September 12, 2010
Teleanesthesia With Remote Anesthesiologists
In the comments of my recent post Anesthesiologists Demand To Outrun Supply? a number of medical doctors, including several anesthesiologists, took strong exception to the possibility of automating anesthesiology. Well, researchers at McGill University in Canada and Pisa University in Italy have recently used videoconferencing to allow anesthesiologists to control drug delivery remotely thru an automated system.
Videoconferences may be known for putting people to sleep, but never like this. Dr. Thomas Hemmerling and his team of McGill's Department of Anesthesia achieved a world first on August 30, 2010, when they treated patients undergoing thyroid gland surgery in Italy remotely from Montreal. The approach is part of new technological advancements, known as 'Teleanesthesia', and it involves a team of engineers, researchers and anesthesiologists who will ultimately apply the drugs intravenously which are then controlled remotely through an automated system.
This achievement is a product of an on-going scientific collaboration between Dr. Hemmerling's team and the Italian team of Dr. Zaouter of the Department of Anesthesia of Pisa University (Chairman Prof. Giunta).
Humans are still making the decisions at this stage of development. This approach does not provide remote anesthesiologists with the ability to do everything they normally do such as intubation and other physical activities that anesthesiologists normally do. But in theory a far less expensive person could be trained to do the physical actions for a remote anesthesiologist. However, if an internet link went down during an operation the loss of remote control could become a big problem.
Check out a related site newanesthesia.com.
Technology will reduce the scope and quantity of labor. This will happen, indeed is happening, much sooner and faster than automation. It is called deskilling. Increases in productivity can lead to worker layoffs just as easily as automation. 10% automation or an 11% rise in productivity - both would result in as much as a tenth of the given workforce being sacked.
Legal barriers to entry pose the greatest obstacle, but less and less as medical costs rise, and the pressure for cost reductions builds.
Intubation, if "perceived" to be successful, result in the "breathing tube" being in one of two places, your trachea or your esophagus. If it remains in the former - as it does in most cases - you're OK, assuming everything else goes well. However, if it ends up in the latter and isn't detected in time, you end up dead or a vegetable. Given the significance of the consequences, I would prefer that the more expensive person puts the tube down my throat.
Why, so there are deeper pockets for your heirs to go after?
A good deal of technological progress consists of removing the necessity for skill to achieve particular results. Why require somebody to have a fine touch, and be able to determine whether they zigged or zagged by relatively subtle cues, when you could put a freaking video camera on the end of the tube, and actually see which way you're going?
And aren't blood oxygen monitors standard practice? How is a misplaced tube going to cause brain damage if the oxygen monitor picks up a drop in blood oxygen BEFORE it reaches A dangerous extent?
Who intubates and extubates the patient in this setup? Who confirms tube placement? Who does CPR in the event of a disaster?
Right now, we have Nurse Anesthesists that can do those things, and they are overseen by MD anesthesiologists. They can intubate and extubate pts, and do CPR etc... ET tube misplacement is rare (it is more of an issue for emergency tubes placed in the field by EMTs, but most of those pts are going to expire anyway).
So effectively this is already a type of "remote anesthesia"... the only difference is the anesthesiologist is in another room instead of another time zone. However, the point is that you still need to have hightly trained, intelligent, capable (read expensive) personel to do all of the hands on management. And then there's the issue of what happens when something occurs that the Nurse Anesthesists can't handle...
I'd prefer improved equipment and methodology that reduces the risk of mistake by orders of magnitude. Why can't the tubes have, say, a fiber optic that shows where they are going so that everyone in the operating room (and remote viewers) can see if the tube is going down the right path?
The arguments for MD anesthesiologists read to me as arguments for development of lower risk, lower error techniques. If individual competence has to be incredibly high then processes need improvement. That's the way quality is approached in manufacturing settings.
Like I said, ET tube misplacement is really really really rare in a controlled OR setting. Much more common is a difficult intubation, where, because of anatomic distortion, you can not see the landmarks to intubate the standard way (which is tricky even in "easy" patients). There are advanced airway kits with different scopes to tackle the problem, but even a lot of MD anesthesiologists lack experience in those techniques because they are not used frequently. On induction of anesthesia, the pt is sedated and paralyzed pharmacologically (eg can not breath on their own)... this makes it a lot easier to intubate patients without complication. However if you can't get the tube in, AND you can't ventilate (eg with bag and mask) the patient, you have the worst emergency you can have... an airway problem where the pt expires in minutes. Right now, no robot it equiped to handle such a situation, and trust me, you want an anesthesiologist or surgeon RIGHT there to fix the problem.
Certainly some other issues could be handled remotely, but still with a skilled (expensive) person there to put in IVs, give drugs, etc.
I'm willing to pay extra for a more skilled and able person to manage my airway. If someone else is happy paying less for a less skilled person, I have no objections nor should it be any of my business. My chief objection is that others (the current party in power) wants to take my money and then determine what is "adequate" care for me so that they can pay for what they think is "adequate" care for someone else. I understand that in an OR setting serious anesthesia mishaps are the exception rather than the rule. When things go as they usually do in the OR, it's "boring". However, when it hits the fan, it often gets really ugly. Given the gravity and irreversibility of the consequences of these uncommon occurrences, my choice is to pay more up front if I believe that will help avoid a catastrophe. Why would someone insist on denying me what I am willing to freely negotiate with a physician anesthesiologist?
Randall - Have you ever tried to intubate someone with the assistance of a fiberoptic scope, particularly in a setting where the patient hasn't been prepped pharmacologically to decrease secretions or has a difficult airway due to upper airway bleeding or anatomical abnormalities? (rhetorical) It's not as easy as one would imagine. Direct visualization (unless contraindicated) is almost always quicker, less traumatic and more reliable. As I said earlier, in the overwhelming majority of cases, a nurse anesthetist (CRNA) can handle the case. It's when "it" happens - and it usually happens when we least expect it - that the "expensive" person is critical. Ironically, 25 years ago, physician anesthesiologists were allowed to supervise a significantly larger number of CRNAs than they can today. But the government said this wasn't safe so they mandated the maximum number of CRNAs that one physician could supervise. Now, it seems that may be reversed. So, what was the REAL issue before - that it was unsafe or that the government wanted to pay less?
CRNAs are cheaper than anesthesiologist and they perform much better. I am not a CRNA. I am a surgeon and I work with CRNAs everyday.