED allows EPs to come into contact with a large number of sick patients and a wide variety of hazardous circumstances. There is a smattering of articles in the medical literature on individual workplace hazards for EPs. To date, there has been no comprehensive review of the

From the Department of Emergency Medicine, Lake Forest Hospi- tal, Lake Forest, IL; the Division of Environmental and Occupational Sciences, School of Public Health, The University of Illinois at Chicago; and the Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL.

Manuscript received August 20, 1999, accepted November 4, 1999.

Address reprint requests to Samuel Dorevitch, MD, University Health Services, University of Illinois at Chicago Medical Center, 901 S. Wolcott Ave, Suite E-144, Chicago, IL 60612. E-mail: sdorevit@ uic.edu

Key Words: Occupational injury, occupational illness, emergency physician, blood-born pathogen, hepatitis, human immunodeficiency virus, tuberculosis, latex allergy, nitrous oxide, workplace violence, shift work, radiation, depression, burnout.

Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1803-0014510.00/0 doi:l 0.1053/JE.2000.6268

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risks for this occupational group. What follows is a review of what is currently known about these risks with an emphasis on recent studies.

INFECTIOUS DISEASES

Blood-Borne Pathogens (BBPs)

The normal duties of EPs include performing procedures that put them in contact with potentially infectious body fluids. To determine the degree of risk of contracting a particular infection, the following need to be assessed: the prevalence of the disease in the ED patient population; the likelihood of the EP being exposed to the pathogen via a route through which it can be communicated; and the likelihood of such an exposure producing infection in the ER Disease prevalence can vary greatly between EDs, depending in part on the population served, with inner city hospitals having a higher prevalence of diseases associated with poverty. The likelihood of exposure can be different in an ED with a high volume of trauma patients where EPs perform potentially bloody procedures, compared with a low-volume ED that sees little trauma.

For many infectious diseases, the question of risk has not been answered specifically for the ED setting and data from other health care settings must be relied on. Another factor to consider in determining the risk of an occupationally caused infection is the fact that many BBP exposures go unreported. One study x found that EPs actually report about one-eighth of their needlestick injuries, so that published calculations of risk may grossly underestimate actual risk.

Hepatitis B

About 5% of the general US population are HBcAb- positive indicating either past or current infection; about 0.3% are HBsAg positive. 2 The rate of HBsAg positivity among ED patients has been reported to range from 0.6% in the Portland, Oregon area 3 to 5% in an urban Baltimore ED. 4 Patients in trauma units have reported rates of HBsAg positivity of 1.5% 5,6 and 3%. 7 In an inner-city British hospital, patients who were the source of BBP exposures to HCWs, 3% were HBsAg positive. 8

Before the widespread vaccination of physicians against hepatitis B, Iserson and Criss found that of 297 EPs who were not known to have been infected with hepatitis B, 13.1% had serological markers of infection. Including those EPs with a known history of prior infection, 15.5% showed serologic evidence of hepatitis B.9 Although this study did not differentiate occupationally acquired infection from that contracted from other sources, the fact that EPs had triple the risk of the general population suggests occupational transmission.

The risk of transmission by a needlestick of hepatitis B

DOREVITCH AND FORST • OCCUPATIONAL HAZARDS OF EMERGENCY PHYSICIANS 301

TABLE 1. Hazardous Exposures of Emergency Physicians

Infectious Disease Blood-borne pathogens

Hepatitis B Hepatitis C Hepatitis G Human immunodeficiency virus (HIV) HTLV I-II

Nonblood-borne pathogens Mycobacterium tuberculosis Other agents

Latex allergy Radiation exposure Physical violence Nitrous oxide Rotating shift work Emotional stress and burnout Electrical injury Emergency Medical System-related injury Hazardous material exposure

virus (HBV) from an HBV-positive source to a nonimmune HCW depends on the E-antigen status of the source. If the source is HBeAg-negative, the risk is about 3%; if the source is positive, the risk has been reported at 20% 20 to 60%. 11

Hepatitis C

The hepatitis C virus (HCV) is a major occupational hazard to EPs. In the 1980s 230,000 new cases per year occurred~2; since then, due largely to the screening of blood, the incidence has decreased to about 36,000 per year. 13 The prevalence is about 1.8% of the general US population. 14 Among patients in EDs and trauma units, seroprevalences of 7.7%, 6 13.8%, 5 18%, 4 and 20% 15 have been reported. The risk of percutaneous or mucous membrane exposure to the blood of an HCV-positive source patient has been reported to be twice as likely in the ED than in other parts of the hospital. 15 When the diagnosis of seroconversion is established by enzyme-linked immunosorbent assay (ELISA), rates after occupational exposure to HCV range from 1.6% 16 to 6%. ~5 Seroconversion rates of 4% 17 and 10% 18 have been reported in studies where diagnosis was made by reverse transcriptase polymerase chain reaction. Although sustain- ing a needlestick is a risk factor, simply being a health care provider who performs procedures does not appear to be an independent risk factor. 19,2° At the present time no interventions have been shown to be of benefit after exposure, emphasizing the importance of preventive efforts.12.2~

Hepatitis G

The hepatitis G virus (HGV) is an RNA virus of the flavivirus family, and was first characterized in 1995. 22 Previously the virus was also known as hepatitis GB virus-C. The virus can be transmitted by blood transfusions, as well as vertically from mother to child. Patients with hepatitis in whom hepatitis A, B, C, D, and E have been ruled out ("non-A-E hepatitis"), have a reported 3% to 16% prevalence of HGV. 23,24,25,26,27 The prevalence of HGV in the general population varies greatly worldwide, with evidence of HGV viremia in about 1% of healthy Americans, 23,26 and

about 12% of South Africans.28,29 Occupational transmission of HGV had been reported as well. It has been known that hemodialysis patients are at risk for HGV. 3° A German study found that 25% of hemodialysis patients and 24% of dialysis staff were HGV positive, compared with 9% of controls. 31 More pertinent to EPs, a Japanese study found that after needlestick injuries from an HGV-positive sources, 7% seroconverted. 32 To date there have been no reports of EPs contracting HGV, probably because of the fact that HGV testing is not routinely performed.

It remains controversial whether the HGV actually causes clinical illness. An excellent review article by Mphahele details the arguments for and against the notion that HGV causes hepatitis, and concludes that while virus is clearly transmissible, it is not pathogenic. 33 Unless it become clear that HGV is a cause of disease, it is reasonable not to test for evidence of viral transmission.

Human Immunodeficiency Virus (HIV)

HIV is one the few hazards for which data specifically addressing the risk to EPs has been studied. Estimates of the prevalence of HIV among ED patients varies from about 0.2% in a suburban ED to 8.9% in an inner-city ED. 34 Studies from large east coast and Midwestern urban centers generally report prevalences of around 4% to 6%7,35,36,37; in the Portland, Oregon area the prevalence remained 1% over a 3-year period? 8 Trauma center EDs outside of inner cities have reported prevalence of 1%39 to 2% 40 of trauma patients and 7% of nontrauma patients. In one study, only 38% of those patients who were HIV positive were aware of their infection. 36 The same group found that although the general ED population had a 6% prevalence, among males it was 8.9% and among people between the ages 25 to 45, it was about 11%. Among nonhomosexual injection drug users the HIV prevalence was 28.8%.41

The risk of contacting HIV-containing body fluids has been estimated as well. Lewandowski found that resuscitat- ing critically ill patients was associated with contacting blood or other body fluids by at least one HCW 31% of the time, and a percutaneous injury 2.9% of the time. 37 When managing trauma patients, opportunities for body fluid exposure occurs in 80% of cases. 39 An Italian study found that 0.13% of all ED patient encounters resulted in exposures (needlesticks, cuts, mucous membrane, or nonintact skin blood contact) to HCWs; when considering trauma patients, exposures occurred in 0.75% of cases. 42

A total of 94 HCWs have contracted HIV via occupational exposures, whereas another 170 may have (ie, they had a blood or body fluid exposure at some point and were found later to be HIV positive, but were not documented to be HIV negative at the time of exposure). 43 Of the 94 "definite" cases, three occurred during resuscitations, and two of these were inflicted on the HCWs by coworkers . 44,45,46 The seroconversion risk of a HCW after percutaneous exposure to HIV is about to be 0.3%. 47 An international case-control study found that percutaneous exposure is associated with a 0.1% risk and for mucous membrane exposure, 0.63%. 48 The factors influencing that risk, and their adjusted odds ratio (in parentheses) are: deep injury (15), visible blood on device (6.2), procedure involving needle in artery or vein (4.3), and

302 AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 18, Number 3 • May 2000

terminal illness in source patient (5.6). Postexposure use of zidovudine has decreased the risk of seroconversion by 81%, and this study 49 is the basis of the current recommenda- tion to provide postexposure prophylaxis. 5° The authors of this retrospective case-control study also found a crude odds ratio of 5.6% for seroconversion if the percutaneous exposure occurred while performing an emergency procedure. It has been observed that HCWs with a history of HIV exposure who do not seroconvert exhibit cellular responses to HIV envelope proteins. 51,52 The intriguing suggestion has been made that chronic low-grade exposure to HIV may result in some partial immunity to the virus. (Needless to say, universal precautions must be followed and one should not be lulled into a false sense of security because of this hypothesis.)

Attempts have been made to calculate the overall risk of an emergency physician contracting HIV because of occupational exposure. Based on mathematical modeling, the cumulative risk for EPs over a 30-year career has been estimated to range from 0.1% to 1.4%, depending on the prevalence of HIV in the patient population served. 53 One set of calculations based on empirical observations concluded that in high seroprevalence EDs 1 in 40 full-time EPs or ED nurses will sustain a percutaneous exposure to HIV during a 1-year period. In low seroprevalence settings, 1 in 575 can expect such an exposure per year. 34 This same group calculated the annual risk of an ED staff member seroconver- ting to be between 1 in 3,800 to 1 in 13,100 in a high risk ED. For an ED with low seroprevalence, the risk would be between 1 in 55,000 and 1 in 187,000. For comparison, using a different mathematical model, the 30-year career risk for a surgeon has been calculated to be 1% and 10%, for respective HIV seroprevalences of 0.01 and 0.1 of the patient population. 54

Related to HIV are the retrovirnses, human T-lymphotro- phic virus (HTLV) I and II. HTLV I is associated with adult T-cell leukemia-lymphoma, and a chronic demyelinating disease, HTLV-I-associated myelopathy. HTLV-II may cause T-cell malignancies. The prevalence of HTLV I and II among ED patients in inner-city EDs is 1% to 2%. 37'41 The degree to which this presents a risk to EPs and other HCWs is not known.

Tuberculosis

The incidence of tuberculosis (TB) in the United States increased in the late 1980s and began to decrease again 1993. 55 TB presents a risk to HCWs in general and ED staff are at increased risk because patients present with active, but undiagnosed, disease. Routinely performing purified protein derivative (PPD) testing found about 17% of patients positive both in an inner city ED 56 and on the trauma service of a university hospital. 57

The risk of an EP converting to PPD-positive depends on the prevalence of patients with active pulmonary tuberculosis as well as the quality of preventive measures in the ED. A study from the ED of an urban tertiary care hospital found that 12% of ED staff converted to PPD positivity between 1994 and 1995. Attending EPs were not included in this study, but residents were. Those who converted were registrars and nurses. This compared with a 2% rate of

conversion for employees who worked elsewhere in the hospital. 5s In the same study, it was found that by implement- ing TB control measures (respiratory isolation rooms, venti- lation improvements, and so on), during 1996 no ED staff converted, whereas 1.2% of other hospital workers did become PPD positive. For comparison, New York City paramedics had an annual rate of PPD conversion of about 1% per year. 59

A study that relied on a self-reporting found that 31% of ED staff became PPD positive during a 3½-year period. 6° The investigators calculated a 5.6% risk of conversion after working 1 year in the ED, going up to 69% after 10 years.

The transmission of multidrug-resistant TB from patients to HCWs, including to physicians 61,62 has been reported and should be of great concern to all HCWs. Employers of EPs should share this concern, particularly in light of a recent report of an EP who contracted TB and is now suing the hospital where he worked. 63

Currently, the preferred methods of prevention are engineering controls (isolation rooms with negative pressure, airflow), and efforts to identify, isolate, and treat patients with active disease. An expert panel advised against the routine use of the Bacillus of Calmette and Guerin vaccine (BCG) for HCWs, unless they care for a large number of patients with drug-resistant TB and other preventive measures have failed. 64

Other Infectious Disease

Transmission of many other infectious illnesses from patients to HCWs in general has been documented. Vari- cella, measles, influenza, rubella, mumps, pertussis, parvovi- rus B 19, respiratory syncytial virus, adenovirns, and hepatitis A, have all been occupationally acquired by HCWs. 65'66

EPs who eat hospital food are at risk for contracting salmonella, hepatitis A, yersinia, campylobacter cyclospora, and typhoid fever infections, all of which have been reported in the context of hospital food outbreaks. 65

Infectious Diseases: Prevention

Although EPs and other HCWs are at risk for contracting a multitude of infectious diseases in the course of their work, effective preventive measures exist to minimize such risks. A knowledge of the hazards is critical; Table 2 provides a quantitative summary of risks to EP for several infectious diseases. Simple preventative steps include immunization, the use of personal protective devices, engineering controls, and, when indicated, patient isolation.

Recommended vaccinations for HCWs without complicat- ing conditions (pregnancy, immunocompromise, and so on) are: hepatitis B, influenza, measles (not necessary for those who received two doses of the vaccine before their first birthday or who have had documented measles do not need the vaccine), mumps (if susceptible; not necessary if born before 1957), rubella (for both males and females; not necessary for those with evidence of vaccination after their first birthday or laboratory evidence of immunity; except for women of child-bearing age, those born before 1957 can be considered immune), tetanus, and varicella (unless there is a

DOREVlTCH AND FORST • OCCUPATIONAL HAZARDS OF EMERGENCY PHYSICIANS 303

TABLE 2. Selected Infectious Agents and the Risks they Present to EPs*

Agent ED Patient Prevalence Risk After Single Exposure EP Risk

Hepatitis B 0.6%-5% HBsAg (+) 3%-60%, depending on e-antigen status of source ? Hepatitis C 18%-20% 1.6%-10% ? HIV 0.2%-9% 0.1%-0.6% 1/3,800 to 1/187,000 per year Tuberculosis 17% ? 0%-12% per year

*See text for details and references. ED prevalence studies have generally been performed on high-risk populations.

reliable history or laboratory evidence of prior infection). 67 BCG, hepatitis A, meningococcus, polio, typhoid, and smallpox vaccines are not routinely recommended, but in special situations may be appropriate. For HCWs with the potential for exposure to TB (EPs certainly fit this category) screening is recommended at least annually. A questionnaire- based study of 209 pediatric attending EPs found that 32% were not aware of the existence of the above national recommendations for immunization and annual TB screening of HCWs. 68 Only 72% received annual TB screening, but those who were hospital or university employees were more likely to be screened than those who were self- employed or belonged to an incorporated group practice. Furthermore, the rates of vaccination for influenza were 60%; for HBV, 91%; of those born after 1956, 38% lacked a second measles-mumps-rubella vaccination. In addition to preventing HBV, the hepatitis vaccine would also prevent coinfections such as delta hepatitis.

To decrease the risk of EPs contracting BBPs through their work, it is essential to follow "universal precautions." As discussed earlier, performing emergency procedures is associated with an increased risk of HIV transmission. When caring for unstable patients, HCWs must remain aware of the need to protect themselves and their coworkers, even during life-saving procedures. It has been argued that some very risky procedures of little clinical utility, such as the ED thoracotomy on trauma patients, not be performed in certain circumstances, in part because of the risk of HIV and other BBPs. 69 Unfortunately, EPs comply poorly with the simple preventive measures that could prevent occupational infections. As the title of one of the studies on the subject states, "universal precautions are universally ignored. ''7° Barrier precaution compliance is about 75% to 97% for glove use, but gown, mask and goggle use ranges from about 5% to about 50%. 71,72,73,74,75,76 Needle recapping occurs about 34% to 50% of the time73,74,75; of these, 78% is two-handed. 74,75 The use of devices designed to minimize the risk of BBP (such as needle-less intravenous systems and retractable needles) has been advised. 77

If an exposure does occur, postexposure prophylaxis recommendations for hepatitis B should be followed. 47 Of note, a new hepatitis B immune globulin is available. It is prepared with techniques to decrease the chances of the vaccine inadvertantly containing infectious material and is marketed as NABI-HB. Likewise, to prevent HIV transmission, EPs should be follow the postexposure prophylaxis recommendations guidelines have been made by the Centers for Disease Control and Prevention (CDC). 5° Modified versions of the original guidelines have been made which make the CDC recommendations less ambiguous 78 and favor three-drug therapy in many cases. 78,79

LATEX ALLERGY

There are two types of latex allergy. Type IV hypersensitivity, also known as cell-mediated, delayed-type, or allergic contact dermatitis, causes red, cracked, blistered or oozing skin hours to days after latex contact. Once established, bacterial superinfection may occur. Type I hypersensitivity, also known as IgE-mediated or immediate-type latex allergy is the more dangerous form of reaction and will be considered here. IgE-mediated reactions present as rhinoconjunc- tivities, urticaria, asthma, and anaphylaxis occurring sec- onds to minutes after exposure.

The prevalence of type I latex allergy in the general population has been estimated to range from 0% to 3% based on skin testing 8°,81,82,83,84,85,86 and between 3.5% and 18% using serological testing 84,87,88,89 (with the larger studies showing rates of 4% to 8%87,88). Among HCWs, studies that rely on historical information to diagnose the condition generally report prevalences of type I latex allergy symptoms in approximately 5% to 15%9°,91,92,93,94; using skin prick testing prevalences 2.9% 8o to 14.1% 95 have been reported, with most studies showing prevalences of about 8% to 12%91,93,96; serological studies of HCWs found prevalences of latex-specific IgE to be 10% to 12%. 91'94 Because EPs have not been studied, data from other physicians may be relevant. A symptom-based study in Taiwan found a prevalence of 4.6% among physicians compared with 28% in surgical nurses and 6.8% among HCWs in general. 92 A Canadian study of physicians using skin prick testing (SPT) found a 10% positivity for latex antigens. 96 The incidence of new latex allergy among previously negative HCWs has been investigated. A 1% per year risk of developing latex allergy has been reported, although two of the four HCWs who became newly sensitive based on SPTs were asymptomatic. The rate was the same for users of both powdered and powder-free gloves. 97

It has been said of latex allergy that, to HCWs "there is no greater threat to ending their career and potentially their lives. ,,98 Latex allergy clearly has interfered with the careers of HCWs and has caused them near-fatal reactions. 99 Nevertheless, there is reason to question whether the prevalence may be lower than reported. Firstly, there is a significant discordance between symptoms and results of diagnostic tests. In other words, a large percent of HCWs who are diagnosed as having latex allergy (by either skin testing or latex-specific antigen levels), have no allergic symptoms when using latex gloves. For example, while one large study found that 12% of HCWs were positive based on skin testing, 40% of these supposedly latex-sensitive individuals denied all symptoms of latex sensitivity. 93 Until a gold standard for diagnosing the condition is agreed on, it is


difficult to speak of its prevalence. Likewise, a study of 741 nurses reported an 8.9% prevalence based on latex-specific IgE levels; yet 14% of those who were seropositive had no symptoms of latex sensitivity. 94 Additionally, selection bias may result in an overestimation of disease prevalence. The prevalence studies reviewed above relied on voluntary participation of HCWs. The rates of participation varied from a low of 12%, 9o with other studies showing about 75% participation rates. 93,94 Those HCWs who had symptoms of latex allergy may have been more motivated to participate in the studies, thus skewing the findings towards higher reported prevalence. In addition studies that rely on patient histories to diagnose latex allergy have lumped together the life-threatening type I and the annoying type IV symptoms to arrive at estimates of prevalence.

Several risk factors for latex allergy have been determined. In most studies a history of atopy had been associated with an increased risk for latex allergy, 94,96,1°° whereas in others, no association has been found. 91,1m The degree of exposure to latex (glove consumption per department) has also been associated with increased sensitivity for sterile surgical gloves but not for latex examination gloves. 93 Others have cautioned against trying to make such correla- tions because those who are latex sensitive may have switched to vinyl or other gloves. 94 Patients with spina bifida who have undergone many surgical procedures, m2 as well as workers exposed to latex in industrial settings 1°3 also have high reported prevalences of latex allergy. For those with several risk factors, such as atopy and frequent exposure, the risk may be considerably higher, m4 Allergy to certain foods, such as avocado, banana, kiwi, has been associated with latex allergy. 93,94,1°5,1°6

Latex-safe precautions should be implemented through- out health care facilities. Powder-free gloves should be used, as the powder promotes inhalation of the offending antigens. Latex-free gloves and other products, as well as a latex-free patient care area should be available.

RADIATION EXPOSURE

Portable radiography is frequently performed on patients in the ED who are not stable enough for transport to and from the radiology department. ED staff at times must apply traction to the upper extremities or support the airway of patients during the exposure of the patient to ionizing radiation. The degree to which this puts EPs at risk has been studied and there is agreement that typical amounts of radiation exposure does not exceed the recommendations of the National Council of Radiation Protection and Measure- ment. 1°7'I°8'1°9'n° Theoretically, if an EP who stabilized the cervical spine of trauma patients six times per day, 200 shifts per year, they could exceed the 50 rem limit for protection against nonstochastic effects in the extremities, in Studies that specifically looked at radiation to the hands concluded that for those frequently assisting with cervical spine radiographs, exposure levels may be exceeded and leaded gloves should be used. 111,112,113 Simply being in the ED when a patient is undergoing a portable x-ray is not a risk; one would have to stand 160 cm from a patient undergoing a portable pelvis x-ray 1,200 times per year to receive an amount of radiation equal one's background (ie, environmen-

tal) exposure, n4 Nurses are exposed to more radiation in the ED than EPs. 1°8,1°9

VIOLENCE

EDs treat patients at risk for violent behavior, such as those involved in violent crimes, people with psychotic disorders, substance abuse, and delirium, as well as those experiencing stressful situations because of their own or their family members' medical emergencies. Consequently, ED staff are at risk for becoming the victims of violence.

Data on violence in the ED are limited, with much of the literature on the subject coming from institutions in the UKY 5 One British study found that in a large (50,000 annual census) urban accident and emergency department (A&E) more than 23 violent incidents occurred per year over a 12-year period, v6 Another study from the UK and the Republic of Ireland found that physical violence occurred on a daily basis in 2% and on a weekly basis in 12% of A&E facilities, n7

Studies specifically addressing violence to HCWs in US EDs are limited to retrospective studies. A survey of violence in Veterans Administration hospitals and clinics reported over 24,000 assaults (including rape, battery with a weapon, and hostage taking) over a one year period in 166 facilities. Psychiatric units were the most common site of assaultive behavior, 13% of events occurred in "triage or admitting area" (EDs were not specifically identified), u8 The most recent study reported 4.7 assaults, and 0.3 assaults with weapons per 10,000 ED patients. After the implementation of an improved security system, the respective rates were 5.8 and 0.1 per 10,000 ED patients (not significantly different from the earlier rates). 119 At a large Los Angeles ED 26.7% of major trauma victims were armed with weapons. 12° The investigators found that over a 14-year period the frequency of automatic weapon carriage went up dramati- cally. In the early 1990s over 500 knives and over 100 guns were confiscated per year. Violent incidents occurred in 1.7% of cases where weapons were brought into the ED, leading to four fatalities of patients and six minor injuries of staff. A survey of 170 teaching hospitals with large (greater than 40,000 annual patient visits) EDs, sought to assess the prevalence of violence. 121 Of the 75% of EDs that re- sponded, 32% reported daily verbal threats to staff and 18% reported weapons displayed to threaten staff once at least once a month. In the preceding 5 years, at least one threat of violence with a weapon had been made in 57%. A physical attack on staff occurred once each month at 43% of EDs and 80% reported injuries to staff caused by violent patients in the preceding 5 years. Two hostage situations at knifepoint were reported. An act of violence in the ED resulted in death in 7% of EDs over a 5-year period. Weapons were confiscated from patients or visitors on a monthly basis in 46% of EDs. Six percent reported involvement with litigation for failure to restrain/detain a violent patient. Litigation involvement for injury resulting from restraint or for unnecessary restraint/detention occurred in 5% and 10% of EDs, respec- tively.

Recommendations to prevent violence range from learn- ing to identify the patient at high risk for violence (substance abuse and psychiatric illness), 122 educating staff to respond


appropriately when such a situation is identified, to having "panic buttons," armed guards, surveillance cameras, and physical modifications to the ED to prevent injury to patients and staff. 116,121,~23 The implementation of an improved security system resulted in confiscation of more weapons from people before they arrived in patient care areas. H9

NITROUS OXIDE

A study of emergency medicine residencies found that 25% use nitrous oxide for patient analgesia and sedation. I24 This drug, administered by inhalation, has been associated with hepatic, renal, immunologic, neurological, psychiatric, and hematologic abnormalities. 125,126,127,128 One area of particular concern is the reproductive health of those who work with the drug. 129,13°,131 One study found that female workers in dental offices that were exposed to inhalational agents (typically nitrous oxide) had double the risk of miscarriage of those who were not exposed to such agents. 131 Retrospec- tive studies have shown that women with the greatest exposure to nitrous had decreased fertility 132 and double the risk of spontaneous abortion 133 compared with women with little or no exposure. One study that may be particularly relevant to EPs is one of midwives who work night shifts. Those with the greatest exposure to nitrous oxide had decreased fertility. TM Use of a Nitronox device without a scavenger system in an ED resulted in levels well above those thought to be safe. 135 Scavenger systems are meant to reduce to ambient concentrations to near zero, and have been shown to decrease the risk of spontaneous abortion. 133 Nevertheless, a recent study in operating rooms found abnormally high nitrous oxide levels 25% of the time, despite the use of scavenger systems. 136 Controversy persists and some have argued that with a functioning scavenger system and adequate vitamin B-12 intake, nitrous oxide should not be considered a significant hazard. 137 A recent editorial in the anesthesia literature has questioned whether the drug should be used at all. 138 Given the vast array of other agents that can be used for analgesia and sedation in the ED, it seems prudent to avoid exposure to nitrous oxide.

ROTATING SHIFT WORK

EDs are staffed 24 hours a day. Consequently, EPs generally perform what is known as rotating shift work (RSW), meaning, in addition to working a portion of their shifts during the day, they work some of the time counter to the normal diurnal rhythm (ie, at night). The following will be reviewed: studies of the long-term studies of the health effects of rotating shift work; the effects of night shift work on EPs; and research into optimal shift scheduling.

Long-Term Health Effects of RSW

Most of the data regarding the long-term effects of RSW comes from non-HCWs; no data exist specifically one the long-term effects of RSW on EPs. The Nurses' Health Study has been following a cohort of over 120,000 nurses since 1976. Nurses who work at least three night shifts per month in addition to either day or evening shifts were found to have higher rates of coronary artery disease. 139 After controlling for age, cigarette smoking, and 11 other risk factors, those

nurses who worked rotating night shifts for 1 to 2 years had 25% increased risk. Those who did so for 10 to 14 years had a 66% increased risk of coronary artery disease. Given the obvious similarities between EPs and nurses in terms of the character of the work and the type of rotating shifts, these finding are of great concern. Increased morbidity caused by coronary artery disease among men doing RSW in a paper mill has been reported, also showing increasing relative risk with prolonged night work (more than double the risk after 10 years, even correcting for smoking, age, and hypertension). 14° A British study found no significant difference in mortality rates for atherosclerotic heart disease among shift workers. 141 This study has been criticized on methodological grounds for not comparing shift workers with day workers; instead they compared both with national mortality data.

Whether impaired reproductive health is a consequence of night shift work has been studied. An excellent review of the investigations evaluating night work and prolonged time to pregnancy, irregular menses, spontaneous abortion, decreased birth weight, and preterm birth notes conflicting results of the reviewed studies. 142 Regarding waiting time to pregnancy and fecundity, three studies showed that night shift work reduced fecundity 134,143,144 whereas two showed that it did not. 145,146 Likewise, of the nine studies on the risk of spontaneous abortion among women with nonstandard work hours, seven found an increased risk. The quality of the studies varied greatly with some using questionnaries retro- spectively whereas others were prospective and more rigor- ous in their definitions; some adjusted for confounding variable while others did not. Based on the available data, there is reason for concern although the relationship between RSW and fertility has not yet been clearly determined.

General reviews of the health effects of shift work point to the association of with impaired sleep and interpersonal relations, higher accident rates, substance use (generally in the context of inducing sleep), and increased symptoms of gastrointestinal disease. 147,148,149,15°,151

Short-Term Effect of Night Shifts on EPs

In the last decade, research has begun on the short-term effect of night shifts on EPs. One study showed that on night shifts EPs took longer to intubate mannequins than they did during the day. 152,153 In addition, EPs surveyed felt that they are less clear thinking before, during, and after a night shift as compared with a day shift. No significant differences in electrocardiogram (ECG) reading or simulated triage exer- cises were found between night and day shift work. One study of 12 EPs measured ambulatory blood pressure and Holter monitor data before, during, and after a night shift. 154 Diastolic blood pressure (BP) increased during the shift. Although various asymptomatic dysrhythmias occurred, there was no correlation between such events and working the night shift. Heart rate variability is reported to be a measure sinus arrhythmia and specific patterns of variability are thought to correlate with the balance of sympathetic and parasympathetic tone. This study found a pattern consistent with increased parasympathetic tone when the shift was over. These parameters were not evaluated during a day shift, so it is possible that the cardiac changes found are those of working in the ED rather than working at night. The


finding of increased BP during the shift is consistent with data from a Spanish study that compared BP of residents during an ED shift with BP on a day out of the ED. Of note, in the Spanish study, the BP increases were more prominent in junior, as opposed to more senior, staff.155

Optimal Scheduling

It has been recommended that EPs be scheduled EPs with the principles of circadian rhythms in mind. These include clockwise rotation of shiftwork (days to evenings to nights); working each shift for 1-month blocks or working isolated night shifts; proper sleep hygiene; bright light use to help adjust to new shifts, and other suggestions. 156

Some of these recommendations were tested in a blinded crossover study. Clockwise rotation, no more than two night shifts in a row, and 48 hours off after a nightshift was compared with dietary interventions previously found to be ineffective. Although the study only had six subjects, rational scheduling had no impact on sleep, mood, performance on intubating a mannequin, and reading ECGs. 152 Melatonin has been tried by those doing RSW, a study of EPs found that taking melatonin after night shifts did not result in improved sleep quality, tiredness scores, or cogni- tive function. 157

The optimal shift length has been debated as well. A 1994 study found that although a majority of EPs prefers an 8-hour shift, only 11% of work such shifts exclusively. 158 Studies comparing 8- and 12-hour shifts among non-EPs show that alertness is relatively decreased at the begin- ning 159 and end 16° of the shift. Furthermore, the quality of nursing care has been reported to be decreased when nurses work 12-hour shifts. 161 Scheduling at a particular ED must take into account both annual census as well as preferences of the EPs. Two suggestions of merit are to pay a premium to individuals willing to work night shifts for extended peri- ods 156 and flexibility with shifts (shorter night shifts to minimize circadian disruptions; or 8-hour shifts on week- days and 12-hour shifts on weekends to minimize social disruptions). 158

BURNOUT AND EMERGENCY PHYSICIAN ATTRITION

Emotional exhaustion caused by work, associated with job dissatisfaction with has been called "burnout." Although no universally accepted definition exists, one that is often used is the triad of emotional exhaustion, depersonalization, and low sense of personal achievement. 162 Among workers in general, it has been found that about one-third expected to burn out in the near future, and that 14% had already quit or changed jobs in the past 2 years because of job stress. One-third considered their job to be the greatest source of stress in their lives. 163

Among EPs, various established psychological instru- ments that rely on self-reporting have been used to gauge the prevalence of burnout. One standardized measure, the Maslach Burnout Inventory (MBI) provides three scores, one for emotional exhaustion, one for depersonalization (the degree to which one has an unfeeling or impersonal response to patients), and one for sense of personal accomplishment. Two studies found that EPs show high degrees of burnout on all three measures with 46% to 93% scoring in the moderate

to high range of burnout. 164,165 One study found that although EPs did have high burnout scores for emotional exhaustion and depersonalization, they did report high levels of personal achievement. 166 Their scores on the MBI are higher than medical professionals in general and the general population. 167 Although a Canadian study 165 found that 46% to 93% EPs fell in the moderate to high burnout range on all three measures, 75.5% said they were satisfied with their jobs. This raises the question of what is actually being measured by the MBI scale if many apparently "burned out" EPs are satisfied with their jobs. A survey of American Board of Emergency Medicine (ABEM) diplomats found that of the 60% who replied, 25% reported feeling "burned out or impaired." 168 Contrasting these findings, The Longitu- dinal Study of Emergency Physicians (LSEP), a recent large randomized survey of EPs found that EPs had high scores on "work and career satisfaction" and that EPs find the current state of EM "exciting." 169 These scores are on unvalidated scales (ie, no comparisons have been made to other physicians or workers in general) so it is difficult to draw conclusions about how high these scores are actually. A study that compared practice satisfaction levels of internists and EPs found that although both groups were fairly satisfied, overall internists are more so. In individual sources of satisfaction, EPs were more satisfied with professional relations than internists, whereas internists were more satisfied in autonomy (this study predates the managed care era), patient relationships and status. 17°

There is reason to suspect that regarding burnout, three categories of EPs may exist: "survivors," those who are not coping, and those in between. The survivor concept has been suggested by the finding that some EPs score in the "low burnout" range despite individual variables such age over 50, more than seven night shifts per month, or more than 16 total shifts per month. 164 Those who are "not coping" have been identified by a survey of EPs which found that although the average scores for depression and stress were in the normal range, a disproportionately high percentage had very high levels of depression and stress. Likewise, although the average work satisfaction scores were high, a disproportionately high percent of EPs had very low degrees of work satisfaction. 172 Whether individual EPs vary along this continuum of coping over the course of their career has not been studied.

Intent to leave the practice of EM has been studied and is thought to be a consequence or at least a measure of burnout. A pioneering study from 1983 found that of recent graduates of emergency medicine (EM) residencies, 5% had already left the field and that in the long-term 11% were planning on leaving. 171 More recent studies show a range of projected attrition, with about 7 .5% 164 to 25% 168'172 of EPs intended to leave EM in 5 years and that 25% 164 to more than 57% 172

expect to leave the field in 10 years. The LSEP found that 11% of EPs were "likely" and 8% "very likely" to leave the field in 5 years. 169 As a comparison, the predicted attrition rate for physicians overall is about 2% to 3% per year. 173 The more recent studies suggesting high rates of attrition were based on asking EPs to predict the course of their career. Studies of two cohorts of EM residency graduates found that 84% 174 and 87% 175 continue to practice EM 10 years after graduation. The gap between the expected attrition of EPs


and the actual attrition rate suggests that EPs are continuing to practice despite their desire to leave the field.

Attempts have been made to determine the risk factors for burnout and EP attrition. Although it has been suggested that residency training in EM leads to a decreased risk of burnout, one study found that residency trained and "practice track" EPs had no significant difference in risk. 168 Data are conflicting whether age is a correlate of attrition or burnout with one study reporting that age is 172 and others reporting that it is not. 168.174

Factors associated with leaving EM include: lack of board certification in EM, being boarded in another specialty, being single, lower income, and an absence of contact with residents. 174 Of the those who left EM, their chief reasons for doing so were, in descending order of importance, shift work, emotional stress, family considerations, physical stress, patient conflicts, and workload pressureJ 74,]75 Rea- sons that were considered relatively unimportant were health reasons, staff conflict, low earnings, and government regula- tions. One study found that the primary sources of stress among EPs are patient load, overwork, emotional drain, and anger on the part of patients or their relatives. 176

OTHER

A study of emergency medical technicians (EMTs) and paramedics addressed the issue of defibrillator-related inju- riesJ 77 The study, which relied on a questionnaire, reported rates of defibrillation-related injury to be 1 per 1,000 shocks for EMTs and 1 per 1,700 shocks for paramedics. The investigators also reviewed reports of such injuries to the FDA. Combining the FDA and the EMT/paramedic data, there were no deaths, four individuals required hospitaliza- tion, and most of the injuries were mild burns. Equipment failure was the cause of injury in 3 of 21 cases; in the remainder, the injury was related to contact with patients or equipment during use or testing of the equipment. It is unknown how often such injuries occur in the ED, but because they use defibrillators, EPs have some risk of electrical injury.

Another risk that has been addressed is that which EM residents face when rotating through EMS services. Based on a survey of residency directors, one death (because of a helicopter crash) and several serious injuries (mainly because of ambulance crashes) have been reported.178

Hazardous material exposure presents another potential hazard. Patients may present to the ED with dangerous substances on their clothing or skin and if proper precautions are not taken, EPs can be put at risk. 179

CONCLUSIONS

Like coal miners, asbestos workers, and those who perform repetitive hand movements, EPs are exposed to a constellation of occupational hazards. A common theme of the above-mentioned findings is that many of these hazards can be prevented by simple measures (universal precautions, immunization). A second theme is that EPs often fail to take such precautions. A more difficult factor to measure is the degree to which the need to act in stressful situations promotes injury. The fact that needlestick injuries are more likely to occur in the ED than other areas of the hospital and

that two of the three HCWs who contracted HIV during resuscitation were stuck by coworkers suggest that by "losing our cool" we put ourselves and members of our team in danger. Likewise, we may inflame the violent patient if we are not calm. Some hazards are more refractory to correction: if the ED is to be open 24 hours a day, an EP must work counter to the normal diurnal rhythm. There is a dearth of data addressing the actual risk posed to EPs by most of the hazards reviewed here; EPs would benefit from further research to identify and minimize the risks they face on the job.

The authors would like to thanks Judy Curtis of the Medical Staff Library of Lake Forest Hospital for her invaluable research assis- tance.

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The occupational hazards of emergency physicians

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