Volume 4, No. 2 • Summer 1989

Special Article: A Safety Tutorial?

E.S. Siker, M.D.

In a recent television commercial, a well know CEO of a major auto manufacturer stated, “Safety is a customer’s right.” Can this be any less true for a patient about to undergo an anesthetic and “cal procedure? Is it true that one shouldn’t have elective surgery in a teaching hospital in IuIY9. Is it for the reason that some staff advise that one shouldn’t buy a car assembled on a Monday or Friday?

July sees a changing of the guard: the CA-3s have departed and the CAI s have arrived. Most Anesthesia Residency Training programs have a series of summer tutorials for the new arrivals. These sessions have a number of objectives which can be collectively described as telling the neophytes how to stay out of the sand traps that await them in anesthetic practice.

The makeup of these tutorials differ markedly from program to program while sharing some common goals: an overview of the specialty; preanesthetic evaluation and medication; technical details about anesthetic set-ups; the anatomy of the anesthetic machine and its appendages; airway management (including endotracheal intubation); a sequence of assigned reading and/or advice about when, where, and what to study; bold print talks about anesthetic agents; and intraoperative monitoring. Ultimately, all of this initially imparted information bears upon patient safety. The current reliance upon the now ubiquitous electronic monitors have created, in some, a perception that patient safety can be more readily assured.

Does monitoring imply “patient saw” or do the sessions about monitors deal with the pathophysiology of complications rather than clinical reliability and practicality of the machines? This vast array of electronic devices is now a part of our workplace. Is their presence synonymous with patient safety? What else should our new residents be told about patient safety during the first few weeks of their training? Most, in the course of their medical school days, have spent either elective or clerkship periods in anesthesia they’ve seen the clusters of monitoring equipment before, but haven’t felt intimidated because the responsibility belonged to someone else. Most, however, if asked during their first few days of training will confess concern about the need to pay attention to the input that the monitors provide while listening to and learning from clinical instruction. Too many of us who teach have forgotten that the introduction of these electronic devices occurred gradually over a period of many years. Compare this level of relative comfort among with the complex monitoring array with the experience of the new resident suddenly thrust into the midst of read-outs, bells, and whistles.

At best, unless the new resident is told what not to worry about, he or she is faced with a Hobson’s choice. Unless told that it’s more important to observe the patient than the array of monitors, they will believe that they must do both.

What the resident should be told about patient safety during the first month of training is and has been the subject of debate. How can anyone dispute the input from a pulse oximeter that announces a falling oxygen saturation or the alarms that report no C02 in the expired mixture? Even if we were to assume that these devices are never wrong (which we know to be untrue), it is the opinion of this observer that the brightest beginner shouldn’t have to be concerned with the numbers on every screen.

The “sink or swim” school doesn’t work as it did when the patient, his blood pressure, pulse, color and the ECG trace were the prin6ple “monitors” for the beginner. Today’s teacher of anesthesia must recognize the need to delay the intrusion of too many diversions and direct the beginner to the basics. It is unreasonable to expect that a new resident will feel any more comfortable with the monitor army than with everything else that there is to learn which can only come with time and experience.

So what do we tell our patients? What is the goal of our tutorial about safety? It begins very simply: “For the first two weeks or so, you watch the patient and don’t worry about all the monitors – we’ll watch them.” The use of monitors is then introduced in a manner aimed at reinforcing clinical judgments. The tutorials include an overview of how they work, and all that can be potentially learned from them. But it also includes input about why they sometimes don’t work, why they malfunction, and how to decide whether the monitor or the patient is to be behind when the numbers just don’t add up.

Dr. Siker is Chairman of Anesthesiology, Mercy Hospital, Pittsburgh and an APSF Executive Committee member.