Power Interruption Still a Major Safety Disruption

C.F. Ward, MD

To the Editor

For decades anesthesia has been compared to aviation. The reasons are numerous and widely known, or at least widely repeated. Consistent with this comparison, the cockpit of modern commercial airplane is a delight to every anesthesia practitioner, filled with integrated electronic displays that reveal the raw navigation/aircraft systems data and the refined “big picture” distilled from that information. Current generation anesthesia machines seem, at first glance, to follow this exact philosophy. However, there is a significant difference that only becomes evident with daily use. Modern aircraft have multi-function displays, which allow critical information to be rerouted and displayed as required when the primary display fails—as it sometimes does. The anesthesia machines do not currently have this luxury. A power supply disruption of the sole display of all vital signs and/or critical flow/concentration/ventilation parameters, leaves the practitioner in the dark, with no raw data. Further, programmed for this event, the machine then abruptly becomes the world’s largest oxygen flow meter, eliminating the possibility of anesthetic overdose, or in fact any dose. The experience is terrifying. There is a significant design flaw at work here—a final common pathway, the disruption of which creates an immediate patient care crisis. Thirty years in the operating room, never having experienced such events, and a so-called improved technology created the longest 15 seconds in my professional career, as I struggled to reanimate an ECG/pulse oximeter display, frozen on a screen, using the last ditch sophistication of cycling the ON-OFF switch.

Everyone must evaluate new equipment from the view of just one question: what happens if it hiccups? Rest assured, from the greatest lesson of the computer age, it will, and at the moment when it is least acceptable. No single malfunction should deprive the practitioner of information required to verify satisfactory vital signs and provide basic anesthetic requirements—a voltage variation or circuit board failure is not a legitimate medical indication to change anesthetic technique. Nevertheless, it has occurred, and will again, until this flaw is addressed and eliminated.

C.F. Ward, MD
San Diego, CA