Man or machine?
Ellison Pierce Lecture to underscore the human factor in anesthesiology.
SPE11 – Ellison C. Pierce Lecture: Integrating Behavior and Technology for Anesthesia Patient Safety
Saturday, October 14 | 3:45-4:45 p.m.
Smart cars. Smart alarms. With so much smart technology, we’re tempted to hand over the reins to a preprogrammed being and trust in the outcome. Not so fast, cautions John H. Eichhorn, MD, who will deliver this afternoon’s “Ellison C. Pierce Lecture: Integrating Behavior and Technology for Anesthesia Patient Safety.”
According to Dr. Eichhorn, retired Professor of Anesthesiology at the University of Kentucky College of Medicine in Lexington and the Founding Editor of the Anesthesia Patient Safety Foundation (APSF) newsletter, losing our grip on the human factor in decision-making can have serious consequences. In anesthesiology, he said, many believe that sensitive electronic monitoring has "solved" and "perfected" intraoperative anesthesia safety. And with that mindset comes complacency, relaxation of vigilance, and danger.
“It is precisely the fact that operative anesthesia is incredibly safe for patients that can for some (or possibly many) lead to relaxation or even complacency. Some of what anesthesia professionals do is inherently very dangerous – for example, administering potentially fatal doses of powerful medications and then ‘catching’ the patients as they ‘fall’ during induction,” Dr. Eichhorn said. “It’s routine, day in and day out. Yes, our sensitive electronic monitors will quickly detect an abnormal patient reaction or an overt practitioner mistake. But those situations are so rare now that anesthesia professionals who have not trained extensively in crisis management simulators may be slow to react and unsure of the best treatment.”
This, he said, is a prime example of the integration of behavior and technology: the technology gives an early alert of an untoward development, but that still must provoke appropriate practitioner reaction behavior.
Part of Dr. Eichhorn’s presentation will trace and analyze the evolution of intraoperative monitoring, from the original Harvard standards, to "smart alarms," and eventually artificial intelligence (AI). However, he noted that most currently practicing anesthesia professionals were not practicing as far back as the late 1980s when ASA instituted mandatory intraoperative “safety monitoring.” Fortunately, this shift was the main contributor to a dramatic reduction (to the point of almost elimination) of the “old” catastrophic injury accidents. However, that same group of anesthesia professionals have had little to no exposure to or even know of a catastrophic accident.
“In one sense, this is great – for anesthesia patient safety. In the other sense … [it’s not],” he said.
The evolution of intraoperative monitoring is a “series of serendipitous coincidences that actually started during my residency,” Dr. Eichhorn said, and led to his 1984 role as chairman of the Harvard Risk Management Committee. At that time, he said, anesthesiologists were 3% of the faculty but generated 12% of the malpractice claim payout from the Harvard captive insurance company. In the committee’s intense review of the anesthesia accidents occurring between 1976 and 1984, they discovered a pattern of failure to recognize dangerous developments during anesthesia care in a timely manner, which allowed them to prevent a downward spiral to catastrophic injury. The committee’s original 1985 Harvard standards identified and addressed the main issues, including physician behaviors and traditional monitoring, he said. It was not, Dr. Eichhorn underscored, capnography and oximetry, the advanced technology at the time.
“This is a central point that is little appreciated. The original ideas mandated behaviors, not technology as so many people think,” Dr. Eichhorn said. “ASA expanded the standards and implemented mandatory ASA monitoring in 1986. Yes, as the technologies evolved over the next few years, pulse oximetry, capnography, and temperature monitoring were made mandatory as part of the ASA standards, which have not been fundamentally altered since.”
AI has entered the scene
Today, of course, AI has not yet evolved to have a direct impact on intraoperative safety monitoring, Dr. Eichhorn said. However, researchers and manufacturers are working toward this end. And he believes the future is promising. For example, although it seems AI-powered robots will not be administering operative and procedural anesthetics in the foreseeable future, the potential implications are virtually limitless, he said.
“AI involves sophisticated pattern recognition and then searching and application of a truly vast database to aid and process the computer’s interpretation of the input data,” he said. “It seems logical that programs will be developed and implemented that will receive signals from all the intraoperative monitoring devices, including EEG, electromyography, and pulmonary flow-volume loops.”
Still, Dr. Eichhorn said sophisticated programming will be required to allow the AI computer to interpret individual data points and trends, generate a differential diagnosis when indicated, and suggest treatment options, including the automatic activation of crisis management protocols when necessary. Of course, implementation of AI output will still depend on the behavior of the anesthesia professional required to consider, accept, and execute the AI-generated suggested actions, he noted.
“Will there eventually be AI-driven servo-feedback anesthesia care delivery in which the computer itself adjusts gas flows, ventilation, and medication administration, both inhaled and I.V.?” Dr. Eichhorn asked. “Only time will tell, but even then, the behavior of setting up the system for each patient and then human monitoring of the computer’s function will be required."
That human touch
Don’t expect human factors to fade, Dr. Eichhorn said. In fact, they remain critically important. There are countless features and factors that an anesthesia professional must be aware of constantly while administering an anesthetic, he said. For example, before ECG was routine, the anesthesia professional would plug a precordial or esophageal stethoscope into their own ear while resting a hand on the patient. They were trained to “keep your eyes always moving,” Dr. Eichhorn said, “over the anesthetic area, surgical field, and even the entire OR.”
“Yes, sensitive electronic monitors can display changes and warn of problems, but the ASA motto of ‘vigilance’ strongly persists for a reason. Now cell phones, texting, social media, and web surfing can threaten that most critical of human factors,” he said.
Dr. Eichhorn said he hopes that anesthesia professionals can derive a renewed sense of responsibility for what they do, which, in thoughtful reflection, is “truly remarkable, even awe-inspiring.” Instead of just automatically checking or clicking the box on the anesthetic record showing “ASA monitors applied,” he encourages anesthesiologists to consider that the current technology of sensitive electronic monitors that greatly extend and intensify the human senses will provide early alert of untoward developments (think pulse oximeter audible tone versus looking over the drape to see the color of the blood in the surgical field). These great advances must not be taken for granted, he cautioned.
“I am humbled to have been able to help stimulate improvements in intraoperative anesthesia practice (permanently, everywhere) that dramatically reduced intraoperative anesthesia catastrophic accidents,” Dr. Eichhorn said. “I am always amazed at the role coincidence played in the start of that story, and I am reminded of Louis Pasteur’s belief that ‘Chance favors the prepared mind.’ I wish that for all my students and colleagues.”