In control or along for the ride? Lessons for anesthesiologists from air traffic control.

PURPOSE OF REVIEW: Anesthesia professionals work in an unpredictable, rapidly changing environment in which they are quickly diagnose and manage uncommon and life-threatening critical events. The perioperative environment has traditionally been viewed as a deterministic system in which outcomes can be predicted, but recent studies suggest that the operating room behaves more like a complex adaptive system, in which events can interact and connect with each other in unpredictable and unplanned ways. RECENT FINDINGS: The increasing complexity of the healthcare environment suggests that the complete elimination of human error is not possible. Complex clinical situations predispose to errors that are the result of high workload, decision making under stress, and poor team coordination. The theory behind complex adaptive systems differs from medicine's traditional approach to safety and highlights the importance of an institutional safety culture that encourages flexibility, adaptability, reporting and learning from errors. Instead of focusing on standardization and strict adherence to procedures, clinicians can improve safety by recognizing that unpredictable changes routinely occur in the work environment and learning how resilience can prevent adverse events. SUMMARY: A better understanding of automation, complexity, and resilience in a changing environment are essential steps toward the safe practice of anesthesia.

An empirical analysis of American Passenger's willingness to fly in commercial airplanes after vaccination against COVID-19.

Although several studies have explored the effects of the pandemic on aviation, little remains known about whether members of the public are willing to fly again after they have been vaccinated. The current study uses the Health Belief Model (HBM) to fill this missing gap by manipulating the following variables: 1) whether or not the participant is vaccinated; 2) whether or not airlines require that all passengers and crew receive vaccinations; 3) length of flight; 4) destination; and 5) the number of passengers. The data from 678 participants revealed that willingness to fly is much higher if the participants themselves have been vaccinated, if the airlines require all passengers to be vaccinated, if the flight is short, if the destination is domestic, and if the number of passengers is low. These findings did not appear to differ as a function of flying business versus pleasure. We discuss the practical implications of these data as airlines struggle to bring back their customer base.

Sudden cardiac arrest in commercial airports: Incidence, responses, and implications.

Billions of travelers pass through airports around the world every year. Airports are a relatively common location for sudden cardiac arrest when compared with other public venues. An increased incidence of cardiac arrest in airports may be due to the large volume of movement, the stress of travel, or adverse effects related to the physiological environment of airplanes. Having said that, airports are associated with extremely high rates of witnessed arrests, bystander interventions (eg. CPR and AED use), shockable arrest rhythms, and survival to hospital discharge. Large numbers of people, a high density of public-access AEDs, and on-site emergency medical services (EMS) resources are probably the major reasons why cardiac arrest outcomes are so favorable at airports. The success of the chain of survival found at airports may imply that applying similar practices to other public venues will translate to improvements in cardiac arrest survival. Airports might, therefore, be one model of cardiac arrest preparedness that other public areas should emulate.

Effects of vaccination status in the United States on willingness to undergo surgery during a pandemic: A prospective survey study.

PURPOSE OF THE RESEARCH: Modifiable and non-modifiable patient and hospital characteristics may affect willingness to undergo surgery during a pandemic. We hypothesized that vaccination of hospital staff and patients, type of surgery, and length of stay, would affect willingness to undergo a surgical procedure. 2006 adult participants in the United States were recruited electronically using Amazon's ® Mechanical Turk ® and answered a 26-item survey in English about hypothetical surgery, manipulating requirements for: staff vaccination, patient vaccination, surgical urgency, and time in hospital. They also answered questions about their opinions about vaccination, personal vaccination status, and demographics. PRINCIPLE RESULTS: Participants are more willing to undergo surgery if they have been vaccinated, if staff vaccinations are required, and if surgery is lifesaving and outpatient. MAJOR CONCLUSIONS: Willingness to undergo surgery varies with hospital staff and patient vaccination. This may inform policies for vaccination, boosters, and resource allocation.

COVID-19, Personal Protective Equipment, and Human Performance.

Clinicians who care for patients infected with coronavirus disease 2019 (COVID-19) must wear a full suite of personal protective equipment, including an N95 mask or powered air purifying respirator, eye protection, a fluid-impermeable gown, and gloves. This combination of personal protective equipment may cause increased work of breathing, reduced field of vision, muffled speech, difficulty hearing, and heat stress. These effects are not caused by individual weakness; they are normal and expected reactions that any person will have when exposed to an unusual environment. The physiologic and psychologic challenges imposed by personal protective equipment may have multiple causes, but immediate countermeasures and long-term mitigation strategies can help to improve a clinician's ability to provide care. Ultimately, a systematic approach to the design and integration of personal protective equipment is needed to improve the safety of patients and clinicians.

A qualitative analysis of social and emotional perspectives of airline passengers during the COVID-19 pandemic.

Background: Fear of illness, economic damage, and stigma have had a devastating impact on the travel industry and have caused a significant reduction in both business and leisure travel. This study examines passengers' social and emotional perspectives during and after the COVID-19 pandemic, building on a prior quantitative study that identified factors that predict a person's willingness to fly during the COVID-19 pandemic. Methods: This study used a qualitative method with a phenomenological perspective and hermeneutic design. Fifteen adults from the United States participated in a personal interview designed to capture demographics, individual safety measures, feelings, and concerns involving air travel during the pandemic. Personal interview transcripts were then inspected by the researchers using a constant comparison method. Results: The personal experiences of participants were dominated by projections of trust issues and emotional heuristics, protective behaviors, and fear of confrontations with others, and a fear of the unknown. These themes emerged even in participants who continued to fly during the pandemic. Conclusion: Insights into travelers' emotions, trust, and fears may help airlines and other segments of the travel industry to develop targeted messaging that supports the trust and safety issues confronted by frequent travelers.

Chest Compression Duration May Be Improved When Rescuers Breathe Supplemental Oxygen.

BACKGROUND: At sea level, performing chest compressions is a demanding physical exercise. On a commercial flight at cruise altitude, the barometric pressure in the cabin is approximately equal to an altitude of 2438 m. This results in a Po2 equivalent to breathing an FIo2 of 15% at sea level, a condition under which both the duration and quality of cardiopulmonary resuscitation (CPR) may deteriorate. We hypothesized that rescuers will be able to perform fewer rounds of high-quality CPR at an FIo2 of 15%.METHODS: In this crossover simulation trial, 16 healthy volunteers participated in 2 separate sessions and performed up to 14 2-min rounds of chest compressions at an FIo2 of either 0.15 or 0.21 in randomized order. Subjects were stopped if their Spo2 was below 80%, if chest compression rate or depth was not achieved for 2/3 of compressions, or if they felt fatigued or dyspneic.RESULTS: Fewer rounds of chest compressions were successfully completed in the hypoxic than in the normoxic condition, (median [IQR] 4.5 [3,8.5]) vs. 5 [4,14]). The decline in arterial Spo2 while performing chest compressions was greater in the hypoxic condition than in the normoxic condition [mean (SD), 6.19% (4.1) vs. 2% (1.66)].DISCUSSION: Our findings suggest that the ability of rescuers to perform chest compressions in a commercial airline cabin at cruising altitude may be limited due to hypoxia. One possible solution is supplemental oxygen for rescuers who perform chest compressions for in-flight cardiac arrest.Clebone A, Reis K, Tung A, OConnor M, Ruskin KJ. Chest compression duration may be improved when rescuers breathe supplemental oxygen. Aerosp Med Hum Perform. 2020; 91(12):918922.

Automation failures and patient safety.

PURPOSE OF REVIEW: The goal of automation is to decrease the anesthesiologist's workload and to decrease the possibility of human error. Automated systems introduce problems of its own, however, including loss of situation awareness, leaving the physician out of the loop, and training physicians how to monitor autonomous systems. This review will discuss the growing role of automated systems in healthcare and describe two types of automation failures. RECENT FINDINGS: An automation surprise occurs when an automated system takes an action that is unexpected by the user. Mode confusion occurs when the operator does not understand what an automated system is programmed to do and may prevent the clinician from fully understanding what the device is doing during a critical event. Both types of automation failures can decrease a clinician's trust in the system. They may also prevent a clinician from regaining control of a failed system (e.g., a ventilator that is no longer working) during a critical event. SUMMARY: Clinicians should receive generalized training on how to manage automation and should also be required to demonstrate competency before using medical equipment that employs automation, including electronic health records, infusion pumps, and ventilators.

Factors that predict passengers willingness to fly during and after the COVID-19 pandemic.

BACKGROUND: Prior research has examined consumer willingness to fly in a variety of situations, including during disease outbreaks. However, to date, no study that we know of has identified what type of person is willing to fly during the COVID-19 pandemic. METHODS: Six hundred and thirty-two participants from the United States were asked to complete a survey designed to capture demographics, personality measures, emotional states and travel purposes. The data were collected in two stages in order to both develop a descriptive regression equation and a predictive model. RESULTS: Regression equations were created for both business and pleasure travel, and the following predictors were significant for both scenarios: perceived threat from COVID-19, agreeableness, affect, and fear. These models accounted for 66-67% of the variance in willingness to fly. CONCLUSION: Airlines and governments could use these findings to help control the message to potential passengers on actions being taken to provide a safe flying experience, such as mask wearing policies and aircraft disinfectant procedures.

Autopilots in the Operating Room: Safe Use of Automated Medical Technology.

Automated medical technology is becoming an integral part of routine anesthetic practice. Automated technologies can improve patient safety, but may create new workflows with potentially surprising adverse consequences and cognitive errors that must be addressed before these technologies are adopted into clinical practice. Industries such as aviation and nuclear power have developed techniques to mitigate the unintended consequences of automation, including automation bias, skill loss, and system failures. In order to maximize the benefits of automated technology, clinicians should receive training in human-system interaction including topics such as vigilance, management of system failures, and maintaining manual skills. Medical device manufacturers now evaluate usability of equipment using the principles of human performance and should be encouraged to develop comprehensive training materials that describe possible system failures. Additional research in human-system interaction can improve the ways in which automated medical devices communicate with clinicians. These steps will ensure that medical practitioners can effectively use these new devices while being ready to assume manual control when necessary and prepare us for a future that includes automated health care.

Shallow metabolic depression and human spaceflight: a feasible first step.

Synthetic torpor is an induced state of deep metabolic depression (MD) in an organism that does not naturally employ regulated and reversible MD. If applied to spaceflight crewmembers, this metabolic state may theoretically mitigate numerous biological and logistical challenges of human spaceflight. These benefits have been the focus of numerous recent articles where, invariably, they are discussed in the context of hypothetical deep MD states in which the metabolism of crewmembers is profoundly depressed relative to basal rates. However, inducing these deep MD states in humans, particularly humans aboard spacecraft, is currently impossible. Here, we discuss shallow MD as a feasible first step toward synthetic torpor during spaceflight and summarize perspectives following a recent NASA-hosted workshop. We discuss methods to safely induce shallow MD (e.g., sleep and slow wave enhancement via acoustic and photoperiod stimulation; moderate sedation via dexmedetomidine), which we define as an ~20% depression of metabolic rate relative to basal levels. We also discuss different modes of shallow MD application (e.g., habitual versus targeted, whereby shallow MD is induced routinely throughout a mission or only under certain circumstances, respectively) and different spaceflight scenarios that would benefit from its use. Finally, we propose a multistep development plan toward the application of synthetic torpor to human spaceflight, highlighting shallow MD's role. As space agencies develop missions to send humans further into space than ever before, shallow MD has the potential to confer health benefits for crewmembers, reduce demands on spacecraft capacities, and serve as a testbed for deeper MD technologies.

Helicopter air ambulance services.

PURPOSE OF REVIEW: Helicopter air ambulances are an integral component of modern trauma care, and are able to transport patients to facilities with greater capabilities, extract injured patients from hostile terrain, and speed transport to a trauma center. RECENT FINDINGS: HAA transport does not reduce the total time required to transport a patient, but it does reduce the time that the patient is between healthcare facilities. Factors that have been suggested to improve outcomes for trauma patients include the availability of advanced interventions, skilled personnel, speed, and trauma center access. Despite their potential benefits to the patient, HAA operations carry significant risks. HAA operations are among the most dangerous professions for both pilot and crew with a mortality rate greater than commercial fishing, loggers, and steelworkers. The US Federal Aviation Administration (FAA) has identified that the four most common causes of HAA accidents as inadvertent flight into instrument meteorological conditions, loss of control, controlled flight into terrain, and night conditions. SUMMARY: HAA operations are safe and can improve patient care, but additional research is needed to improve our understanding of HAA operations and their effect on outcomes.

Medical Guidelines for Airline Travel: Management of In-Flight Cardiac Arrest.

INTRODUCTION: Although cardiac arrest during airline flights is relatively uncommon, the unusual setting, limited resources, and the variability of the skills in medical volunteers present unique challenges. Survival in patients who suffer a witnessed arrest with a shockable rhythm who are treated promptly has improved since the advent of widely available automated external defibrillators (AEDs). In general, the chances of survival from an out-of-hospital cardiac arrest (OHCA) are greater when ventricular fibrillation (VF) is seen as the initial rhythm or if there is return of spontaneous circulation (ROSC). Not all in-flight cardiac arrests are witnessed because cabin crew or fellow passengers might simply assume that the victim is sleeping. Based upon a review of the literature on resuscitation after OHCA, we recommend that automatic external defibrillators be carried on all commercial airline flights, regardless of duration. Patients presenting with shockable rhythm (e.g., VF, unstable ventricular tachycardia) have the best prognosis for survival and usually require diversion of the aircraft for advanced cardiac life support (ACLS). Because diversion may require interruption of cardiopulmonary resuscitation (CPR) and may impact flight safety, the volunteer rescuer, cabin crew, flight crew, and medical consultation services should discuss the possible outcome and operational considerations before recommending a diversion for a patient with a nonshockable rhythm. The recommendations in this article were developed by members of the Air Transport Medicine and Aerospace Human Performance Committees and approved by the Council of the Aerospace Medical Association.Ruskin KJ, Ricaurte EM, Alves PM. Medical guidelines for airline travel: management of in-flight cardiac arrest. Aerosp Med Hum Perform. 2018; 89(8):754-759.