Anesthesiology article. "A framework for critical to the success of this whole con- sible for the BAS or its successors to comeintegrating anesthesia monitoring and con- cept. To achieve reliability it is essential to close to perfection.trol has been created. Some previously im- be able to decrease to a small value the For now, though, the BAS can cut a pathpractical physiological monitoring tech- number of interconnections in a design. It through the operating room jungle for theniques and record-keeping concepts can has only recently been possible to develop anesthetist.Obe re-examined. Automated record-keeping a system with such sophisticated perform-becomes more plausible, innovative clini- ance with a modest number of compo- References:cal teaching methods suggest themselves, nents. The number required will continue 1.N ewbower RS, Cooper JB, and Long OD: Learning tromAnesthesia Mishaps. Quality Review Bulletin, March 1981and studies of the anesthesia control loop to decrease rapidly over the next few years 2. Newbower, Cooper, and Trautman ED: A Microproces-may be facilitated." as advances in electronic technology con- sor-Based Anesthesia Delivery System. MicrocomputersThere is much more work to be done, tinue and higher levels of integration are in Patient Care (Park Ridge, N.J.:Noyes Medical Publica-

and some of it depends on the continued achieved," team members stated. tions, 1981).3. Ream AK: New Directions: The Anesthesia Machine

improvement in technology. The BAS was But even then it may not be enough for a and the Practice of Anesthesia. Anesthesiology, Volumedesigned in 1974-76 and the electronics perfect system. While advances in electro- 49, Number 5, November 1978.and microprocessor used in the prototype nic technology come in quantum leaps, im- 4. Cooper, Newbower, Trautman, and Moore JW: A Neware not obsolete. All the electronics will provements in mechanical and electrome- Anesthesia Delivery System. Anesthesiology, Volume 49,

be replaced in a commercial version by a chanical components come in relative 5 Cooper, Newbower, Long, and McPeek B: Preventablemuch simpler set of boards and much more hops. New forms of switches and electrical Anesthesia Mishaps: A Study of Human Factors. Anes-sophisticated CPU and memory. "The cur- connectors, and pipe fittings and hose con- thesiology, Volume 49, Number6, December 1978.rent technical revolution in electronics is nectors, must be developed to make it pos-

Clinical engineers and anesthesiologyA mutually productive association

By JAY ANTHONY,ELIZABETH JUDEN

and ADRIANA REYNERIEMB Magazine Staff

T he clinical engineer is a new breed trained just as long and hard as a physi- maintenance, and especially the devel-and, like any newcomer, is still trying cian. opment of new equipment for use by theto carve a niche in his world. It's "The success, or lack of success, in this anesthesiologist, the clinical engineer has

been a struggle in many cases because the most strange marriage of disciplines was a found valuable employment." Here, themedical establishment can be slow to ac- function of the temperament of the engi- clinical engineer is involved with equip-cept those trying to come in from the out- neer as well as the particular climate in ment, services, research, and teaching.side. There is a tendency on the part of which he found himself working," notes Al- The clinical engineer's services and ex-some in the medical world to view anyone vin Wald, Ph.D., Department of Anesthesio- pertise have proven invaluable in the oper-outside of direct patient care as a mere logy, Columbia Presbyterian Medical Cen- ating room, and, with increased involve-technician, and not as a potential partner in ter in New York. "It was often not a ment by anesthesiology staffs in thetreating the ill. question of acceptance of the engineer by recovery room and intensive care units,

fniga outside the OR. The clinical engineer isThe first clinical engineers encountered the medical staff, but rather of finding a heavily involved in the maintenance andvarious degrees of acceptance when they role that was acceptable to both the engi- improvement of anesthesia equipment.began working in hospitals and medical neer and the medical personnel." The clinical engineer is also concernedschools. Some were welcomed openly and with services in the operating room, suchgiven a range of responsibility that fulfilled Anesthesia offers a home as electrical power, central gas supply, andthe engineer's needs. Some received luke- There has been, however, one area of the suction, that are the direct responsibility ofwarm welcomes, finding themselves toler- hospital in which clinical engineers have other departments in the hospital. The op-ated as someone needed to keep machin- found a high degree of acceptance. "The erating room environment is also an area inery running; this was the most common anesthesiology service is a particularly fer- which the clinical engineer becomes in-case. Still others were met with outright tile area for engineering applications in volved; temperature and humidity in the ORhostility and disdain, treated as second medicine. Departments of anesthesiology must be controlled for the comfort of pa-class citizens even though they may have have long been a home base for clinical en- tients, staff, and equipment.

gineers," says Wald. "In the operation, the More and more clinical engineers are be-

42 EMB MAGAZINE MARCH 1982

coming involved in patient monitoring, en- The relationship between the engineers neering staff for their anesthesia depart-suring that the equipment anesthetists and the anesthesiologists is good at MGH, ments, Welch says. The average hospital,need to monitor patient condition in the Welch says. "We provide them with a serv- with about 500 beds, does not have enoughOR is in top operating condition. ice they wouldn't normally get." The engi- equipment to justify having engineers who

Clinical engineers in anesthesia depart- neers are especially accessible to the phy- cover only the anesthesia department.ments are also increasingly involved in sicians in times of emergency since the Though most clinical engineers cover allteaching and research, instructing resident engineering facility is located in the same departments as a result, Welch says theyanesthetists in the proper operation of the area as the operating rooms. "We can re- should consider anesthesia a primary re-anesthesia equipment and developing spond within minutes and seconds," sponsibility.more sophisticated, efficient equipment Welch says. "Most clinical engineers are shy of anes-for the future. Sodal says he enjoys a good working thesia," Welch says. One reason he gives

relationship with the physicians with is that the drama of life support in the oper-A look at three situations whom his research groups deals at Ohio ating room frightens them. "Often the engi-

Three clinical engineers in different State. Sodal's group works closely with the neer feels isolated from anesthesia. He'sparts of the country offered examples of hospital's clinical staff. Once a week they not familiar enough with the equipmentthe various roles that can be filled in an an- meet with the physicians to share informa- and its applications to be comfortable."esthesiology department. Charles Water- tion and discuss new approaches to their Welch says that those engineers who areson is involved mostly in maintaining the work. In addition to the weekly meetings, uncomfortable with anesthesia do not haveequipment at the Arizona Health Sciences doctors and engineers interact daily. "It's a a sufficient background in it to put togeth-Center at the University of Arizona in Tuc- dynamic group for discussion," says So- er a service that's meaningful. Because ofson with a little research work thrown in. dal. "Often one idea will come out of an- this they might be viewed by the institutionJim Welch works in three areas at Boston's other. There are more ideas around than we for which they work merely as maintenanceMassachusetts General Hospital: mainte- can use. The key is selecting out the good personnel.nance, research, and education. Ingvar So- ideas." In such situations the engineers need todal is exclusively involved in research in Sodal values the rapport he has with the elevate themselves, Welch says. "Theyanesthesiology equipment at the Ohio clinical staff. The impetus for the interac- need to introduce themselves to the newState University Hospital in Columbus, tions needs to come from the technical equipment and then teach the physicianOhio. members of the group, says Sodal. Physi- how to use it."Why has the clinical engineer been more cal presence is also important. "We work Often the impetus to set up a separate

accepted in the anesthesia department in scrubs and breathe in the atmosphere of anesthesiology clinical engineering depart-than in other areas of the hospital? It is the operating room. On-site research is im- ment comes from physicians. Watersonmainly because anesthesiologists have al- perative for good design." was hired, says Ken Mylrea, Ph.D., of theways been dependant on mechanical Welch and his staff have no trouble with UA Electrical Engineering Department, be-equipment to do their jobs and have a their professional images at MGH. Be- cause the anesthesia department felt itgreater appreciation of technology overall. cause they know both the applications and would do better with its own clinical engi-"Anesthesiologists tend to be gadget- limitations of anesthesia instruments, they neer, rather than having to borrow one fromeers," says Waterson. He adds that most command respect from the physicians they the hospital's general clinical engineeringanesthesiologists tend to be more techni- work with. "We are doing what we should department. It was felt that such a personcally sophisticated than other physicians. be doing," Welch says. would give the anesthesia department bet-Because they deal so much with sophisti- Waterson has seen the other side of the ter control over its own equipment becausecated equipment, says Waterson, anesthe- situation for clinical engineers. Before such a person would be more committed tosiologists soon realize their own technical going to UA to pursue a masters in electri- the department, more concerned about itslimits and are more ready to turn to an ex- cal engineering with a clinical option, he problems. In addition to taking care ofpert for assistance and advice. "We're the worked at the Wesley Medical Center in Wi- existing equipment, Waterson keeps trackinterface between the technology devel- chita, Kansas, as a technician/equipment of new equipment coming on the market,oped by industry and the application by the inspector in the clinical engineering de- participates in the planning/purchasinganesthesiologist," says Welch, Clinical En- partment. The work was mostly preventive process for the department, and helps con-gineering Manager of Anesthesia at MGH. maintenance with the department viewed duct research into new instrumentationWaterson notes that the interest in mainly as a service organization, Waterson with a current emphasis in high frequency

equipment isn't true across the board be- says. The single certified clinical engineer ventilation.cause many anesthesiologists are more in- who headed the department was consid- In the MGH anesthesia department, theterested in the pharmacological aspects of ered by the hospital hiearchy more as an clinical engineering staff keeps the equip-their field than in the technological. But on administrator than as a professional col- ment running, introduces new technologythe whole, the situation is positive, he league, hesays. to the anesthesiologists and helps deter-feels. mine whether an instrument suits physi-This is certainly what he has found Separate departments rare cians' needs, as well as being involved in

among the anesthesiologists with whom Though anesthesiology is a fertile field research and teaching.he works at Arizona. "I've found them easy for clinical engineers, opportunities to Welch and his staff of three biomedicalto work with," says Waterson. "There are work in it aren't all that plentiful. Only a engineering technicians and two nurses fa-things they can learn from me and me from handful of health care institutions can at- miliarize themselves with all the possiblethem." ford to maintain a separate clinical engi- applications of the equipment as well as its

EMB MAGAZINE MARCH 198243

operating problems and limitations. Welch gives three reasons for the pro- and settled, it's time to shorten the coffee"Physicians have an awareness of what gram's importance: breaks, buckle down and change environ-

the equipment can do, but not of its limita- 1. In many cases, equipment failure is ment." Sodal often isolates members oftions," Welch says. "We need to be aware due to an operator's mistake. "If we can the team to allow them to concentrate on aof the limitations so we can show them the train the resident (in the proper use of the problem.pitfalls they may encounter in operating equipment), we won't see equipment fail- During the development of the group'sthe machines." ures as often," Welch says. AIMS anesthesia monitoring system, physi-Welch learns from the anesthesiologists 2. The classes form a strong communica- cians and engineers collaborated closely.

what requirements they have for their in- tion link between the residents and the en- The engineers built their own hardwarestruments and, taking industry limitations gineering staff. Meeting and learning from system, using packaged circuit boards.into account, acquires equipment that the engineers personally gives the resi- With the help of the clinical staff, theycomes as close as possible to fitting the dents cause to respect and trust the clini- composed more than 10,000 lines of codephysicians' needs. cal engineer in the operating room. for the system.At MGH, the clinical engineer in anesthe- 3. The engineers get good ideas about Sometimes engineers enhance the re-

sia covers 42 operating rooms and works equiprnent application from the physi- search of the clinicians, who aren't alwayswith more than 100 physicians, including cians. Sometimes an anesthesiology resi- well-trained in research methods. Sodalresidents. Part of the technician's daily dent discovers that an instrument can do also draws on scientists in other fieldsroutine is morning rounds of the anesthe- something that it was not originally de- when the research requires outside ex-sia equipment to see that it is in operating signed to do. By describing new applica- perts.condition. Welch's two nurses actually op- tions to the engineers, the residents and Sodal sees himself as a futurist. "Ourerate some of the equipment in the operat- physicians can either introduce a marvel- function is to break new ground. We re-ing room. They calibrate instruments, mon- ous innovation to the anesthesia depart- search anesthesia monitoring in particular.itor them during the operation, perform ment or learn that what they are doing with In more general terms, we are bringingblood transfusions and other specialized an instrument is impossible, dangerous or technology into the clinical world."technical tasks. will not be possible for long. As Wald notes, "The specialty of anes-Because these nurses are working along- thesiology offers the clinical engineer an

side the anesthetists and using some of Research offers rewards opportunity to work in an area of intensethe same instrume-nts, they are able to re- Though many clinical engineers perform patient care with an unlimited variety ofport back to the engineering department maintenance services, Sodal's work at equipment and services." Liany problems they or the physicians en- Ohio State emphasizes research. Sodal, ancounter. Assistant Professor, directs a team of engi-

neers who are developing monitoring sys-Education a key service tems to advance clinical anesthesia.To minimize the problems that arise with "I don't really consider myself a clinical

the anesthesia equipment, Welch and his engineer, in a way, because here we are sostaff offer several educational tools to the research-oriented," Sodal says. "We doanesthesia staff. Regular case conferences very little of what might be considered theallow the engineers and physicians to dis- daily chores of the clinical engineer."cuss why specific problems have occured At University Hospital, a group of bi-and ways to prevent them from reoccuring. omedical technicians, headed by an engi-Welch's staff holds an occasional lecture neer, install, repair and calibrate equip-to explain the operation of a new piece of ment. Sodal's group, composed of aequipment or newly modified instrument. A systems analyst, an electrical engineer, adepartment newsletter, called "Anesthe- computer scientist and a biomedical engi-siology's Technology" (see article else- neer, is concerned with implementing newwhere in this section detailing this effort), anesthesia technologies. The engineers fo-also helps the engineer to reach anesthe- cus their research on two aspects of anes-tists with important instructions or infor- thesia delivery - developing improvedmation. ways of monitoring anesthesized patientsBut probably the most effective, and for and designing hardware to package their

Welch the most rewarding, educational systems.tool is the resident orientation program. The feeling in the lab is relaxed in oneResidents spend eight to 10 class hours sense and tense in another, says Sodal.training on the anesthesia equipment. They "We tend to work hard," he says, "but thebecome familiar with equipment operation, interactions are straight-forward and re-calibration of instruments and the prob- laxed. Often we get together semi-sociallylems and failures that they may encounter. to discuss work in a different environment.They also learn what to do when such prob- Changing environment, changing pace islems arise. Welch's entire staff is involved important in research."with this program, and he, the technicians The gr-oup interacts extensively duringand nurses average 40 hours a month the planning stages. Then, specific tasksteaching. are assigned. "Once ideas have fermented

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