To the Editor
I am responding to a recent APSF Newsletter (Volume 5, Number 3, Fall 1990, pgs. 25 and 27) relating to proposed standards for basic monitoring in the PACU. I have never been in favor of pulse oximetry as a standard of care. While it is very useful in certain situations, I find its use being mandated routinely by the ASA is unfortunate. The unfortunate aspects of this are: 1) it contributes to camouflaging of the bad anesthesiologist’s or anesthesia caregiver’s incompetence and 2) it propagates incompetence by making trainees monitor-dependent as opposed to honing their clinical acumen/skills.
As astutely noted in a recent excellent editorial by Dr. Arthur Keats entitled “Anesthesia Mortality in Perspective” (Anesthesia and Analgesia 71:113, 1990): “pulse oximetry was made a part of our monitoring standards without demonstration of its efficacy.” In addition, “making a monitor part of the standard of care guarantees that the experiments necessary to document its efficacy can never be carried out because we automatically rule out a control group.” Now your committee and your newsletter are trying to mandate pulse oximetry as a standard of care in the recovery room environment. You state that “closed claims studies indicate that hypoxic injuries in the PACU continue to occur and in fact may be increasing.” Again, as Dr. Keats so astutely points out, some of the closed claim data is now being called into question by Dr. Cheney, the investigator who has been responsible for the study over these recent years.
The presence of an instrument such as the pulse oximeter encouraw users who do not understand its technology to be even less vigilant in physical observation of the patient than they were before its use. In other words, it takes the caregiver farther away from the patient because “the little red number is okay.”
Another important aspect of this is the impact of such a decree on medical economics. We have a hard enough time in our hospitals getting state-of-the-art equipment to administer safe anesthesia in the operating room. We will probably have an equally difficult time in our PACU to find the resources to purchase state-of-the-art monitoring equipment for this area. With a 15-bed recovery room, if we were to suddenly, as of January 1, 1992, be required to purchase pulse oximeters for all stations, that would represent a cash outlay, perhaps, of $75,000 – 100,000. Failing that, we would then be in violation of standards. You can rest assured that if such equipment is purchased, not only in our hospital but in every other hospital in this country, the cost of the use of that device will be passed on to the consumer or patient. Up goes the cost of medical care again, which is already too high in this country.
If I may at this point refer you to yet another astute publication of Dr. Keats’ (the Rovenstein Lecture, Cardiovascular Anesthesia, Perceptions and Perspectives. Anesthesiology 64:67, 1984) he noted how “the pendulum swings in patient cam practices over the years.” With that thought in mind, if I could be permitted to gaze through a crystal hall for a few seconds, I would submit to you that the time will come when the results show that all of this fancy technology does not help one bit if you have a careless and/or unskilled operator at the helm. In the meantime, making the use of this equipment mandatory when it has not been scientifically validly proven that it is beneficial, will have cost the medical care system in this country millions of dollars. Is there no room for nurse and physician judgment in patient care any longer of will we all have to become robots who can only function with assistance from machines?
I would ask that you and your committee and others who think along these type of lines would give this problem serious consideration. I do not think what you are about to do is wise or beneficial.
Lawrence L. Priano, M.D., Ph.D.
Associate Professor of Anesthesiology
Oregon Health Sciences University, Portland
Editor’s Note: The favorable action of the ASA House of Delegates on the PACU monitoring proposal will be covered in the Spring issue. Comments on the interaction of safety-promoting technology with “careless and/or unskilled” anesthesia providers are enthusiastically anticipated and will be published in future issues.