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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.


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May 2014 Number 78 Number 5
Situational Awareness, Multitasking, and Distraction in the O.R. Sara E. Neves, M.D.
Committee on Patient Safety and Education

Roy G. Soto, M.D.
Committee on Patient Safety and Education

Traffic accidents are attributed to texting while driving; parents worry about their children’s phone addiction; psychologists define new technology-related disorders; employers struggle to maintain productivity while employees tweet during work hours. Everywhere there is concern about the evolving role of technology in our lives and our ability to adapt. Anesthesiologists are familiar with this controversy: we use rapidly changing technology-driven data to care for our patients on a daily basis. We are aware of the potential for distractibility in the O.R., whether from multiple alarms and ambient noise and lights, or from reading, talking or crossword puzzles. We want our trainees to pay better attention, yet they work in an increasingly distracting environment. Are we better adapted to a distracting environment or are we deluding ourselves as much as any texting driver? Must we prepare our trainees to adapt to this technological environment, or are they already more suited to it than those of use who trained but a decade ago?


When we talk about distraction in the O.R., we often talk about improving our situational awareness, or our ability to multitask. In fact, situational awareness (SA) and multitasking are two sides of a coin. SA is how we function in a complex environment. It’s composed of three components: the perception of environmental elements, the comprehension of their meaning and the projection of their status after an intervention.1 Having good SA means successfully incorporating many pieces of information into a cogent plan. In the O.R., this is how we use pulse, blood pressure, capnography, what surgeons are saying to each other, and the sound of suction to recognize hemorrhagic shock and treat it. SA is how we react in a complex and distracting environment.


Multitasking, in contrast, is the practice of performing multiple, often unrelated tasks at the same time. Clifford Nass, a researcher on the interaction between humans, technology and distractibility, describes it as follows:


“The problem with multitasking is not that we’re writing a report of Abraham Lincoln and hear, see pictures of Abraham Lincoln and read words of Abraham Lincoln and see photos of Abraham Lincoln. The problem is we’re doing a report on Abraham Lincoln and tweeting about last night and watching a YouTube video about cats playing the piano, et cetera ... It’s extremely healthy for your brain to do integrative things. It’s extremely destructive for your brain to do non-integrative things.”


In our practice, that translates into listening to the monitors, talking to the surgeon about the weekend and checking email on a smartphone while drawing up the next dose of antibiotics. Multitasking creates a complex and distracting environment, and our brains are notoriously bad at adapting, despite our own beliefs to the contrary. Just recently, a study in the New England Journal of Medicine from January 20142 demonstrated that texting or dialing a phone while driving significantly increases the risk of a car crash. Translate those findings to the distracted anesthesiologist caring for a patient and we see a bleak picture. Those who think they are good at multitasking are often actually worse at it than those who don’t multitask regularly. As a corollary, then, while the younger population may be more adept at troubleshooting an app on their iPad, there’s no evidence to suggest that they are any less susceptible to distraction when multitasking and may in fact be more addicted to distracting personal electronic devices than those who grew up without them.


So how do anesthesiologists fare functioning in distracting environments? Slagle and Weinger in 20093 showed that while anesthesiologists read during a significant portion of many cases, it did not appear to affect vigilance. On the other hand, in 2013 Stevenson et al.4 demonstrated that background noise caused as much as a 17 percent reduction in the ability to recognize changes in O2 saturation. To date, there has not been a study to specifically address multitasking on our ability to take care of patients in the O.R. We train ourselves and our residents to have better situational awareness, either through mentoring or simulation, yet we never address the problem of multitasking. It’s difficult to incorporate distraction and multitasking into a simulated scenario; in fact, it’s nearly impossible for the multitasker to even recognize that he or she is distracted. We can do better.


Recently, it was suggested by Dr. Papadakos in Anesthesia and Clinical Research5 that a modified CAGE questionnaire (traditionally used to assess risk factors for alcohol abuse, Table 1) could be used to identify those with a significant addiction to their personal electronic devices (PED). In effect, it would help identify those at risk of being distracted by their own actions before they entered the O.R. Perhaps formally recognizing that there is a problem would make it easier for anesthesiology departments to implement limitations on electronic devices in the O.R., either for individuals or groups. Attempts to control PED use in the O.R. are usually frustrated by a blanket policy that doesn’t address variations in individual use. Perhaps a more tailored approach to regulating PED use may improve compliance.


The outlook is optimistic. Our brains can thrive in complex, stimulating environments such as the O.R. Trainees should be taught to hone their situational awareness, recognize distraction and learn to overcome the impulse for multitasking. Similar to the federal government’s statement on “cellphones and texting while driving,”2 perhaps it is time for us to develop a protocol that fits our unique environment in the O.R. – a place where distractions are inevitable and technology can help us and hurt us. Increase our situational awareness and perhaps we will increase our ability to recognize multitasking and eradicate it.


May 2014 ASA Newsletter

Sara E. Neves M.D. is a CA-3 resident, Yale-New Haven Hospital, Yale University, New Haven, Connecticut.


Roy G. Soto, M.D. is Professor, Oakland University William Beaumont School of Medicine, Residency Program Director, Department of Anesthesiology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan.


1. Schulz, et al. Situation Awareness in Anesthesia. Anesthesiology. 2013; 118:729-42.

2. Klauer et al. Distracted Driving and Risk of Road Crashes among Novice and Experienced Drivers. N Engl J Med. 2014; 370:54-59.

3. Slagle JM Weinger MB Effects of Intraoperative Reading on Vigilance and Workload during Anesthesia Care in an Academic Medical Center. Anesthesiology. 2009; 110:2.

4. Stevenson et al Effects of Divided Attention and Operating Room Noise on Perception of Pulse Oximeter Pitch Changes. Anesthesiology. 2013; 118:376-81.

5. Papadakos PJ. The Rise of Electronic Distraction in Health Care is Addiction to Devices Contributing. J Anesthe Clinic Res. 2013; 4:e112.

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