Sunday, December 18, 2011

The Predicament of Immediate Availability

     Sometimes, I really miss carrying a hospital pager. My old pager was a Motorola with a large digital read-out, a variety of pleasing alerts, and a Brother P-touch label on the back which read "I Like Cheese." It was also capable of receiving text messages, either via SimonWeb or a cell phone registered within the Emory system. It had a "silent" feature, which could really get you into trouble if you accidentally activated that function while you were on call, and if you didn't answer it right away, it would beep every few seconds, continuing to do so until you pressed the button and viewed the message.
     As a brand new attending, I carried the same pager I'd used during residency, and I had a love-hate relationship with it. The "I Like Cheese" label on the back of it found its place on a particularly slow afternoon in the pain clinic during which my fellow residents, Ahmet and Curt, and I came across a label maker in the supply room, and amused ourselves with it for several hours. We decorated each other's name tags and our pagers, and we had a lot of fun. SimonWeb paging was also a beautiful thing, sort of a hospital-wide precursor to the text message. You logged into the application, selected a person to page, and typed in your message. Our residency class was well acquainted with the wonders of SimonWeb, and we actually got in a bit of trouble because of the unsavory content featured within some of the messages; we were unaware that Big Brother was watching (LOL). But, enough about pager love. The reality of the situation was that I hated the sound of that pager, and every time it sounded, it evoked in me a silent primal scream. In an attempt to circumvent this problem, I frequently reset the alerts. The battery life on my pager was dismal. When the battery was low, the device issued an especially annoying high-pitched alarm, which would startle you awake in the middle of the night if you left your pager turned on when you weren't on call. It was like a ball-and-chain, signifying someone's urgent need to get in touch, as well as your corresponding immediate availability. I really hated that pager, until I took a job where we didn't carry pagers, and the only way for the OR front desk, my residents, or my anesthetists to get in touch with me was by calling me on a cell phone.
     On the surface, my complaint may seem trivial, but this seeming advance in technology has subtly redefined the concept of immediate availability. Anesthesiologists routinely sign anesthesic records, stating that we are "immediately available" for key portions of the anesthetic, such as induction and emergence. Hospital-based anesthesiologists have always been required to be immediately available, whether we take in-house call or call from home. In-house call is a no-brainer because you're already physically present on the premesis. As a rule, home call involves an expectation that you'll arrive at the hospital within 30 minutes of receiving the initial communication. In general, the types of call anesthesiologists take are institution and practice-specific, and vary depending upon whether there is an associated labor and delivery ward or trauma center, as well as the presence of residents or physician extenders. In stark contrast to my battered old pager, my cell phone demands ultra-immediate attention, and it is not just annoying, it is intrusive. This may be too much information, but I can't tell you how many times I've been in the bathroom, on the toilet, answering that damn phone. (Those of you who aren't in the field of anesthesia probably aren't aware of the fact that we spend an excessive amount of time at work with very full bladders, either because we're in the operating room with our patients, or simply too busy to pee.) Yes, it does provide a direct connection with whoever is trying to reach me, but I'm not convinced that communicating in this fashion has improved patient care, and sometimes, I think it actually interferes with it.
     The scenario which I think best illustrates my point typically occurs during induction, the first portion of an anesthesic. In my pager-carrying days, I would receive a message that the patient was in the operating room with my resident or anesthetist, ready to "go to sleep." (This is an unfortunate and incorrect term which I despise, and try never to use with my patients). One of us would manage the airway while the other pushed the drugs. The induction of anesthesia, which usually goes smoothly if you've dotted your i's and crossed your t's, can be accompanied by immediate and profound physiologic shifts in a patient's blood pressure, heart rate and rhythm, as well as the much-dreaded "can't ventilate, can't intubate" situation. This is a time where all eyes, ears, and hands in the operating room should be focused on the patient. If my pager happened to sound, I felt reassured that in just a moment, after the patient was stabilized and intubated, I'd be able to divert my attention to it. If I was tied up, and there was a true emergency occurring elsewhere in the peri-operative suite, the front desk would page overhead for "any available anesthesiologist", and within seconds, someone would respond. The problem with cell phones lies in the knowledge that there is a person on the other end who is waiting for you to answer the call immediately. Unless that person is texting you, or you are familiar with every number coming through, you have no way of knowing whether it's a recovery room nurse calling for a sign out, or the operating room calling with an emergent patient-related issue. I currently work in a small facility where most calls are routed through the main hospital number, making it nearly impossible to tell who's calling or to call them back. I have asked the nurses in pre-op and recovery to text me for non-emergent issues, instead of calling me, but this requires them to use their own personal cell phones, and not all of them have plans which permit unlimited text messaging.
     An even deeper dilemma accompanying our reliance upon cell phones is that it seems to increase the margin for errors, or even complete breakdowns, in communication. An example of this occurred a few weeks ago, while I was placing an epidural in labor and delivery. I set my cell phone down on a bureau as soon as I walked into the patient's room, so that the nurse wouldn't have to fish it from my pocket, in the event a call came through in the midst of the procedure. I had just positioned my Tuohy needle within the epidural space when the phone rang. The nurse, who is new, answered it for me, and after hanging up with the caller informed me, "They need you in MRI." Prior to my arrival in labor and delivery, I had assisted with an induction in MRI, which is a particularly scary place to give anesthesia because of the restrictions on magnetically charged equipment, as well as limited access to your patient. "What do they need?" I asked. She wasn't sure, because the caller from MRI had neither specified the circumstances nor the urgency with which they needed me. Assuming there was an evolving problem of an emergent nature, I had her call one of my two other colleagues down in the OR, quickly finished the epidural, and went flying down to MRI. Indeed, there was an emergency, and both of my colleagues were present, helping to stabilize my patient. The patient ended up being OK, and the specifics of the emergency itself are not the issue here. The problem is that precious minutes were lost as a result of inadequate immediate communication, underscoring how the sense of reassurance we obtain from communicating immediately is absolutely dependent upon the caller's ability to accurately convey the immediacy with which we should be available.
     For physicians, cell phones have been a curse and a blessing. We no longer have to be tracked down at a restaurant when we're on call, like my father did in the days before he had a pager. We no longer have to find a phone to answer our pagers, because we all carry cell phones in our pockets. The advent of the smartphone puts the world of clinical 'need-to-know" information in the palms of our hands; we can look up drug information on Epocrates or refresh our memories about an obscure disease without ever having to leave the patient's bedside. There is no doubt that cell phones have revolutionized the way in which modern society communicates. The downside of this technology, however, has serious implications which cannot be ignored, and for anesthesia providers, begs the obvious question: if driving while talking on a cell phone is like driving drunk, how can answering your phone during an anesthetic induction be any different?

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