From chaotic antiques to closed-loop systems

I am typically the first person to walk into the O.R. in the morning. I turn on the lights and start running through a long check-list of items that must occur before I can bring the patient to the O.R.

I run safety checks on the anesthesia machine, medical gasses, backup tanks and make sure that rescue equipment is available. I boot-up the O.R. computer, check the Pyxis (our in-O.R. pharmacy) machine, and draw out medications. I set up fluids and drips, program pumps, verify that monitors are on and functioning correctly. Preparation is key to my job. I need everything to work and be readily available in seconds if a situation were to go awry; and, working with high risk patients, it does more often than I want it to.

Let’s pause for a second. Take a look at the operating room. What you will see is technology and processes that are surprisingly labor intensive and unbelievably antiquated.

Take for example the medication infusion pump. The pump is a standalone unit that doesn’t communicate with the O.R. computer, yet the two are right next to each other. Its operating system is ancient. Its interface is a DOS-like black and green. The computer doesn’t communicate with the pump even though both require the input of the same variables like patient weight, medications type, and rate. The Pyxis pharmacy machine doesn’t connect to either. And, throughout the case, I have to log what the pump is doing on the computer. Sometimes I am adjusting and running 6 pumps at the same time while trying to manage a critically ill patient. Hello? Did someone just say we live in a connected age?

Did I mention this is what’s happening in state of the art top academic medical center operating rooms? You can imagine what it’s like elsewhere.

Uncrossing the Wires

Anyone who has walked into an O.R. will quickly note the almost unintelligible mess of wires and tubes chaotically surrounding the patient. “Interconnected” or “wireless” are not likely the first words that come to mind.

These tech frustrations extend beyond the O.R. as workflow has ripple effects to virtually every part of the hospital, affecting patient flow from wards to ICUs to the ER. On top of that, surgical services are quoted to comprise 68% of hospital revenue and subsidize many of the net-loss hospital services. A single minute of O.R. time is touted to run at combined revenue-cost of $147.

And still, this is all overlooking the even bigger issue. Patients are sick. Stakes are high. Life-altering events can happen on the order of seconds.

<0>O.R. technology needs to live up to 21st century so that our time can be spent caring for patients, not untangling wires and making 1970s pumps work while the patient is crashing.

Closing the Loop

Technology will catch up, and change will happen. In time, our job as anesthesiologists will change drastically.

Ultimately, we will get devices that intercommunicate, self check, and run through those same checklists we run through every morning. What may happen, and this is really exciting, is the advent of closed-loop systems in medicine.

Generally speaking, today we have open-loop systems. There is a measurement, blood pressure for example, and there is a small change. To get the blood pressure back within target range I would go to my Pyxis, draw up a medication, and administer it. For me to complete the loop, it takes direct attention, intervention, and an awful lot of hand work.

A closed-loop system, however, is adjustable and self regulating. With it, an anesthesiologist could determine and preset parameters, somewhat like a thermostat that adjusts a temperature based on a preset value. A computer would detect a change in blood pressure; the medication would be preloaded; and then it would be administered in small amounts until the result is achieved. All done by the machine, monitored by a human, and based on preset parameters.

It may seem incredible, but it’s not that lunatic. Currently, research work evaluating closed-loop systems is being completed, published, and validated. It will truly allow anesthesiologists to evolve.

Anesthesiologists spend an enormous amount of time learning and understanding human pathophysiology so we can act as interventional physiologists in what is for a human body arguably the most hemodynamically stressful and high-risk time. We have the ability to measure and augment on a second-to-second basis virtually every single body vital function. Yet, with all that knowledge and power, we spend too much time acting as technicians, drawing up medications, untangling wires, and doing other tasks that distract us and underuse our intellectual ability.

In the future, with interconnected devices and closed-loop systems, we will be able to concentrate on what we do best: high-level problem solving, physiology, procedures, and patient safety. We will reduce variance and employ more evidence-based and targeted approaches. And perhaps we would even be able to take care of more than one patient at a time.

Autopilot didn’t replace the airline pilot. It made his job safer, streamlined, and more efficient. As our patient population is aging and becoming more medically complex, I see technology helping us achieve the same.