To the Editor

I have read with interest both the original letter and its many responses concerning reading in the OR during cases. As a practicing anesthesiologist, and as the Chairman of Anesthesiology in a large private hospital, I feel that some important points have thus far been overlooked. First, let it be clear that no one in this debate disputes the need for vigilance during the provision of anesthesia care (whether MAC or any other type).

The debate concerns the questions ‘What is the necessary and appropriate level of vigilance?’, and ‘How best can we assure that level of vigilance?’ Certainly, the necessary level of vigilance varies during the provision of anesthesia care. Rapidly changing clinical situations (i.e., induction and emergence, highly invasive surgical procedures, the .unstable’ patient, etc.) require the full and constant attention of the anesthesiologist, and none among us would argue with that.

However, anyone who has personally provided anesthesia care for very long will attest that, when anesthesia is done deftly, there are often long periods of clinical and physiologic stability. While certainly these times require sufficient vigilance to assure that such stability persists, even the most thorough evaluation of the patient, the surgery, and the monitors requires only five or ten seconds. Even if repeated twice a minute, more than two-thirds of one’s time is “unoccupied’, and even the ‘occupied’ time contains no novel stimuli.

A number of studies, in our field and others, have addressed the problem of how to best maintain vigilance in a monotonous or non-stimulating environment (such as these long periods of intraoperative stability), and almost all conclude that even with the best of intentions, without varied stimuli there can be frequent lapses in vigilance. Those who claim that their vigilance is ‘unflagging’ in these situations may be unaware of their own lapses.

Some of us clearly feel that the appropriate use of reading materials during the intervals between evaluations can enhance their overall attentiveness others clearly find it to reduce theirs. Probably, no single, absolute ‘rule’ on the subject will be feasible.

However, reading is by no means the only potential obstacle to vigilance in the OR. I have found that of equal concern are the use of the telephone (whether for clinical or other purposes), record keeping (clinical or personal), and even impassioned conversation with the surgeon. Any of these can and has led to decreased vigilance. (I once received a report of an anesthesiologist who was said to be inadequately vigilant-he was on the phone to the MH Hot Line!)

Lastly, I must comment on the ubiquity of the practice. Except for academic or training situations (which rarely provide the aforementioned ‘periods of stability” required), almost all of those who personally provide anesthesia care will at some times read, talk on the telephone, or engage in other “nonclinical” behaviors that could potentially decrease their vigilance. In some situations, these behaviors are both necessary and appropriate, and may actually improve the quality of care.

However, none of ” relieves the practitioner of his or her responsibility to provide adequate vigilance and care, in any and all situations. It is for each of us to determine how best to provide this in our own practice of anesthesia.

William F. Styler, D.O. Greenwood Village, CO