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Anesthesia is a hands-on specialty. We use our manual skills daily to place breathing tubes, insert intravenous and intra-arterial catheters, and place needles for spinal punctures, epidural catheters, and regional nerve blocks. The Merriam-Webster dictionary defines the internet as “an electronic communications network that connects computer networks and organizational computer facilities around the world.” This definition seems to have has very little to do with inserting breathing tubes, catheters, or needles, yet the internet changed anesthesiology forever.
The internet is the biggest change in anesthesiology since the FDA approvals of propofol in 1989, the laryngeal mask airway in 1991, and sevoflurane in 2002.
Picture this: your job requires you to spend the majority of your day in a windowless room with four other people. You cannot leave the room, and if you make a serious error in your work, someone can die. There is a telephone on the wall. You’re allowed to bring along a briefcase or a backpack.
This was the description of the anesthesiology workplace prior to the internet. Vigilance regarding a sleeping patient’s vital signs was always paramount, but the constant effort to be vigilant could be mind-numbing. No one can stare at an ECG/oximeter/blood pressure monitor for hours without interruption. Anesthesiologists could chat with the surgeons and/or nurses, make an occasional phone call, and at times read materials they brought with them into the operating room. Major adverse events seldom occur during the middle of a general anesthetic of long duration on a healthy patient. A comparison would be a commercial pilot flying an airplane from San Francisco to New York. The flight lasts 5 hours, but there would likely be only minor adjustments in course or altitude during the middle 4 hours. Anesthesia is said to be “99% boredom and 15 panic,” because 99% of the time patients are stable, yet 1% of the time, especially at the beginning and the end of anesthetics, urgent or emergency circumstances could threaten the life of the patient.
Since the development of the internet, anesthesia practice has changed forever. Every hospital operating room is equipped with a computer connected to the internet. Every anesthesia provider carries a smartphone connected to the internet. Many anesthesia providers carry a laptop or a tablet in their briefcases. These devices enable an anesthesiologist to remain connected to the outside world during surgery. Let’s look at the specific ways the internet has changed anesthesia practice:
- Electronic medical records (EMRs). Love it or hate it, the EMR is here to stay. The EMR requires a computer terminal and screen in every operating room, and every hospital operating room must be connected to the internet. A patient’s EMR combines information from previous clinic visits, emergency room visits, laboratory and test results, and all data from the preoperative, intraoperative, and postoperative course on the day of surgery. Anesthesiologists type information into the EMR multiple times during each case.
- Immediate access to medical search engines. A major advantage of internet connectivity is the ability to immediately research any medical question or problem. Abstracts of every published medical study are available on Pubmed. For those of us on the faculty of a university hospital, hundreds of medical textbooks are immediately available online as reference sources. The entire catalog of FDA-approved drugs is listed on the PDR (Physician’s Desk Reference) website, or on the PDR app on our smartphones. These are all invaluable tools which empower a physician anesthesiologist and improve care to every patient.
- Connectivity to other anesthesia providers is a third important advantage of the internet. We’re now able to immediately contact a colleague by cell phone, text message, or email if we have a question or a problem. In anesthesia care team models, in which a Certified Nurse Anesthetist (CRNA) is physically present in the operating room while being supervised by an attending physician anesthesiologist, the MD anesthesiologist can be summoned to return to the operating room in seconds if a problem arises. You can also imagine a future vision of telemedicine in which an experienced physician anesthesiologist, who lives many miles or time zones away, can supervise a CRNA or an inexperienced anesthesiologist performing in-person patient care via Zoom conferencing.
- Other uses of the internet by anesthesiologists in the operating room. In 2012 the journal Anesthesiology published a study examining use of computer workstations in the anesthesia workspace for non-record-keeping applications. This study examined 1,061 anesthetics performed by 171 anesthesia providers. The median duration of non-record-keeping computer activity time was 14 minutes, which represented 16% of the anesthesiologist’s operating room time. Variables associated with a higher rate of anesthesiologist non-record-keeping computer activity included: a) an attending anesthesiologist working unassisted, b) a longer duration anesthetic, c) a lower American Society of Anesthesiologists status (i.e. healthier patients), and d) general anesthesia (as opposed to cases in which patients were awake). Of note, there was no correlation between non-record-keeping workstation computer use and patient instability or increased complications. The conclusions of the study were: “anesthesia providers spent sizable portions of case time performing non–record-keeping applications on AIMS (anesthesia information management) workstations. This use, however, was not independently associated with greater hemodynamic variability or aberrancies in patients during maintenance of general anesthesia for predominantly general surgical and gynecologic procedures.” An accompanying editorial in Anesthesiology stated: “Protracted periods with vigilance tasks, as during maintenance of anesthesia in a routine case, can . . . harm performance. . . . Driving on monotonous roads also impairs vigilance.” The editorial also stated: “anesthesia work does not involve continuous attention to physiological monitors and surgical conditions. Anesthesiologists glance at monitors briefly and intermittently, spending less than 5% of time looking at the monitor display. Only 25% of intraoperative time is spent on monitoring the patient, with the bulk of time devoted to secondary activities.Of concern, however, are distractions that might impair vigilance and affect patient safety. Distractions are common during anesthesia maintenance. Slagle and Weinger observed reading of printed material in 35% of cases, occurring during maintenance of anesthesia when workload was low. Anesthesia providers spent less time talking, carrying out manual tasks and record-keeping during reading periods. Reading did not affect vigilance, as measured by response time to a simulated red alarm light. Other types of distractions during clinical care are numerous and include noise, interruptions, phone calls, pages, conversations, and computers. Trainees may be more distracted by the additional tasks than more experienced anesthesiologists are.” The editorial concluded with the statement that, “Until additional data are available, we suggest that intraoperative internet use be restricted to acquiring medical information pertinent to the current patient’s care.”
A 2010 publication in the journal Anaesthesia and Intensive Care stated, “Experienced anesthetists are skilled at multi-tasking while maintaining situational awareness, but there are limits. Noise, interruptions and emotional arousal are detrimental to the cognitive performance of anesthetists. While limited reading during periods of low task load may not reduce vigilance, computer use introduces text-based activities that are more interactive and potentially more distracting.”
From what I observe of anesthesia practice in the year 2021, intermittent use of the internet during anesthesia duty is not uncommon. The windowless confines of the operating room are now connected to the world.
Further scholarly research regarding computers, tablets, cell phones, and internet use in the operating room will no doubt be forthcoming. Stay tuned.
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