Sadly, recent world news has fixated on the disastrous second crash in five months of a Boeing 737 Max aircraft, a plane that was supposed to be the pinnacle of performance, technology and even safety. The plane, an Ethiopian Airways jet (owned by the same airline I flew last summer to a medical mission in Tanzania), was lost shortly after takeoff on March 10, killing all 157 people aboard. Boeing insisted the plane is safe and that the crashes have nothing to do with defects in the plane. Owners of the plane are skeptical, leading many airlines in nations including (after a conspicuous and controversial delay) the United States to ground their fleet of 737 Max’s until the question of safety and/or defects is resolved.
The FBI is currently involved in a potential criminal probe of Boeing, related to whether the company had knowledge of the software defect that is believed to have led to the crashes. So, too, there have been recent stories of “jump seat” pilots having to take over from perplexed and panicked pilots who were not trained, briefed or otherwise skilled to handle this seemingly prevalent flaw that kept turning the plane’s nose down.
How does any of this apply to medical practice and patients, you might ask? Easy—technology and the increasingly limited role of human operator control. There have long been comparisons made between aviation safety and medical safety, particularly in the areas of anesthesia and surgery. Indeed, in my own specialty of anesthesiology, inducing anesthesia has often been compared to “take-off,” and emergence from it has been likened to “landing” the patient. What happens between those events has often been compared to maintaining stability, avoiding turbulence and keeping the ride (and anesthetic course) smooth.
But as companies who make planes, anesthesia equipment, surgical equipment and self-driving cars (who have had their share of injuries and even deaths) might not want to admit, this move away from operator control towards automation, often showcased to drive profits with technologic glitz and sexiness, might turn out to be a dangerous one. This is nowhere more evident than in this entry from the front page of The Washington Post on March 12th, 2019, where reporters Aaron Gregg and Christian Davenport write:
“The crash…puts the spotlight on Boeing, which already faced scrutiny for its October crash in Indonesia and concerns that a software update to the 737 could make it hard to override a malfunctioning autopilot system when it steers the plane into a nose dive.”
It is this possible inability to override that reminded me of personal experience with some anesthesia and surgical equipment that has, in the past, caused or could have caused patient harm. I recall one case where a woman was undergoing a hysteroscopy, where fluid is flushed in the uterus to help visualize the female reproductive tract with an endoscope. Everyone was paying attention to the screen where the interior of the uterus was visible, but no one was really paying attention to the patient. Instead, an alarm system that kept going off due to imbalances in fluid-in versus fluid-out of the patient occupied much of the staff’s attention and efforts. Repeated fiddling with warning sounds controls and real-time trouble-shooting the equipment cost valuable attention to the patient, whose lungs were rapidly filling with fluid due to a severe fluid imbalance caused by faulty input to the monitor. The patient went into severe congestive heart failure and required a tracheostomy (cutting a breathing hole in her neck to her trachea) because of an inability to intubate her (which involves inserting a breathing tube down the windpipe). Eventually she did well, but it was a close call.
Similarly, I remember when laparoscopic gall bladder removal first emerged in the early 1990’s. Prior to that, gall bladders were removed with a large, open incision in the upper abdomen. The learning curve to skillfully operate the laparoscopy equipment for abdominal surgery required extra time, effort and attention by the surgeon. Bells and whistles went off like crazy, as pressure gauges, electrocautery connections and gas supply meters to insufflate (blow gas into) the abdomen all needed attention. This took critical attention away from the patient and onto equipment. The very technology that was supposed to help patients instead, at least in the learning phase of practice, ended up putting the patient at risk. Not only that, as surgeons came to rely on laparoscopic gall bladder removal as the primary method, they lost their skills in the old method, a method that sometimes they might have to fall back on in case the laparoscopic way failed. Many newer surgeons are not even adequately trained in the older method.
The point of this discussion is that in medicine, as in aviation, more technology and fancy equipment may not be better. In fact, anything that takes away from human operator control, flawed as that might be, might actually be more dangerous than previously thought. The same Post article concluded by saying:
“…the controversy revived an ongoing debate about what degree of automation is safest for airplanes—and how much human pilots should maintain.”
So what can you, the patient, do to protect yourself? Unfortunately, not a lot, short of telling your medical team, “Remember me and pay close attention, not to just your equipment!”
What really needs to happen is that both the medical and aviation industries, as well as any industry entrusted with the public safety, ensure that skilled operators are well versed in the use and design of their equipment…have the ability to understand and override faulty warning systems…and, most importantly, are enabled to devote primary attention to what they were trained to do, whether that would be wielding a scalpel, steering clear of turbulence or landing a multi-ton plane full of hundreds of people safely. After all, pilots, doctors and even cab drivers were meant and trained to do a job with their heads and their hands, not troubleshoot overly complex systems that might well have been designed to make the product used appear to be more sophisticated, modern and appealing.