A few years ago, I went to a car dealer to buy a new hybrid electric car. I didn’t know how to start it. I was a bit disoriented and a tad embarrassed. I’m not sure I would have figured it out if the salesman hadn’t told me (I’m an engineer so I’d like to think I could). It didn’t take much—there’s no key and thus no place to insert one. Perhaps if someone gave me the fob and said, “Here’s the key, there’s no hole to put it in, take it for a spin,” I might have instinctively put my foot on the brake and pushed the button marked “POWER.” If you don’t put your foot on the brake, it will only turn on the auxiliary power; it won’t power up the engine or engage the battery driven motor. Once I was shown how to start it, I still wasn’t sure how to drive it away; the gearshift is more like a joystick. I got the gist of it but didn’t know what the “B” symbol meant (engine braking to be used to downshift to maintain a safe speed on a steep downhill). When it came to learning some of the cool features, like the hands-free, voice-activated phone that connects via Bluetooth to my cell phone, once again I needed instruction. This is an important safety feature. I could have driven the car without it but, had I not enabled this system, I wouldn’t have been able to use my cell phone as safely.
This situation is similar to the current world of anesthesia technology. In the old days, if you were an anesthesia professional with the usual training, you could just walk up to a new anesthesia machine, monitor, or just about any device and figure out how to use it in its basic mode. You might even figure out some special features. A few decades ago, it was pretty easy to understand how it all worked, at least I thought so given my engineering background. Yet, when trying to teach residents about the basic concepts of how an anesthesia machine works, I was always surprised that it was impenetrable for many. I can only imagine how difficult it is for most providers to use, not to mention, understand the inner workings of new complex machines by themselves. How much can we possibly expect people, few of whom have backgrounds in physics or engineering, to understand how a BIS monitor arrives at the displayed value, how algorithms that generate non-invasive blood pressure measurements interpret the signals and decide what numbers to display, or what hazards lurk when using some new airway device? The answer is “not much.” Yet, many anesthesia professionals still expect to be able to do that. I’d call that hubris. It’s dangerous. How can we make it safer?
Anesthesia is one of the most technology-dependent specialties. The modern anesthesia professional must have at least basic competence to use at least twice as many devices as a decade ago; devices which are far more complex. We are similarly challenged with “techno-overload” in our everyday life, where we have choices regarding which technologies we choose to buy and use, unlike the clinical arena. But these new devices are not the only additional elements of modern anesthesia. There are also a vastly increased number of drugs, procedures, regulations, patient-centered care requirements and production pressure, and a demand to know much more about the system within which they all must inter-operate. This situation creates more ways in which failures can occur. In the language of human factors, these are each “latent conditions” or “latent failures,” lurking to trigger, enable, exacerbate, or obscure the evolution of an adverse event. You, the anesthesia professional, must not be complacent about this additional risk under which you are operating. To do so is to tempt fate. While there is no magic cure, surely the more you know about the technology the more you can help either prevent an event from evolving or improve your chances of stopping it once it has started on a path of potential destruction.
The opening paragraph might lead you to ask, “Do you need to know how a car works in order to drive it?” The answer is no. Almost anyone with normal intelligence and basic physical abilities can learn to drive a car, even quite competently, without having a clue about what goes on inside. But, how much do you need to know to drive it safely, or at least how much do you have to learn about the features and hazards to stay out of trouble or to get out of trouble? Take the key fob for instance. What if it malfunctions? Would you know how to get into the car and start it? If you weren’t shown what to do or don’t read the manual, I doubt that 20% of people could get into the car, and only 1% could start it (check online to find out the trick). What about the navigation system? If you haven’t used one a lot, you might not figure it out so quickly or perhaps not at all. If you are lost and in a hurry to get someplace, it might not be of much use. Perhaps more important, while not recommended, it’s easy to be lured into trying to program it while you are stopped at a light. You can easily get distracted and lose situational awareness. A few years ago there was a widely publicized report of airline pilots becoming distracted with a computer program for over an hour, missing the airport entirely, proof that it can happen even to well-trained professionals. If you’re in a rainstorm, lost at night, or otherwise at higher risk, the risk of a distraction-induced accident increases. Sure, you are not supposed to try to use this feature unless you are stopped on the side of the road, but in a pinch, you’ll be tempted to try.
For all of these situations, there are analogies to the challenges and hazards of modern anesthesia technologies. Anesthesia machines are now essentially computers, as are most devices used in the operating room. They have so many features, just like any kind of software, that you’d have to be very committed to learning how to use all of them. Trying to do that in the midst of a problem isn’t wise. Opportunities for distraction now abound, exacerbated perhaps by electronic record keeping. AIMs may be a great tool for many reasons, but don’t try to learn how to use it for the first time during a real procedure. And don’t get stuck exploring its features when a challenging moment arises. What makes the situation worse in anesthesia is that, typically, the human factors design of anesthesia equipment is much less user friendly than that of a car. That just makes it easier to get trapped into not knowing how to use some feature when you need it or trying to use a device incorrectly.
So, what is the minimum you need to know about anesthesia technology to use it effectively and safely? Every health care provider should take responsibility to learn how to use a device and practice using its features before they first use it on a patient. That may sound obvious. But, there are few, if any requirements for it, and there isn’t always time set aside in busy practices to really get to know a device before you first use it. That’s a situation that needs to change and soon.
This idea was the underlying theme of the recent APSF workshop and the report that has followed (see page 49 and following). Should there be requirements to require training and/or demonstrate competence on anesthesia devices? It’s required in almost all disciplines that impact on public safety, e.g., aviation, nuclear power, chemical production, and even many trades. Why not in anesthesia? Why is it acceptable for any clinician to decide for himself or herself that they know enough to use a device without training or, even if they get some training, that they are competent to use it? The Anesthesia Patient Safety Foundation took a position on this in 2009. Here’s what we said:
“Although existing literature does not describe frequent adverse anesthesia events owing to the anesthesia professional’s lack of understanding of equipment, the APSF believes the logic is compelling to require confirmation of competency before using unfamiliar and/or complex anesthesia equipment that can directly affect patient safety. In this regard, the APSF believes that each facility should develop a required, formal process to assure that anesthesia professionals have received appropriate training and/or demonstrated competence in the use of such medical devices. Manufacturers should refine and initially offer this training. This required process for administering training and/or for demonstrating competence should be efficient, timely, and pertinent in addressing new critical features and relevant failure modes. The most effective manner to successfully accomplish this training and testing is not known and requires deliberate investigation.” (https://dev2.apsf.org/newsletters/html/2008/winter/03_formal_training.htm)
Until there are such requirements, you, the individual provider, can adopt the spirit of this statement. Above all, know your limits. When my wife drove our car for the first time, I tried to show her how to use the “B” control on the joystick. At the time, we were going down a steep hill. She knew she couldn’t do that without looking down for the joystick and its markings and said, “I can’t do that now.” That was the right move (she’s wiser than I am). The engine braking is nice and saves fuel, but is not necessary for safe operation. My wife knew she wasn’t comfortable with the joystick; its use is not obvious and requires that one look down to find it. That’s not the thing to be doing while you are driving, especially on a winding hill. Fortunately, she had better sense than I did. I hope you do, too. Don’t try to figure out new features during patient care. Find a better time before you need the feature.
How much do you need to understand about how a measurement is made to use it safely and effectively? I suspect more than most people generally know. I doubt that most anesthesia providers today really understand how a non-invasive blood pressure monitor determines the blood pressure it displays. More importantly, many likely don’t know all (or even most) of the ways that measurement can be fooled as a result of the way it is made. There are lots of ways that can happen. Depth of anesthesia is another example as is the more common measurement, pulse oximetry. With both, there are plenty of ways to get fooled and do the wrong thing based on misleading information. In typical use, this isn’t a problem. In the unusual patient or unusual circumstance, it can be. Having at least some basic understanding of the basis for the number you are using to guide care can be life saving.
Where are you going to get the training you need? There are several good textbooks to help, but that’s just a start and not likely to help most of you since most adults learn experientially. There are various ways to get training, but not nearly enough. I hope that one result of the APSF workshop on technology education will be to motivate more training programs to improve technology training, especially on-line and via simulation. Practice and experience are great teachers.
I bought the car. I adapted to it quickly. I’ve learned almost all the cool features. The real test will come when it doesn’t start or breaks down somewhere. Will I have a chance of getting it going without calling a service truck? And, when you confront a new situation with your latest anesthesia technology, how well prepared will you be to cope? Improve your chances. Read a book. Take a workshop. Ask your colleagues. Please don’t fail to act.
Jeffrey B. Cooper, PhD is Executive Vice President, APSF, Professor of Anaesthesia, Harvard Medical School and Executive Director of the Center for Medical Simulation, Boston, MA. .