Residents In a Room
Episode Number: 36
Episode Title: Past to Present – Technological Changes
Recorded: January 2022
(SOUNDBITE OF MUSIC)
VOICE OVER:
This is Residents in a Room, an official podcast of the American Society
of Anesthesiologists, where we go behind the scenes to explore the world from
the point of view of anesthesiology residents.
If we combine all these
advancements, the culmination of these advancements is the contemporary
anesthesia machine.
As we get more
advanced technology, we're trying to get better with safety as well.
If we were to have
these systems in place, I'm pretty sure most of us would feel rather
uncomfortable.
I'm like, Oh, this is like the beginning of the end.
I'm not afraid of
robots taking our jobs for a couple of reasons.
DR. DILLON TINEVEZ (HOST):
Hi and welcome to Residents
in a Room, the podcast for residents by residents. I'm your host for this
episode, Dr. Dillon Tinevez, Chief Resident and PGY4
at Advocate, Illinois Masonic Medical Center. Today, we're going to put the
history of our specialty under a lens to consider the many ways anesthesiology
has changed from the past to the present. In this episode, we'll focus on
technological changes. We'll pick the conversation up next month to dig into
human changes. But of course, I can't do this alone, so let's meet our guests.
DR. SHYAM DESAI:
I'm Shyam Desai, I’m a CA1 at Rush.
DR. MIKE PETRAVICK:
I’m Mike Petravick, a CA3 at Rush.
DR. JANHAVI DHARGALKER:
I'm Janhavi Dhargalkar,
intern from Advocate Illinois Masonic.
DR. ARTUSH GRIGORYAN:
I am Artush Grigoryan.
I'm a CA1 resident at Masonic Medical Center.
DR. KANNAN ARAVAGIRI:
And I’m Kannan Aravagiri, PGY1 at Advocate Illinois.
DR. TINEVEZ:
All
right, let's get into it.
First question. Late 19th century advances in pharmacology and physiology led
to the development of general anesthesia and the ability to control pain. The
very word anesthesia was coined by Oliver Wendell Holmes in the nineteen
eighties from the Greek words without sensation. And of course, in the 20th
century, the safety and efficacy of anesthesia was made safer, with
improvements in airway management, monitoring, anesthetic techniques, tracheal
intubation, and other advancements. It's easy to take for granted how quickly
the specialty has evolved and how enormous its impact on public health has
been.
So let's start with the big picture. What kind of
technological changes come to mind when we think about how the specialty of
anesthesiology has evolved? What advancements, discoveries and inventions do
you think have made the most significant impact? Artush?
DR. GRIGORYAN:
Ok. So
I think there are a lot of technological advancements that made modern and anesthesia
possible. But the main technological changes that come to my mind include some
advancements in pharmaceutical agents that we use,, methods
of their administration to the patients, and subsequent monitoring. So modern
pharmaceutical agents such as sevoflurane, desflurane, isoflourane
and their delivery to specific vaporizers enhance the administration of
inhalational anesthesia.
And additionally, I.V.
anesthetics, propofol, ketamine and analgesics like modern opioids, they also
enhance the delivery of intravenous anesthesia.
And with respects to
methods of administration, the invention of masks, endotracheal tubes or specialty tubes, they made it possible to deliver
the previously mentioned inhaled anesthetics, whereas the invention of
intravenous needles, catheters, infusion pumps, newer target controlled smart
infusion pumps use that speed algorithms. They have come a long way from using
good squeals and pork bladders for IV injections.
And lastly, about monitoring
multi-wavelength gas analyzers made it possible to measure inhaled exhaled
anesthetic gases, carbon dioxide levels and paramagnetic oxygen analyzers. They
made it possible to measure, inhale and exhale oxygen concentrations, or the
invention of Wheatstone, which made it possible to digitally measure invasive
blood pressure through A line transducers or the anesthetic gas pressure,
airway pressures, breathing circuit pressures.
And if we combine all
these advancements, the culmination of these advancements is the contemporary
anesthesia machine, which is now used to safely administer anesthesia.
DR. TINEVEZ:
That was a fantastic
answer.
DR. ARAVAGIRI:
That was so beautiful.
DR. TINEVEZ:
I agree with you. I
think as anesthesiologists, you know, essentially for the most part of what we
do, we monitor patients. We do other things. We put them to sleep and intubate
them and all that other stuff. But for the most part, ninety five percent of
our time is really just monitoring patients under
anesthesia. So I think that's been the most important
technological advances in anesthesiology.
And after nineteen eighty five, when the ASA recommended five standard monitors
for all patients under general anesthesia, the amount of complications declined
significantly. So I think monitors are probably one of
the most important things that we use in anesthesia, and a lot of the
technological changes have been increasing or advancing the technology with
those monitors, right? So now we have the ClearSight
system, for example, we have a tiny little blood pressure cuff on the tip of a
finger that can show us what second by second blood pressures. We can gather
data that you would find on a flow track that used to be invasive. Now we can
get it just off of pressure readings and software
that's been developed. So yeah, monitors.
DR. PETRAVICK
I think some even more
recent advancements in the past 10 to 20 years using ultrasound that before
when you had to landmark base or do buy nerve stimulator for nerve blocks, we
can now use ultrasound to more precisely pinpoint where to go to use less
medication or blocks very effectively. So things that
improve patient safety by giving less, giving less is appropriate in a more
direct targeted way really makes a difference. And then being able to use
ultrasound for point of care ultrasound where before you may have gone to do
other imaging, we can use more real time, which can only only
improve patient safety.
DR. DESAI:
Yeah, I totally agree
with all of these. And I think that kind of the big picture here is that as we
get more advanced technology, we're trying to get better with safety as well. So with, for example, invasive non-invasive monitors,
obviously we're able to safely administer anesthetics. But I think another huge
technological advance over the last couple decades is just having electronic
medical records to be able to kind of preop for patients, but also see what
things have been done in the past, what we're getting ourselves into when we're
going to the O.R. And with the advancement of being able to see records from
all over the country, it's definitely made administering
anesthetics a lot safer as well.
DR. TINEVEZ:
All right. I think we
can jump to the second question. We all know that the practice of anesthesia
involves making rapid decisions in critical moments. And we all want to get it
right every time. Anesthesia Information Management Systems and Clinical Decision
Support Systems digitize and organize information so we can better monitor
patients. These tools have shaped our practice. But how much? I'm wondering how
you view and use these tools. Do they inform, support
or drive the decisions you make? It they disappeared tomorrow?
Would you feel safe doing what we do start with? Let’s start with Dr. Janhavi.
DR. DHARGALKER:
Sure. So
from my perspective, I think Anesthesia Information Management Systems, or AIMS
as they're somewhat shortened to be known as, they’re sophisticated pieces of
hardware and software technology that provides solutions to us providers in
real time. These are almost hardwired into the electronic health record itself,
and it can provide valuable feedback to a clinician in moments of importance
when they're making rapid decisions.
The real power, however,
of such systems is to analyze data and to detect ongoing clinical issues or
deviations, and prompt alerts to help guide best practice protocols. If we weren’t
to have these systems in place, I'm pretty sure most of us would feel rather
uncomfortable, and if not, highly, it would be unsafe to perform a lot of our
procedures. In fact, most of these systems are now geared to make sure that we
follow protocol to the T and they are resulted so as to
make sure that everything is standardized from the minute the patient is under
induction to maintenance and the activation of the patient.
DR. TINEVEZ:
Do any of you feel like
the notifications for having a redose ansef every three hours is annoying? Do you experience any-
DR. GRIGORYAN:
I think that one is
helpful.
DR. TINEVEZ:
That one is helpful.
DR. ARAVAGIRI:
Whoops.
DR. TINEVEZ:
How about the
temperature being under thirty six degrees centigrade,
even though there's nothing we can do about it?
DR. GRIGORYAN:
That's not helpful.
DR. TINEVEZ:
That’s not helpful. So
sometimes helpful, sometimes not helpful. Do you think you can live without
these notifications and alarms?
DR. ARAVAGIRI:
The issue is that, if you take away the safety net,
right? So it's like, Oh, I'm getting a notification
every five seconds about something. But then you don't have that safety net.
It's like, Oh my god, do I remember all of this
information? And then something bad happens. You never know, right? So it's always like, Are you willing to take the
responsibility of your own personal choice in these critical decisions? Or are
you willing to allow yourself the safety net for this other system to take you
on this ride? Right?
DR. TINEVEZ:
Do you think anesthesia
would be just as safe without these systems in place?
DR. ARAVAGIRI:
I mean, we're always
transitioning between the idea of like medicine as an art versus a science,
right? At some point, it is a science in the sense that we need to have these
protocols that allow us to do our work safely, effectively, and to have these
safeguards for us. But like, back in the day, it was kind of just like there is
a science behind it. But at the same time, it was a lot of personal decision
making that changed the outcome. And now it's like we're having these protocols
and safety measures to make sure we deliver anesthesia effectively and safely
throughout everybody equally.
DR. TINEVEZ:
Great answer. All right.
Let's jump to the next question. Let's talk mobile, because let's face it, apps
have changed our lives in a lot of different ways. But how are you using mobile
apps as an anesthesiology resident? Any apps you'd refer to your colleagues or
our listeners? I know we all look through our phones to see what apps we had,
and we all wrote them down. So let's go. Let's start your
top three apps.
DR. ARAVAGIRI:
My top three?
DR. TINEVEZ:
Yeah, everyone’s top
three.
DR. ARAVAGIRI:
Yeah, besides the ones I
use all the time, which is like epic or the paging system….
DR. TINEVEZ:
No, those count.
DR. ARAVAGIRI:
Those count? Ok, cool.
DR. TINEVEZ:
Those are apps. So EMR on your app.
DR. ARAVAGIRI:
I have the EMR in my
app. I have up to date and I also have MD calc.
DR. TINEVEZ:
Ok, stole a couple of mine.
DR. ARAVAGIRI:
As a PGY1, Right?
DR. TINEVEZ:
Right. How about you,
Dr. Grigoryan?
DR: GRIGORYAN:
I also use MD calc and
epic, of course, and also … for pediatric doses or airway
equipment sizes. I use itiva for intravenous
anesthesia. Nysora nerve blocks. The one that's my
favorite is the train of four app that we can monitor train of four ratio
without bumps.
DR. TINEVEZ:
How does that work?
DR. GRIGORYAN:
That's based on the
accelerometers that are built in our smartphones. And if you just put your
phone in patient palms and you just use your peripheral nerve stimulator to
stimulate that other nerve, and it records the twitches and then it subsequently
calculates train of four ratio.
DR. TINEVEZ:
You have combine something with it? Or, put it on the patient’s face?
DR. GRIGORYAN:
No, the accelerometer is
built into a smartphone.
DR. ARAVAGIRI:
That’s pretty dope.
DR. DHARGALKER:
That’s amazing.
DR. TINEVEZ:
Don't think I've heard
that because I've never seen that. Not that I use nerve monitors much anyways.
DR. DHARGALKAR:
Yeah, yeah. I think
starting with the electronic medical record app, the epic app got. It's good to
have for interns. But there's a new app I found, I think it was called the
Anesthesiologist app, and I guess it, you plug and chug numbers from anywhere
from the age of the patient to the weight, their BMI, and it pumps out various
airways, the patient's physiology, various medications
and dosage ranges from pediatric to adult induction agents, everything you
might need from at your fingertips. So I'm really
excited to utilize this next year.
DR. TINEVEZ:
I'm curious to see what
you have to say because when I was a junior resident, I had a whole bunch of
apps, and now that I'm almost done, I don't use any.
DR. PETRAVICK:
Yeah, I really like the asra coags app. That’s useful for
not just the standard anticoagulants you see patients on, but as new ones come
out. It's being updated with those. So if you
encounter an anticoagulant that you haven't seen before, we can tell you how
long it needs to be held before any regional anesthesia has guidelines for both
neuraxial and for peripheral nerve blocks. So I think
that one's really useful as we develop newer and newer drugs.
But then also there's
one Block Buddy Pro, just a lot of information about idealized pictures of
different blocks, and they have a wide variety of them on there, so I find
those to be very useful.
DR. TINEVEZ:
Alright, your top three
apps?
DR. DESAI:
I would have to agree
that probably epic is the one that I use the most, but kind of mirroring off Mike
my asra coags app, often,
especially when patients are on anticoagulants you don't see all the time,
doing visual catheters and things like that. But another app that I use pretty
frequently, that many may have used in medical school is Tompkin,
just to keep up with random facts that I may forget not only for exams, but
also for practical use, keeping up to date on dosing of medications and drugs
and things like that.
DR. PETRAVICK:
One more that, while not
standard medical app is doing pediatrics, a YouTube to play requested videos or
music for kids in pre-op and as we're heading back to the O.R. is a great way
to help help to calm them down is to give them
whatever they would like to listen to.
DR. ARAVAGIRI:
What do you play?
DR. PETRAVICK:
Whatever the kid asks
for.
DR. ARAVAGIRI:
Whatever the kid asks
for?
DR. PETRAVICK:
Whatever the kid asks
for, yeah.
DR. TINEVEZ:
I think that a ketamine dart
works better.
DR. DESAI:
It's also useful for
patients who are just super anxious. Background music, especially for regional
blocks where you're not administering anesthetic.
DR. TINEVEZ:
Never done that. Yeah,
that's a good idea. It's a great idea. Let them play their own music while you
do the block. All right. So let's move on telemedicine
and wearable health care technology or examples of products in the consumer
space being adapted for use in preoperative exams, ICU care, intraoperative
monitoring, and post-operative assessments. They even impact our ability to
collect patient data. And as a practical matter, the pandemic made telehealth
more accessible for many Americans. Do you use telemedicine or wearable
technology in your job now? If so, how? And if not, do you want to? And where is
this all going?
Me, at our hospital, we
do telemedicine really only for preoperative exams and
our clinic. So we used to do half of them on the phone
and half of them would come in to the clinic. But now they're either on Zoom,
Microsoft Teams or. So we've gone completely 100
percent telemedicine now. Essentially, that's all we use it for currently. How
about you guys?
DR. DESAI:
I would agree that
that's definitely an area that we use it. But also in
our chronic pain clinic, other than that, there's always a patient that shows
up to pre-op and ask them if they have any problems with their heart, and
they're like, No, my Apple Watch tells me that.
DR. TINEVEZ:
There’s your wearable
technology right there. That's that's the second
question. Does anyone have any examples of wearable technology? Again, all I
could think of was my Apple Watch.
DR. AVAGIRI:
Yeah, different forms of
that Fitbit Apple Watch smartwatch.
DR. TINEVEZ:
Yeah.
DR. DESAI:
I think those are actually really useful, especially if you're trying to
figure out nets for others.
DR. TINEVEZ:
Have you ever put your
Apple Watch on a patient to see if they were a-fib? I have done that twice.
DR. AVAGIRI:
Really?
DR. TINEVEZ:
Yeah.
DR. DESAI:
Has it worked?
DR. TINEVEZ:
It worked. It's FDA
approved to detect it. So, you know, the teli
monitors we have sometimes are garbage. So I've done that. It works.
DR. PETRAVICK:
For telemedicine or at least a change in technology being able to use video
interpreters on an iPad for a patient. I find most
them find that much easier to use than trying to use a call on your cell phone
to a phone interpreter, which is good when you need to use that. But having
them on an iPhone, patients respond better to that. They have a wide array of
languages to choose from. I think patients are more comfortable when there's
somebody to physically talk.
DR. TINEVEZ:
Now a follow up question
for you. What about augmented or virtual reality from the video game industry?
You do any of you see any augmented reality being part of anesthesiology
anytime soon.
We discussed it
yesterday, and we thought that, you know, virtual reality for practicing
intubations, practicing lines, practicing neuraxial or regional techniques may
be in the future for anesthesiology. What about you guys?
DR. DESAI:
I was reading an article
not too long ago, actually augmented reality while
placing blind pediatric patients. So I think that in
the future, you know, especially with that more advanced ultrasound techniques
DR. TINEVEZ:
Do you think we'll ever
have robotic intubations? The Da Vinci intubation? A Billion
dollar machine to put things in the throat?
DR. DESAI:
It might take five times
as long.
DR. AVAGIRI:
In the future.
DR. GRIGORYAN:
That's actually a very
good idea, especially during this pandemic, because it's like a work-related
hazard to intubate COVID positive patients. So we were
able to have robots that during intubation for us.
DR. TINEVEZ:
There was a team in
Beijing that I saw in an article online. They’re using Microsoft Kinect
sensors. The same thing that you have on the Xbox, where you can sort of play
bowling and baseball without a controller and camera just senses your movement.
But Kinect, they're using it in ICUs to track patient mobility and seeing how
much the patients are moving, how often are they moving? And a lot of data is
being collected from that. So that's the one thing I found online for augmented
reality in our specialty.
All right, next
question. Let's talk about AI. Who harbors secret fears that a robot will take
your job one day? Change isn't going to stop today, and the specialty will keep
evolving. What do you imagine artificial intelligence will or won't do as the
specialty continues to change?
DR. DHARGALKAR:
I think AI has been a
very remarkable change in medical practice so far. In fact, it seems like
almost until a couple of years ago, the FDA even approved a novel software that
can help diagnose diabetic retinopathy based on the images of the fundus. And
this was basically done by AI. Currently, from our perspective, in the
anesthesia field, it would make sense to maybe have some sort of AI to help us
track possibilities of intraoperative hypertension or any alternative drug
medication reactions that we could seek out from our patients. I think there's
a lot of scope for AI to help improve some of our practices in the OR.
DR. AVAGIRI:
I saw a paper or a
research project essentially in cardiac anesthesiology, where they were able to
manipulate the blood pressure of a rat to a certain level, and it would just
have the AI decide how much fentanyl and how often it would have to give to
create that certain blood pressure for a certain amount of time. And I'm like, Oh, this is like the beginning of the end. You know, it'd be
like, we never know the scope of which A.I. and robotics can enable to just
increase patient safety, right? It's just determinate of whether technology is
better at humans at this practice. Right? That's the final straw.
DR. TINEVEZ:
So what you're talking about is actually closed
loop anesthesia delivery systems. None of these have been approved, but there is quite a few studies on this. And the study you're
alluding to is actually a randomized control trial
done by Puriet… multicenter. And what they looked at
was giving propofol and fentanyl to a patient and using a BIS monitor and a
machine, or essentially a robot, to detect the BIS monitor and will titrate the
propofol and fentanyl to keep that BIS spectral index in a certain range to
keep the patient asleep. And when they compared that how the robot does and how
they titrate the medications, it turns out to be a lot better than a human
doing it. And there's actually been several studies on
this. Anyone else have anything?
DR. GRIGORYAN:
Another example would be
about neuromuscular monitoring smart infusion pumps. They are integrated with
objective neuromuscular monitors, so they monitor to train up for ratio and
based on that control, neuromuscular blocker infusion rates. So
another example.
DR. TINEVEZ:
Do you think
anesthesiology will be almost completely automated in the next few decades?
DR. PETRAVICK:
I will play the
contrarian and say, I'm not afraid of robots taking our jobs for a couple of
reasons. One, I think we have to remember that we are
trained not just to take care of keeping somebody asleep in a case where
everything is going smoothly, but also trained to care for patients when
emergencies happen. I think that is much harder to automate. Not saying that it
can't be done eventually, but I'm not seeing that being done any time soon as I
think we were still trained for when emergencies happen. I'd like to see a
robot put a line under the drapes. But then also, I think we have
to remember we take care of people and people want to talk to somebody
that’s real. They don't want to just talk to a robot or have somebody say, this
robot is going to do your anaesthesia. I think we'll
become will integrate technology more and more into our practice to do what's
safest for the patients. We have to remember that it's
a lot of, again, not just the science, but part which involves a lot of the
human connection. I think they … have somebody there as a person taking care of
them, not just a robot.
DR. GRIGORYAN:
Also, robots
can take care of routine things that we're doing, or we can concentrate more on
those emergency situations. Take care of the patient now.
DR. AVAGIRI:
Would you say the
classical model where it's like anesthesiologist with one patient monitoring
throughout and operating at that point? Is that model changing rapidly? And
will that change as automation gets more advanced instead of one just has to
deal with a full operating just in case something bad happens, right? Is that
the go to at that point, or are you saying classic models still sustains with
technology?
DR. PETRAVICK:
I think we're already
seeing shifts from decades ago where it was one call just for room to enhance
the security model, whether it's one anesthesiologist, residents
anesthetists or with anesthesia assistants. We're seeing that we are trained
for the whole perioperative period, have a team to take care of people. I don't
think we'll ever move away from the time where we have an anesthesiologist
supervising everything, no matter what else is being being
involved.
DR. TINEVEZ:
I certainly think maybe
not in the near future, but the distant future we'll
have anesthesiologist supervising robots.
Ok, perioperative
technology, mobile technology, automation, non-invasive monitoring. Modern
anesthesiology is a marvel. It's also inextricably dependent on technology.
It's not a stretch to say that technology made anesthesia possible. That made
it safe, and it's still making it more efficient and scalable.
Do you think this is
truer for anesthesiology than other specialties? And if so, why do you think
that is? You think we use technology more than other medical stuff?
DR. GRIGORYAN:
I do think so. So anesthesia is arguably the most acute setting that a
patient may enter. And this mandates extreme vigilance, precise monitoring, and
timely treatment. As such, to help ensure each action by an anesthesiologist is
delivered with precision, technology is required. And I agree with the belief
that technology has made our profession more efficient, scalable
and safe. When I decided to pursue anesthesiology, and people would ask me what
it involves, aside from putting the patient to sleep, I would ask them to
imagine that they were not only putting someone to sleep, but also shutting
down most of their organ systems and needed to use tools to keep their organs
functioning. And this requires an absolute precision in order
to execute these actions, and that's why technology plays a critical
role in anesthesia.
DR. TINEVEZ:
Anybody else think that
we use more technology than other physicians?
DR. AVAGIRI:
Equal.
DR. TINEVEZ:
What about an infectious
disease specialist? The technology they use?
DR. AVAGIRI:
They have
to use like, I guess technology says that they have their own systems in
which they gather knowledge.
DR. TINEVEZ:
Can do their job without modern technology?
DR. DESAI:
I think that we use
technology probably more than any other specialty. If you come into the
operating room, every second, we're on modern technology, whereas no other
specialty because no other specialty does that second by second. So in that perspective, absolutely more than any other
specialty.
DR. DHARGALKAR:
Exactly. And I was just
going to add to that being highly technical field that's undergone massive
changes in over the last 50 years or so. Majority of it is because of these
technological changes that we talk about and to discuss this, our ability to
work with the technology and also have to improve over
the course of the last 50 years or so. And it's almost undeniable that our job
is very much become very technical and very driven by machines on a daily basis.
DR. TINEVEZ:
And the data shows that.
The more technology or the more technological advancements we see in
anesthesiology, the less patients are dying, right?
All right. Is all this
change all good? Are there risks? Do you worry about keeping up or do you think
the change is such a net positive, any risks or
concerns pale by comparison to the benefits?
DR: PETRAVICK:
I think it's important
to say that as we introduce these new technologies to do studies to see how
much the benefit you have, there is always a cost benefit ratio that we see.
The cost of health care in the United States just continues to increase and
increase. And we do have new technologies to make drastic changes in people's
lives. But we have one that provides a standard of care that equal, or perhaps
only slightly better to what we do. Not only is it statistically different, but
can we say it makes a comfortable difference as well? And we have to weigh that with how much does this cost do something
patients can access and is it crowding out paying for other things that would
make an impact on people's lives as well? I don't think you can say that a
change is necessarily all good. You have to weigh it
against the other factors.
DR. TINEVEZ:
Can anyone give me an
example of a technological advancement that didn't really show much benefit
DR. PETRAVICK:
If we are looking at it
in the air in general? I was going to use the example of somebody using a robot
to take out a gall bladder.
DR. TINEVEZ:
The $900 upcharge for
that.
DR. PETRAVICK:
If only it was $900. And
I just would like to know, is this any better for this one patient? And I know
the surgeons will make their arguments. That you just have to
be aware is what we're using, making a clinical difference for the patient and
it's costing them x more.
DR. TINEVEZ:
Right. And the data for
robots is a slightly decreased risk of surgical site infections. That’s about
it. I was going to say exparel, which that that's
very controversial. We're all know the ASA published study showed that it was actually no real benefit for post-op pain with extra costs,
400 times more than generic marcaine. So I don't think there's a whole lot of benefit to that
technology. Anything else?
DR. DESAI:
I think that as technology
advances get more data operating, it's going to be important to kind of keep a
big picture of things get lost. You know, at some point, I think overall
there's a net cost.
DR. TINEVEZ:
Okay, now, for the second part of that question, what I really wanted to hear
what you guys have to say about this. Do you think older anesthesiologists have
a tough time keeping up with the new technology? For example, some of our
attendings can't use an ultrasound for the life of them. Half of our cardiac
attendings are never trained in transit, esophageal echo and they still have
not learned this, but they're doing cardiac. Half of our attendings have
troubles charting. They don't even know how to use the EMR. You have to help them all the time. What do you guys think?
DR. PETRAVICK:
I think the natural
progression with age, I use the example of when I was a kid Nintendo 64, I laughed
at my parents for not being able to play on the mariocart.
Now on a Wi, I'm terrible at it, but it's still bigger. N sixty
four, as you get older, it can be harder to learn some of these new
things that doing thinks our careers where we rely on some of our younger
colleagues 30 years from now to help teach us. So I
don't think it's a poor reflection on them for something that I think is fairly
natural that we'll all have to work, maintain these skills. I think they
trained in a different era and learned to the best of their ability and solid
quite good care with the knowledge that they've gained over the years. And it's
a shared environment that we have to care for
patients. The knowledge they have, the skills that we have on newer technology.
DR. TINEVEZ:
You don't think that the
gaming generation and the computer generation, like our generation who grew up
with computers and video games are going to adapt a lot quicker than the
Boomers did?
DR. PETRAVICK:
We, I think we may adapt
to some of the computer-based things, but there will be still get some new
technology we did not have.
DR. AVAGIRI:
Isn’t our job as
physicians to always be on top of our game?
DR. TINEVEZ:
Ideally.
DR. AVAGIRI:
The goal is that our try
to be at the forefront of technology in order to keep
the patient safe, right? So at what point are we allowed
to say, Look, I am worried about technology overtaking what I'm able to do,
even just starting out. At what point will I not be able to adapt? And at what
point should we be like, Oh, there's no way to adapt?
We should be able to change, right? The whole point.
DR DESAI:
I think that to an
extent that's true, but it's kind of hard to keep up with things after a
certain point in your career, especially if it's me versus an older attending
who did not grow up with a computer. For example, I've been using computers
since I was, I can’t even remember. But so just that much time makes it a lot
easier to pick up things that are computer based. So, for example, like things
with virtual reality, I've never really mess around too much with virtual
reality. But in the future, if our career does incorporate a lot of virtual
reality, I think that that's something that I'll have to put full time to pick
up.
DR. TINEVEZ:
The Metaverse is coming
for us.
All right, last question.
Before we wrap up this episode, if you could step back in time 20 years or 50
years or a hundred years, you think the anesthesiologist of the past relied on
different skill sets? And are there skills they employed you wish you had more
of? I'm wondering if you think something important is lost with these advances?
DR DHARGALKAR:
Oh, absolutely. I think
over a hundred or fifty or so odd years ago and we weren't relying on, say,
this monitor to tell you the depth of the anesthesia or trade or anything like
that probably rely on your best judgment. Everything that you would need to use
and then been taught to word of mouth would have to be applied into real time
physiology. I'm sure that involved doctors making a lot of mistakes at the
time, but I think you stand on the shoulders of giants. And so
we learn a whole lot from their mistakes. But also
something that maybe we've lost through the scope of these advances is being
able to think without this machinery, without knowing that would we have still
come up with the same standardized protocol as we do for patients now, despite
the machines alerting and prompting us at every point, no matter how annoying
it might get? Would we still count on ourselves to deliver the best possible
patient care? Maybe not utilizing so much of technology all the time. I think
that's a much harder question. And I don't think any of us would be prepared to
sort of go into an O.R. without any of these advances in our arsenal.
DR. TINEVEZ:
I don't think we're at
the point yet where we're sort of losing all these skill sets that the older
anesthesiologist had. I'd say maybe 15 percent of the time I'd use a video
laryngoscope, still 85 percent of the time I'm using direct as they aways have since anesthesiology was, I think. Same thing
with ultrasound putting in lines. The only thing that I could think of where
the skill set is lacking in the skill set is regional anesthesia without an
ultrasound. That's the one thing that we always use ultrasound for now. So I wouldn't be able to do an axillary block without an
ultrasound. Well, some of these older attendings do this with their eyes
closed. What do you guys think?
DR AVAGIRI:
I think just like both
of you said, I think back in the day without these kind
of monitors and ultrasounds, it's more almost an intimate experience, right?
You're trying to understand the human body as much as physically possible
without any backup, without ultrasound, without any of this technology we have.
And you're just guided by your own knowledge of like probably exploring
cadavers, trying to figure out where everything is, like understanding how the
person feels at the time.
DR. DESAI:
I agree with and one
really big thing with technology is that has provided us a kind of a fallback,
even though we use direct laryngoscopy 85 percent of the time, we know that we
have bioscope, at least in the building. So just that fallback is really a huge
step forward in safety.
DR. TINEVEZ:
All right. Well, thanks,
guys. Thanks for listening to Residents in a Room, the podcast for residents by
residents. We hope you'll join us again next month. We also hope you will
subscribe to residents in a room wherever you get your podcasts.
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