The Distracted Anesthesiologist
When is it acceptable for anesthesiologists, or nurse anesthetists or anesthesiologist assistants, to use their smart phones in the OR?
It is obviously not acceptable when the patient requires the anesthesiologist’s attention and the distraction is gratuitous. A Dallas, TX jury will consider, in a malpractice trial due to start in September 2014, whether the anesthesiologist’s checking email, exchanging texts, looking up scheduling and accessing the Internet may have contributed to a patient’s death. The 61-year-old patient died 10 hours after undergoing an AV node ablation at Medical City Dallas, according to the Dallas Observer. The surgeon (and co-defendant) testified in his deposition that the anesthesiologist was distracted during the case and didn't notice the patient's low blood-oxygen levels until 15 or 20 minutes after she had turned blue.
If the trial results in a verdict for the patient’s family, the anesthesiologist’s own deposition testimony about posting to Facebook will have helped to hang him. After stating that putting information about patients on his personal Facebook page would be improper, the anesthesiologist was forced to acknowledge as his own the following Facebook post: "After enduring the shittiest Friday I've had in a while, I just found out my next patient has lice. Freakin lice. I didn't even know they still made those. Help."
More critical to the issue of distraction is the admission that the anesthesiologist had in fact updated his Facebook page while providing anesthesia on at least one occasion. In the exchange below, reproduced from the Dallas Observer article, “W” is the plaintiff’s attorney and “S” is the defendant.
W: Can you read the highlighted portion?
S: Okay. "Just sitting here -- sitting here watching the tube on Christmas morning. Ho, ho, ho."
W: And what is the photograph of?
S: An anesthesia monitor.
W: Is that anesthesia monitor hooked up to a patient?
S: Yes.
W: Are -- is the data on the anesthesia monitor that of a patient?
S: Is the data -- like the vital signs? The vital signs are, but there's no identification of the patient.
W: And I think you told me earlier in your deposition that it would be inappropriate to post anything about a patient on your Facebook.
S: Well, specifically, but these are just numbers and there's no way to really identify it with a particular patient.
W: So do you think it is appropriate to post the anesthesia monitor with patient data on it on your Facebook?
S: Well, there's no specific patient data. It’s just numbers.
W: So I'm -- so you don't have a problem with it; you think it's okay?
S: No. It's okay.
W: Now, I think you told me earlier that you never post on Facebook while you're doing anesthesia -- while you're managing anesthesia.
S: Not to my recollection.
W: Well, clearly you do post on Facebook sometimes when you're managing anesthesia because you were managing anesthesia at that moment.
S: Well, not necessarily because I took the picture but that doesn't mean I posted it at that time, because you can take a picture and then go to your pictures and then upload it onto Facebook after --
W: Okay. So --
S: -- wards.
W: -- where it says "just sitting here watching the tube on Christmas morning," you are clearly referring to the fact that you have to be doing an anes -- managing an anesthetic procedure on Christmas morning and you're watching the anesthetic monitor, fair?
S: Uh-huh.
W: So obviously --
S: Yes.
We can probably all agree that posting to one’s personal Facebook page during an anesthetic is purely a distraction for which is there is no good excuse. Other uses of information technology are less clear, however.
Some practices have long-standing policies in place that prohibit the use of all personal electronic devices (including smartphones, tablets and laptops) in the OR, except for checking medication information online or “for any reason unrelated to the care of that patient,” if not altogether. “Medical centers throughout the country have started to develop guidelines and recommendations on the use of electronic devices and professional behavior. Hospitals, medical schools and clinical departments have addressed the issue thorough grand rounds and staff education. It is being addressed in operating rooms throughout the United States through the recommendations of AORN [Association of Operating Room Nurses],” wrote Peter Papadakos, MD in Digital Distraction: Signs of Improvement, But More Focus Needed in the January 2014 issue of Anesthesiology News. As Dr. Papadakos noted earlier, “A study presented at the 2011 annual meeting of the American Society of Anesthesiologists found that nurse anesthetists and residents were distracted by something other than patient care in 54% of cases—even when they knew they were being watched! Most of what took their time were pleasure cruises on the Internet (abstract 1726).” (Electronic Distraction: An Unmeasured Variable in Modern Medicine, Anesthesiology News, November 2011.)
The challenge is to distinguish between using technology in such a way as to benefit the anesthesia patient and using it for personal diversion. The Dallas anesthesiologist indicated his familiarity with the basic distinction when he testified that occasionally he looked up medical information about the patient’s medications or the procedure on the Internet.
In between the two poles of tasks that benefit the patient on the OR table, on the one hand, and surfing the Internet, on the other, are phone calls and electronic communications related to the care of other patients or to the management of the OR. Some anesthesiologists ask whether checking the Internet or one’s email is really more of a distraction than interacting with an anesthesia information management system (AIMS) or electronic health record (EHR), or engaging in conversations with the surgeon or other members of the OR team. One thoughtful resident pointed out that “the use of mobile devices and smart phones can greatly aid in patient care and education of health care workers and also contribute to increased patient safety. The same devices that are used for education and patient safety are also used to view media that may distract people from their work. While it is the personal responsibility and duty of every physician and nurse to avoid such distractions, this unfortunately is not always the case, and it then becomes the responsibility of the institution to prevent access to certain media.” (DiMiceli M. Resident Review: Digital Diversion: A New Form of Addiction… or Symptom of What’s Ailing Today’s Health Care System. ASA Newsl. 2012:76(3).)
In Case 2012-11: For Want of a Light Bulb an Airplane Was Lost from the Anesthesia Incident Reporting System, the AQI-AIRS Steering Committee noted that “13 of 632 (2.06 percent) of the cases in AIRS are related to problems with AIMS, and seven (1.11 percent) led to intraoperative distraction from patient care.” The report calls for further study of the effect of AIMS-specific distractions on anesthesia safety. It also notes that:
An AIMS requires a computer to run, and it should have access to at least the hospital-wide network so that patient data can be imported to the system. Most also allow at least limited access to the Internet, e-mail or other Web-based sites. This, of course, opens up an assortment of potential distractions. Cell phones, PDAs, tablets and other electronic devices further expand this problem. No data exist of the impact of these distractions on the performance of anesthesia, but extrapolation from data on operating a vehicle is sobering. Texting while driving lengthens stopping distance nearly 20 times more than does being drunk.
The general problem is far from new: John W. Pender, MD published an editorial in the March/April 1962 issue of Anesthesiology entitled “Unjustified Distraction” in which he stated:
Unfortunately, anesthesiologists often deliberately divorce themselves from close patient observation. Some seem to think it permissable [sic] to read while an anesthetized patient is entrusted to their care. Others engage in prolonged conversation irrelevant to the patient.
. . . .
Obviously, it is not possible to set hard and fast rules concerning permissible and nonpermissible distractions. As each situation arises, the anesthesiologist must consider it in the light of the existing problems. He must constantly guard himself against unnecessary diversion of attention.
How should one decide, then, whether a specific instance of electronic communication in the OR is consistent with anesthesia safety?
Michael Hicks, MD, MBA laid down a relatively workable principle in comments he posted to the online discussion of the Dallas case on the MGMA-Anesthesia Administration Assembly listserv on April 4th (that we reproduce with Dr. Hicks’s permission):
[F]or those who believe that they can provide excellent care for patients while engaging in non-patient care activities like those described I suggest disclosing this to patients and families beforehand as part of the consent process. Let patients and their families know that the iPad/newspaper/magazine/email is going to be active during the case and see how many of them sign up for care.
. . . .
Probably the better question is to ask ourselves what behavior would transpire if the families were allowed to watch the actual surgical care of their loved ones in real time. If our answer is anything other than it would remain unchanged then we really need to question whether it is acceptable now when they can't see it. After all, as the saying goes it’s what you do when you think no one is watching.....
A variant on Dr. Hicks’s “sunshine” principle would be to use electronic technologies only in such ways as the anesthesiologist would want them used if the patient were his or her own family member. We suspect that in the next several years, as more and more forms of digital diversion appear in the OR, a consensus opinion will emerge. Ideally, no more patients will be harmed in the process.