Tuesday, May 26, 2015

Technological Crutches and Agenesis and Atrophy of Procedural Skills

This article in the New York Times describes the possibility that with increasing reliance on technology and automation, there is atrophy of human skillsets which can lead to untoward outcomes, especially when technology fails and humans have to take back the steering wheel.  One example it called upon was a crash in 2009 of an Air France jetliner that was caused by icing over of the airspeed sensors upon which the autopilot program relied.  When the autopilot failed and the pilots took over, they were confused and ill prepared, and the plane crashed into the Atlantic Ocean.
I am no general fan of romanticizing dated technology (except for the pager) such as the physical examination when superior and ubiquitous technology supercedes it.  Spending five or ten minutes flipping the patient into different contortions trying to identify a gallop or a subtle murmur seems quixotic if an echo has been ordered or the result is pending (although if this interests you as it did me, indulge yourself, its performance and ponderment reinforces the underlying physiology poignantly).  On the other hand, if a patient in the coronary care unit crumps and you cannot identify the obvious holosystolic murmur from a chordae rupture….

I am reminded specifically of certain technological crutches graduates of internal medicine and critical care training programs have come to depend upon in the past decade such as ultrasounds for the placement of central lines and performance of thoracenteses, and fiberoptic aids for endotracheal intubations.  These devices certainly have a role in both training and patient care, and I am generally familiar with the favorable data on success and complication rates, but something is certainly lost when a trainee’s or a practitioner’s efficacy is overly dependent upon use of these technological crutches.

What to do during a Code Blue on the floor when there is no ultrasound and no intravenous access?  I recall several Code Blues where I inserted a subclavian line during brief epochs when chest compressions were held, but it is not uncommon nowadays that trainees leave a critical care fellowship with no proficiency in the subclavian approach whatsoever (or worse, that they learned erroneously that the jugular approach is generally superior to the subclavian approach).  What to do when there is a Code Blue but the Glidescope is in the ER, or there is no Glidescope, the Glidescope malfunctions, or there is a Glidescope but there is also a GI bleed or profuse vomiting and no fiberoptic visibility?  How can you know how to instinctually position the head and neck for a direct view of the larynx if you have trained almost exclusively on a device that obviates a direct view of the larynx?  How do you percuss and tap a pleural effusion when there is no ultrasound available if you have learned this procedure by the “point and poke” method?

One approach to this problem is to insist that trainees learn the tried and true methods first, and resort to the technological aids only for difficult cases or those in which the simple methods have failed.  Make an attempt with the Miller 2 blade (one brief attempt) and if that fails, proceed to the Glidescope.  Identify the internal jugular using proper patient positioning and identification of anatomical landmarks and make a pass with the finder needle before resorting to the use of the ultrasound, or use the ultrasound to confirm or refute your estimation of the jugular position prior to making a pass, rather than relying on it from the get-go.  In this way, the technology can be a way to calibrate predictions and can enhance learning of the underlying basic techniques, while also bolstering proficiency in their performance, and increasing optionality in procedural approaches.

Even with widespread availability of echocardiograms, cardiologists must be able to identify basic murmurs.  If trainees are leaving their programs where 90% or more of their procedures were performed with a technological crutch or aid, they may have rude awakenings when atrophy of basic skills (or the absence of their development) becomes apparent during exigent circumstances in real world settings.