READING IN THE OPERATING ROOM

1 Dec 20131 Nov 2018THE ANESTHESIA CONSULTANT 1 Comment

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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You’re an attending anesthesiologist. You enter another colleague’s operating room to give him a bathroom break during his 6-hour plastic surgery case, and you find him tapping on an iPad and reading in the operating room. What do you do?

Discussion: Is it OK for the anesthesiologist to be reading in the operating room? Is it OK for him to be referencing the Internet? Answering email? Sending text messages on his smartphone? Or should that anesthesiologist be staring transfixed at the monitor screen for hour after hour, maintaining flawless vigilance?

In the Anesthesia Patient Safety Foundation Newsletter Summer 1995 edition, Dr. Matthew Weinger discussed the issue of reading in the operating room. He emphasized that there were no scientific data on the impact of reading on anesthesia provider vigilance or task performance. He cited data that anesthesiologists are ‘idle’ during 40% of routine cases. He asserted that “anesthesia providers read during these idle periods to prevent boredom, and that boredom was a problem of information underload, insufficient work challenge, and under-stimulation…Adding tasks to a monotonous job may decrease boredom and dividing attention among several tasks (time-sharing) may, in some circumstances, actually improve monitoring performance.” Weinger concluded that, “in the absence of controlled studies on the effect of reading in the operating room on anesthesia vigilance and task performance, no definitive or generalizable recommendations can be made. The decision must remain a personal one based on recognition of one’s capabilities and limitations. From a broader perspective, the anesthesia task including associated equipment must be optimized to minimize boredom and yet not be so continuously busy as to be stressful.”

In the Anesthesia Patient Safety Foundation Newsletter, Fall 2004 edition, Dr. Terri Monk opined that reading in the OR seriously compromised patient safety. She was opposed to reading for the following reasons:

Reading diverts one’s attention from the patient.
The patient is paying for the anesthesiologist’s undivided attention, and most well-informed patients want to know if the anesthesiologist plans to turn over a portion of their anesthesia care to a nurse or resident. If we are obliged to honestly answer that concern, then, shouldn’t we also be obliged to inform the patient that we plan to read during a portion of the anesthetic?
Reading is medico-legally dangerous. Dr. Monk wrote, “Any plaintiff’s attorney would love to have a case in which the circulating nurse would testify, ‘Dr. Giesecke was reading when the cardiac arrest occurred. Yep, he was reading the Wall Street Journal. You know he has a lot of valuable stocks that he must keep track of.’ It is possible that if anesthesiologists informed their malpractice carriers that they routinely read during cases, the companies might raise premiums or cancel malpractice coverage.”
The practice of reading in the OR projects a negative public image. Nurses, technicians, and surgeons may think the anesthesiologist is less professional.

A 2009 study looked at 172 selected general anesthetic cases in an academic medical center. Vigilance was assessed by the response time to a randomly illuminated alarm light. Reading was observed in 35% of cases. In the 60 cases that involved reading, providers read during 25 +/- 3% of maintenance time but not during induction or emergence. Vigilance to the alarm light was no different between readers and non-readers.

Miller’s Anesthesia (7^th Edition, 2009, chapter 6) states, “Although it is indisputable that reading can distract attention from patient care, there are no data at present to determine the degree to which reading does distract attention, especially if the practice is confined to low-workload portions of a case. Furthermore, many anesthetists pointed out that reading as a distraction is not necessarily any different from many other kinds of activities not related to patient care that are routinely accepted, such as idle conversation among personnel.”

A 2012 study concluded there were no data concerning the effects of the use of laptops and smartphones in the operating theatre on anesthetist performance, and that these devices were now in frequent use. They discussed the use of laptops and smartphones in regards to the two pertinent issues of vigilance and multitasking. There were data that in some circumstances the addition of a secondary task (i.e. using a laptop or smartphone) during periods of low stimulation can improve vigilance and overall task performance, but the workload and the nature of the secondary task were critical. The authors made the following points regarding the nature of anesthesia work and the factors that affect performance in anesthesia:

Anesthesia involves multi-tasking and the maintenance of situational awareness. Studies have shown that attending to a range of tasks simultaneously is a key characteristic of anesthetic practice, and that anesthetists are superior to non-anesthetists in performing additional tasks while monitoring patients.
Anesthetists typically only glance at monitors. Covert observations of anesthetists in British Columbia revealed subjects spent less than 5% of their time observing the monitoring display. This was made up of brief glances (1.5 to 2 seconds duration) occurring 15 – 20 times during each 10-minute segment of time.
Anesthetic work is reduced during prolonged maintenance, potentially resulting in boredom and/or secondary activities being undertaken. The maintenance phase in some anesthetics (typically cases of longer duration, lower complexity and where the patient is stable) may be a time of low workload and infrequent task demands. In a study of 105 anesthesia clinicians, half reported being bored infrequently, but 90% admitted to occasional episodes of extreme boredom. Boredom can result in severely decreased vigilance if the anesthetist is suffering from sleep deprivation.
The authors concluded there was no evidence to support a blanket prohibition on the use of smartphones and laptops in the operating theatre, and there was good reason to avoid edicts that are not supported by solid evidence. They stated, “There is no doubt that reading or computer usage gives the appearance of being less attentive, even if there are no measurable effects on routine care…Computer and phone tasks that also require immediate responses appear to provide a greater risk than reading (whether from a book or screen). While boredom may be cognitively unpleasant, there is no evidence of anesthetist boredom (in the absence of sleep) harming patients.”

I recently attended the American Society of Anesthesiologists national convention in San Francisco. At the conclusion of the meeting, the ASA emailed me a full text edition of the Refresher Course lectures as an email attachment, in a format designed to be downloaded onto a computer. Like myself, more than 10,000 anesthesiologist attendees of the ASA meeting will now have access to the Refresher Course curriculum on their laptops or iPads. Will some of them read these Refresher Courses during the stable maintenance phases of anesthetics in their operating rooms? Perhaps.

Returning to the Clinical Case for Discussion above, what will you do about your colleague you discovered using his iPad in the operating room? My guess is, based on what has been published in the anesthesia literature, you’ll give him the bathroom break as intended, and say nothing about his use of the iPad in the operating room.

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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

IS ANESTHESIA 99% BOREDOM AND 1% PANIC?

15 Jul 20122 Sep 2020THE ANESTHESIA CONSULTANT 8 Comments

Author
Recent Posts

THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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When you have surgery, do you care who administers your anesthetic? You should. An oft-repeated medical adage states:“anesthesia is 99% boredom and 1% panic.

36164768-a-depiction-of-the-pearly-gates-of-heaven-open-with-the-bright-side-of-heaven-contrasting-with-the-d

GOALIES AT THE PEARLY GATES

As an anesthesiologist who’s delivered over 50,000 hours of operating room care over 25 years, I can attest that the adage is true. Ninety-nine percent of the time, the anesthesia provider’s job requires vigilance during a patient’s stable progression of metronome heartbeats and regular breathing, but 1% of the time requires clear thinking and prompt action during moments of sheer panic. These stress-filled episodes of panic are unknown to the general public, yet represent ordeals that every anesthesia provider must rise above to protect their patients.

Webster’s Dictionary defines panic as “ an overwhelming feeling of fear and anxiety.” If you were to observe an anesthesiologist at work, you would see little or no evidence of overwhelming fear or anxiety. Even under dire emergencies, most anesthesia providers remain outwardly composed and efficient while they make the necessary diagnoses and apply the appropriate treatments. But anesthesiologists are human–no human can watch another human trying to die without feeling intense emotions. These emotions are fear and anxiety.

No field of medicine provides the stunning variety of anesthesia. Patients vary from neonates to centenarians, from laboring women to motor vehicle accident victims at three a.m., while surgeries vary from repair of a broken finger to the transplantation of a heart or a liver. Technologic advances have led surgeons to operate on older and sicker patients, and to attempt more complex surgeries than decades ago.

The operating room is an intense environment. Operating room medicine is pressure-packed for four reasons:

Anesthetic drugs change the physiology of patients in profound ways.
Surgeons do dangerous things to patients.
Surgical patients have diseases. Some of these diseases are urgent or severe.
Human beings make errors. This includes both surgeons and anesthesia providers.

Unbelievable events occur at unexpected times in operating rooms, and your anesthesia provider must keep you safe. He or she is in control of your airway, breathing, and circulation at every moment. Your anesthesia provider is your insurance policy against medical complications during surgery. Your anesthesia provider’s job is to play Goalie at the Pearly Gates, and keep you alive.

The individual administering your anesthesia can vary–your anesthesia provider may be:

a medical doctor (an anesthesiologist),
a certified registered nurse anesthetist (CRNA) or anesthesia assistant (AA) supervised by an anesthesiologist, or
a CRNA working without anesthesiologist supervision.

In the United States, anesthesiologists personally administer 35% of the anesthetics. Anesthesia care teams, in which an anesthesiologist medically directs a team of AA’s or CRNA’s, administer 55% of the anesthetics. CRNA’s, working unsupervised, administer 10% of the anesthetics.

There are people who perceive anesthesia care to be so safe that it can be taken for granted. They are wrong. Anesthesia care is safest when a physician, a board-certified anesthesiologist, directs the anesthetic care. Published data shows that:

Mortality rates after surgery are significantly lower when anesthesiologists direct anesthesia care.
Failure-to-rescue rates (the rate of death after a complication) are significantly lower when anesthesiologists direct anesthesia care.
Death rates and failure-to-rescue rates are significantly lower when board-certified anesthesiologists supervise anesthesia care, compared to when mid-career anesthesiologists who are not board-certified supervise anesthesia care.

“Failure-to-rescue” implies that the anesthesia provider wasn’t successful in preventing a 1% panic moment from turning into a death statistic. The phrase “failure-to-rescue” is a key theme of this book. Or more precisely, the phrase “successful rescue” is a key theme of this book. When unexpected events occur during surgery–the 1% panic moments–your anesthesia provider needs to make the correct diagnosis and apply the correct therapeutic intervention to successfully rescue you.

When you meet your anesthesia provider prior to surgery, you’re about to trust your life to a stranger. It matters who that stranger is. As a patient, do you have any control over who your anesthesia provider will be? If your surgery is an emergency at 2 a.m. when only one anesthesia provider is available, you will not. But for most surgeries, and all elective surgeries, this book will teach you what to expect in anesthesia care, and what you can do to receive the best in anesthesia care.

Anesthesiologists must finish a minimum of 12 years of post-high school education–four years of college, four years of medical school, and four years of anesthesia internship and residency. Nurse anesthetists must finish a minimum of 7 or 8 years of post-high school education –four years of college, a minimum of one year of critical care nursing experience, and two to three years of anesthetist training. Anesthesia assistants must finish a minimum of 6 years of post-high school education–four years of college, and a 24-month program to obtain a Master’s degree as an anesthesia assistant.

Why would an individual choose to become an anesthesia provider? It’s rare for teenagers or college students to dream of themselves as anesthetists. Most popular television, movies, and fiction portray physicians in more conventional careers as surgeons, emergency room doctors, or in clinics. Only 4% of medical school graduates choose anesthesiology.

I believe that individuals who choose anesthesia for their medical career are individuals who love the adrenaline rush of acute medical care. Operating room anesthesia is a 180-degree turn from outpatient clinics, where practitioners take histories, order lab tests, write prescriptions for pills, and make appointments to see their patient weeks into the future. Instead of experiencing clinic visits over months or years, the anesthetic encounter is immediate care with immediate results. Instead of a clinic patient returning weeks later for a recheck, the anesthetic patient wakes up from their anesthetic, and is discharged to their home or their hospital bed within hours.

I had already completed a three-year residency in internal medicine before I began my years of anesthesia training. The diagnosis and treatment of complex medical patients appealed to me during internal medicine training, but I found the glacial pace of outpatient clinic care boring. When I worked along side anesthesiologists in the intensive care unit, I was wooed by their skills in placing breathing tubes, intravenous and intra-arterial catheters, and their apparent calmness no matter how ill any patient was. The world of acute care medicine is the world of airway, breathing, and circulation. No specialty mastered all three as completely as anesthesiologists did.

The beginning of specialty training in anesthesia brings both intimidating power and overwhelming challenge. For the first time in your life, your profession is to inject powerful medications into patients and watch them lose consciousness in seconds. Administering your first anesthetic is an unforgettable experience. One minute you are chatting with a patient, telling them to picture themselves relaxing on a beach in Hawaii, and the next minute you’ve rendered them unconscious and totally dependent on you to manage their airway, breathing, and circulation.

Moving from novice anesthesiologist trainee to experienced specialist requires hard work and patience. On the first day of my anesthesia residency, I was so green I didn’t even know which hoses connected my anesthesia gas machine to the patient. While learning the anesthesia profession, trainees must learn to endure the 99% boredom factor and glean their most valuable lessons during the 1% panic time. During my first week of training, after my patient was asleep with the breathing tube inserted and the anesthesia gases flowing, my faculty member, Dr. Gregory Ingham, said to me, “This procedure will take four hours.” He stood next to me for a minute or two in silence, then he said, “I hope you’re of a contemplative nature.”

Why would he say such a thing to a first-week trainee? I believe he said it because much of operating room anesthesia care is tedious vigilance over a stable situation. The anesthetist needs to cope with this fact, and hopefully even appreciate and enjoy the stability.

One week after my first exposure to Dr. Ingham, I was on call overnight in the hospital with him again. We had four consecutive emergency cases, all young healthy men with injuries suffered in motor vehicle or motorcycle accidents. Prior to the fourth case, at 2 a.m., I evaluated the patient and proposed my anesthetic plan. “Our patient is a healthy 25-year-old male except for his open femur fracture,” I said. “I thought we could do the anesthetic the same way we did the last three.”

Dr. Ingham nodded at me and sighed, “Richard, the patients are all different, but the anesthetics are all the same.”

Is this true? Why would he make a statement like this to an impressionable young trainee? There is a great deal of cynicism and battle fatigue in his comment, but a grain of truth. Patients are all different, and many anesthetics are similar, but not every anesthetic is identical. There are always choices for the anesthetist to make–crucial, life threatening decisions–every day, and on every case. Decisions are made before the surgery, during the stable phases of the anesthetic, and during the 1% of moments when the anesthetist’s mind is reeling.

Patients see none of this. Patients typically have ten minutes or less to meet their anesthesia provider. In the internal medicine clinic, patients are awake for 100% of their face-to-face time with their doctor, but before a surgery the anesthesiologist has only a brief encounter to gain their patient’s trust. In the internal medicine clinic, a large number of patients had chronic complaints that were difficult to cure: chronic pains, high blood pressure, obesity, or diabetes. The treatments usually involved a prescription for pills. At the next office visit, the patient might feel better, but there was a significant chance that the patient would feel the same or feel no better, or perhaps they would have a new side-effect symptom from the pill you prescribed for them.

The anesthetic patient encounter is markedly different. Prior to the surgery, most patients are anxious but they treat their anesthesiologist with soaring respect. After the surgery, I find my patients are often gushing in their gratitude for the fact that I had delivered them safely back to consciousness. In contrast to my sometimes-disappointed medicine clinic patients, the anesthetic patients are so upbeat that they make me feel wonderful.

When I describe the elation of interacting with anesthesia patients, my best friend offers a simple explanation: “Of course your patients respect you before the surgery. You’re about to knock them unconscious. They’ll have no control and they’re completely dependent on you. They want you to like them. They want you to keep them alive.”

I believe that assessment is accurate. Every patient wants the same thing from their anesthesia provider. A successful, complication-free experience. And that’s what happens . . . almost every time.