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.