Distraction in the OR?

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There's no metadata with print newspapers, magazines, and crossword puzzles.

The metadata on electronic health records, computers, and phones does make us easy targets for lawyers. A jury doesn't understand how quickly things can happen in an OR and even if you were checking your email 20 minutes prior to an event like a cardiac arrest, it looks bad. However, it is a slippery slope. What about the surgeon who listens to music in the OR? Isn't that a distraction? If there is a surgical complication, will the Spotify playlist be entered in as evidence? There are distractions everywhere in medicine.
 
My problem is, an expert witness stated that the "anesthesia provider" does not have the authority/capacity to stop the procedure if the patient is unstable. All he can do is communicate the instability to the other doc.

Couldn't disagree more.

Really?
 
Although I am on my phone during a case, I am ALWAYS looking up dosages, differential diagnosis, etc. This is where a burner phone would really come in handy.
 
From now on I'm only available by smoke signals.
 
caligas said:
Tip of the iceberg on this stuff
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That's exactly right. It won't just be our phones, either. These electronic health records with their "behind the scenes" metadata are going to be a boon for the lawyers. They will be able to see exactly what time you looked at that x-Ray and how long you looked at it.

"Doctor, tell me, is 33.6 seconds really enough time to look at and evaluate an x-ray?"
 
facted said:
Anyone use a vpn?
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Yes, but this wouldn't help if nurses are testifying that you were on your phone.

Also, side rant: everyone should be using a VPN service for their everyday internet activities. If you don't believe me, read Glenn Greenwald's book No Place to Hide about NSA domestic surveillance programs. In addition to the government agencies, your ISP is also recording all of your internet habits and selling that data to anyone with $$.
 
Maybe everyone needs to be re-educated that depending on the intensity of the case we can be on our device and still be paying attention to the case.
 
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teacher2md said:
Yes, but this wouldn't help if nurses are testifying that you were on your phone.

Also, side rant: everyone should be using a VPN service for their everyday internet activities. If you don't believe me, read Glenn Greenwald's book No Place to Hide about NSA domestic surveillance programs. In addition to the government agencies, your ISP is also recording all of your internet habits and selling that data to anyone with $$.
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How do I start using a VPN?

I know virtually nothing about them, except what it stands for.

I know it slows down your internet connection by 25%. I know it costs money. I know it hides your IP address.

Honestly, I don't care if the NSA knows about my google searches and my emails. I wouldn't be embarrassed. However, I am a firm believer in my privacy as a general rule (fully supportive of Snowden and anyone who thinks he should have gone the whistleblower route needs to read more) and I would likely do a VPN just in the name of privacy.
 
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epidural man said:
How do I start using a VPN?

I know virtually nothing about them, except what it stands for.

I know it slows down your internet connection by 25%. I know it costs money. I know it hides your IP address.

Honestly, I don't care if the NSA knows about my google searches and my emails. I wouldn't be embarrassed. However, I am a firm believer in my privacy as a general rule (fully supportive of Snowden and anyone who thinks he should have gone the whistleblower route needs to read more) and I would likely do a VPN just in the name of privacy.
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Ive been using one called Private Internet Access. Very impressed. 3.50 per month. Does not noticeably slow anything down and is easy to use.

People mainly use them to hide IP from things they are searching/doing/posting, or download illegal software, or access websites currently forbidden by their current IP.
 
epidural man said:
How do I start using a VPN?

I know virtually nothing about them, except what it stands for.

I know it slows down your internet connection by 25%. I know it costs money. I know it hides your IP address.
Click to expand...

There are several commercial VPNs available (you can google and read reviews of them). I use BolehVPN, which I really enjoy. There is no noticible latency with most of the servers that I use. I think I paid $70 for a year's service, which includes access from your phone.

Hoya11 said:
People mainly use them to hide IP from things they are searching/doing/posting, or download illegal software, or access websites currently forbidden by their current IP.
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Many people (myself included) use them for perfectly legal Internet use. It's more an issue of privacy, and whether you think a government or any other entity should know (almost) everything about you, and store that information forever. Even if you think the current US government can be trusted to not abuse this power, what about every future government to come?
 
does a VPN prevent the judicial system from reviewing your internet history ? I would think it's fairly easy for lawyers to figure out you have a VPN and maybe a subpoena if those private records be available ?


Sent from my iPhone using Tapatalk
 
nimbus said:
Maybe everyone needs to be re-educated that depending on the intensity of the case we can be on our device and still be paying attention to the case.
Click to expand...
That's a hard sell when you standing over a corpse....even if the case was bread and butter stupid simple. I heard about a case of a lap appy in a 20 something year old that died because the surgeon put a trochar in the aorta. Not anywhere near anesthesia's fault...but let some defense attorney find out I was on Twitter leading up to the disaster.....which is why I try my best to not Tweet during my cases. I'm not always successful, but this thread will make me more mindful
 
Twiggidy said:
That's a hard sell when you standing over a corpse....even if the case was bread and butter stupid simple. I heard about a case of a lap appy in a 20 something year old that died because the surgeon put a trochar in the aorta. Not anywhere near anesthesia's fault...but let some defense attorney find out I was on Twitter leading up to the disaster.....which is why I try my best to not Tweet during my cases. I'm not always successful, but this thread will make me more mindful
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It is a hard sell. And on second thought I think the care described in the OPs link is substandard. The anesthesiologist should have been more insistent in finding a cause for hypotension as he was treating it. I've never started a dopamine infusion during an ablation. And really tamponade is on top of the differential. Maybe he was more interested in whatever he was doing on his phone.
 
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Skip2myLou said:
does a VPN prevent the judicial system from reviewing your internet history ? I would think it's fairly easy for lawyers to figure out you have a VPN and maybe a subpoena if those private records be available ?


Sent from my iPhone using Tapatalk
Click to expand...

There are no VPN records theoretically. Not to mention VPN companies are offshore so a subpoena is not that easy to enforce.
 
facted said:
There are no VPN records theoretically. Not to mention VPN companies are offshore so a subpoena is not that easy to enforce.
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Presumably the VPN companies don't even keep records in the first place.


Every hospital I've worked in for the last 5 or 10 years, cell phones / texts were the primary means of communication with other staff members. Many people get pages forwarded to their phones and don't even carry pagers any more.

I just counted 43 texts in my phone in one group/conversation alone, between me and two other people on Mon & Tues of this week. And that's just for intraop TEE coordination. There must be 100 more coordinating breaks, preops, transport, schedule changes, academics, etc.

We can't just not use cell phones during cases because some observer might think we're playing Scrabble or surfing some online celebrity gossip rag.
 
facted said:
There are no VPN records theoretically. Not to mention VPN companies are offshore so a subpoena is not that easy to enforce.
Click to expand...

I think it depends on the laws of the country that the VPN is based in. You should actually read the fine print regarding logging data and know the data laws of the country before you choose a VPN service. I do agree that if a malpractice lawyer is trying to subpoena a VPN company in Bulgaria then you really must have f***ed up.
 
Unfortunately, as with most things in court, the facts matter much less than the appearances. The jurors are not Hercule Poirots; they have average IQ of 100-ish, which is a very polite way of saying they are much dumber than the doctors they pass judgment on (and probably too dumb to pass judgment at all). It's one of the reasons why most civilized countries have specialized medical malpractice systems, even judges, and definitely no juries, and don't let any Joe Sixpack count as a physician's "peer". And why smart and/or rich people become "elitist" and would rather govern without the plebes.

It's all smoke and mirrors, and about who has the better smoke, mirrors and magician, especially in malpractice courts in certain areas of the country. There is one illogical and unpredictable jury decision after another; hence people settle out of court at malpractice insurance limits, to avoid nasty surprises. Most of these jurors are not passionate about justice; most of them didn't want to be there in the first place.

In a case like this, even if the anesthesiologist has done no harm to the patient, one can expect punitive damages levied on him. Why? So that all anesthesiologists are taught a lesson, not to do anything else while taking care of a patient, even if providing excellent care. Why? Because that's what "the people" want. They don't care about guilt, they don't care about facts, they care about appearances. That's why minority physicians are still discriminated against by some patients; appearances and brainwash shampoos matter more than most sheep realize. Let's not speak about the entire atmosphere stoked against physicians, with a lot of negative public sentiment to start with. The public wants its doctors to be Mothers Theresa; this guy was not.
 
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FFP said:
Unfortunately, as with most things in court, the facts matter much less than the appearances. The jurors are not Hercule Poirots; they have average IQ of 100-ish, which is a very polite way of saying they are much dumber than the doctors they pass judgment on (and probably too dumb to pass judgment at all). It's one of the reasons why most civilized countries have specialized medical malpractice systems, even judges, and definitely no juries, and don't let any Joe Sixpack count as a physician's "peer". And why smart and/or rich people become "elitist" and would rather govern without the plebes.

It's all smoke and mirrors, and about who has the better smoke, mirrors and magician, especially in malpractice courts in certain areas of the country. There is one illogical and unpredictable jury decision after another; hence people settle out of court at malpractice insurance limits, to avoid nasty surprises. Most of these jurors are not passionate about justice; most of them didn't want to be there in the first place.

In a case like this, even if the anesthesiologist has done no harm to the patient, one can expect punitive damages levied on him. Why? So that all anesthesiologists are taught a lesson, not to do anything else while taking care of a patient, even if providing excellent care. Why? Because that's what "the people" want. They don't care about guilt, they don't care about facts, they care about appearances. That's why minority physicians are still discriminated against by some patients; appearances and brainwash shampoos matter more than most sheep realize. Let's not speak about the entire atmosphere stoked against physicians, with a lot of negative public sentiment to start with. The public wants its doctors to be Mothers Theresa; this guy was not.
Click to expand...

In the words of Hozier....

A-a-a-a....Amen....Amen........Amen
 
From now on , any complication that ever happens in or will be the anesthesiologists fault. Its pretty rare for the anesthesiologist to not be on their phone
 
Not to go off topic here but tamponade is 1-10 on my top ten differential here in this case. The response and physiology playing out in this scenario screams tamponade.
 
The main medical error in this case was that there was a TEE in the room, and yet nobody used it to see what was wrong.

Next time you miss an easy diagnosis because you don't know TEE/TTE, don't expect the jury to be sympathetic. It's 2017, and even first year EM residents know how to take a look at a heart. The same way regional is a requirement nowadays, basic ultrasound skills are a must, and that applies to most of the body.
 
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FFP said:
The main medical error in this case was that there was a TEE in the room, and yet nobody used it to see what was wrong.

Next time you miss an easy diagnosis because you don't know TEE/TTE, don't expect the jury to be sympathetic. It's 2017, and even first year EM residents know how to take a look at a heart. The same way regional is a requirement nowadays, basic ultrasound skills are a must, and that applies to most of the body.
Click to expand...


Many anesthesiologists haven't touched a TEE since residency. They don't know when to use it and have no desire to learn.
 
maybe a TEE wasn't accessible? or maybe esophagus was deviated? idk but when i do EP, theres just a ton of hypotension from them causing tachycardia to the high 100s.
 
FFP said:
The main medical error in this case was that there was a TEE in the room, and yet nobody used it to see what was wrong.

Next time you miss an easy diagnosis because you don't know TEE/TTE, don't expect the jury to be sympathetic. It's 2017, and even first year EM residents know how to take a look at a heart. The same way regional is a requirement nowadays, basic ultrasound skills are a must, and that applies to most of the body.
Click to expand...
I'm not sure we can reasonably call TEE "standard of care" yet.

Of course, juries can be unreasonable.
 
This is an insane precedent. What about the circulator who goes on Amazon or Travelocity during the case? What if there is music being played? What if there are conversations not related to direct patient care: What did you do this weekend? Did you see that new movie? It seems like any minutae of distraction could be used against you in a court of law.
 
pgg said:
I'm not sure we can reasonably call TEE "standard of care" yet.

Of course, juries can be unreasonable.
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Not TEE, TTE. Basic transthoracic cardiac echo (PLAX, 4-chamber) should be standard of care, the same way it is for a central line. At least at the level of diagnosing an effusion.

Regarding TEE: in this case, there was a TEE in the room and at least one person who knew how to use it.
 
nimbus said:
They might have wheeled it out after initial exam to exclude thrombus.
Click to expand...
Good point. I didn't think about that.

I just want to encourage non-cardiac/non-ICU people to start learning basic thoracic ultrasound, at least TTE. Today it's an extension of the stethoscope. Five-ten years from now, as the cost for portability decreases, it will be the stethoscope. Even if not, it gives a tremendous advantage to the knowledgeable user. One can even do gastric ultrasound to check for gastric contents. There are even techniques to measure ICP by optic nerve ultrasound.
 
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nimbus said:
Many anesthesiologists haven't touched a TEE since residency. They don't know when to use it and have no desire to learn.
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I know. I've been there. But it's a fantastic tool, especially in the more ICU-ish limited versions which allow one to measure cardiac output and get just a few major views. Probably much better than all the bioimpedance/arterial waveform contour crap.
 
FFP said:
I know. I've been there. But it's a fantastic tool, especially in the more ICU-ish limited versions which allow one to measure cardiac output and get just a few major views. Probably much better than all the bioimpedance/arterial waveform contour crap.
Click to expand...

The problem is our current fellowship system acts as a silly gatekeeper in preventing people from learning and subsequently using ultrasound in its various forms. Many hospitals now require people to have a cardiac fellowship to be TEE certified, so the thought process is that since you need a fellowship, there's no point in even learning the basics. I agree with you that basic ultrasound skills should be required of all anesthesiologists, but the fellowship system puts an obstacle in place that prevents people from learning new skills beyond residency.
 
GravelRider said:
The problem is our current fellowship system acts as a silly gatekeeper in preventing people from learning and subsequently using ultrasound in its various forms. Many hospitals now require people to have a cardiac fellowship to be TEE certified, so the thought process is that since you need a fellowship, there's no point in even learning the basics. I agree with you that basic ultrasound skills should be required of all anesthesiologists, but the fellowship system puts an obstacle in place that prevents people from learning new skills beyond residency.
Click to expand...


As a nonfellowship trained anesthesiologist, I completely disagree. We didn't even have ultrasound for lines and blocks when I was a resident. TEE was biplane, you got 0 or 90 degrees. Nothing is stopping you from acquiring new skills. Learning resources are plentiful and free for those who want to learn. You do need a fellowship to be TEE certified but anyone can become a testamur and that is good enough for most hospitals. Around here, even if you're not boarded or a testamur, nobody is going to stop you from using echo when you need it. The hospitals have no idea even what an echo board is. It's usually up to the anesthesia department to determine what certifications are needed.

I think I learned more after residency than during. A fellowship may be an efficient way to learn, but it is absolutely not the only way to continue your education.
 
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nimbus said:
As a nonfellowship trained anesthesiologist, I completely disagree. We didn't even have ultrasound for lines and blocks when I was a resident. TEE was biplane, you got 0 or 90 degrees. Nothing is stopping you from acquiring new skills. Learning resources are plentiful and free for those who want to learn. You do need a fellowship to be TEE certified but anyone can become a testamur and that is good enough for most hospitals. Around here, even if you're not boarded or a testamur, nobody is going to stop you from using echo when you need it. The hospitals have no idea even what an echo board is. It's usually up to the anesthesia department to determine what certifications are needed.

I think I learned more after residency than during. A fellowship may be an efficient way to learn, but it is absolutely not the only way to continue your education.
Click to expand...

I'm not disagreeing with you. I think every anesthesiologist should be able to use a ultrasound to make a quick diagnosis...especially in a code situation. There is a ton of information online and frankly a better use of time than MOCA minute (that's another story). However, the pure fact that fellowships exist is a sort of psychological obstacle for some people to learn new skills. You likely started practicing before fellowships became the norm. Now many places won't let you step into a heart room without a fellowship. When is that non-fellowship person going learn and then maintain TEE skills? I think my point is that the downside to this new fellowship culture is a tendency for some anesthesiologists to not develop a wide breadth of knowledge...especially once you start practicing.
 
And here I thought the article was going to be about the distracted doctor in the room. You know, the guy who was so focused on squiggly lines and all the other tech that he couldn't take a few minutes to evaluate why the patient was dying right underneath his hands.
 
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