What has society come to?

A medical student who corresponds with me wrote the following. It has been edited for length.

She was shopping at a mall with her husband and their children.

As I walked underneath the escalators, I heard a horrific sound. I looked up and saw a body cartwheeling down. I ran to front of the escalator to push the stop button. An 80 or 90 year old gentleman was lying partly on and partly under his walker. He seemed unconscious with blood all over the place. I said "Sir, sir," saw his fingers move, and called 911.

A black man from the top of the escalator made eye contact with me and came running down to see how he could help. He hesitated, his face and body language screaming fear, but he came over. He knew he had to once we made eye contact because I was the only one actually doing something.

A security guard who was heading to work arrived. He had no gloves, no radio, nothing. Why wasn't anyone from security coming? What's the point of security cameras? Wasn't there anyone watching? I turned around to see who else could help. About a dozen people were just standing there with their cell phones taking pictures and videos. Not a soul asked me if they could call 911. In fact when I called 911 a second time, the dispatcher asked me if there were more people with me because I had placed the only two calls.

Epidemic viruses contaminate healthcare workers’ mobile phones

As if bacterial contamination of cell phones wasn’t enough of a problem, a new paper finds that viral RNA can also be found on the devices. But before you put your phone in the autoclave, read on.

The study was conducted in France and involved 114 healthcare workers (35 senior physicians, 30 residents, 32 nurses, 27 nurse assistants) who used both mobile and cordless phones in a university hospital.

Phones were swabbed and tested for viral RNA, and the subjects answered anonymized questionnaires regarding their behavior.

Viral RNA was recovered from 38.5% of the phones with rotavirus RNA on 93% of the virus-contaminated phones.

About two-thirds of the healthcare workers used their mobile phones while caring for patients, and 28% of them said they never wash their hands before using the phones, 37% never used hand hygiene after using the phone, and 21% said they never performed hand hygiene either before or after using a phone. This held true for personnel who interrupted caring for patients to answer their phone.

In an article about the study, one of the authors said, “It was surprising that 20% of them admitted never carrying out any hand hygiene procedures, either before or after using their phone, even though all said they knew phones could harbor pathogens.”

Telephone and television evolution through my lifetime

6-5-4. That was my home telephone number when I was growing up in the early 1950s. You may wonder how that was possible. I'll explain.

We lived in a small town. Telephones looked like this.

In order to place a call, you picked up the handset from its cradle, and an operator said "Number please."

You said the number, and she (operators were always women) made the connection for you via a switchboard.

Some folks in my town were on "party lines," which were less expensive but involved more than one household on the same line. If you picked up the phone in a home with a party line and it was being used by someone in another house, you could hear their conversation. You would have to hang up and wait until they were through before making your call. For incoming calls, the ring sequence was different for each household.

Is student test performance impaired by distracting electronic devices?

After listening to a lecture, third-year students at the Harvard School of Dental Medicine were surveyed about distractions by electronic devices and given a 12-question quiz. Although 65% of the students admitted to having been distracted by emails, Facebook, and/or texting during the lecture, distracted students had an average score of 9.85 correct compared to 10.444 students who said they weren't distracted. The difference was not significant, p = 0.652.

In their conclusion they authors said, "Those who were distracted during the lecture performed similarly in the post-lecture test to the non-distracted group."

The full text of the paper is available online. As an exercise, you may want to take a look at the paper and critique it yourself before reading my review. It will only take you a few minutes.

As you consider any research paper, you should ask yourself a number of questions such as are the journal and authors credible, were the methods appropriate, were there enough subjects, were the conclusions supported by the data, and do I believe the study?

Ask Skeptical Scalpel-Why Do We Still Use Pagers?

Stephen Zintsmaster ‏(@szintsmaster) tweeted me this question:

“@Skepticscalpel - I need some wisdom as a new 3rd yr. Y do they still use the damn pagers? This will forever annoy me!”

Stephen, I believe there is still a use for pagers in medicine. This question came up in some comments on one of my more popular blogs called “What happens when a doctor is paged.”

Chris Porter, a surgeon who has a popular blog called “OnSurg,” took me to task by asking why my hospital still used pagers and hadn’t I heard about cell phones?

I replied, “I don't know about your area, but where I practice, cell phone service can be spotty. The hospital is one of the worst places. Some cell phone carriers have little or no coverage. You can be in the OR or radiology and have no bars on your phone. Since pagers work by radio, there is no coverage problem. When cell phones are 100% reliable, let me know.”

I also pointed out to another commenter that when the nurses have your cell phone number, they may call you when you’re not on call. This has happened to me. When they have to look up your pager number, they seem more likely to check the on call schedule.

To me, phone calls are also more intrusive and harder to ignore. I was debriding a pressure sore in a patient's room the other day when my phone rang. Because I was wearing gloves, I couldn’t hit “Ignore” and it went on for 30 seconds. A pager stops beeping after just a few seconds.

Dr Roy Arnold, ‏who tweets as @Cholerajoe, pointed out that another reason to use pagers is that there may be one pager for the on call doc that gets handed off when call changes. Nurses know to always call the same number.

Update 7/10/2012. Dr. Mary L. Brandt (@drmlb) tweeted a link to a blog that describes the history of the pager and another important reason we still use them--the "group page" for codes. The blog also mentions some new ideas for eliminating the pager.

Bottom line: I know in some areas, doctors are happy to completely rely on cell phones. This has not worked for me.

Electronic devices distract doctors. So do other things.

Another hand-wringing piece about the dangers of distraction by electronic devices, this time from The New York Times, prompts these comments.

According to the article, Dr. Peter J. Papadakos, an anesthesiologist and director of critical care at the University of Rochester Medical Center reportedly said he had seen nurses, doctors and other staff members glued to their phones, computers and iPads. It goes on to say the following:

“My gut feeling is lives are in danger,” said Dr. Papadakos, who recently published an article on “electronic distraction” in Anesthesiology News, a journal. [Anesthesiology News, a journal? Since when?]

This is interesting coming from an anesthesiologist, whose colleagues were notorious in the analog age for doing crossword puzzles and reading the [print] Wall Street Journal during cases.

Here, via the AHRQ, is a nice example of an adverse event that occurred because of a distraction. A resident forgot to place an order to stop warfarin because she was interrupted by a text. Curiously, the electronic computer order entry program, while described as being “robust,” did not alert anyone. When his INR reached 8.5 three days later, the patient developed a hemopericardium requiring surgery. It’s a little disingenuous to blame a text for this complication when a team of doctors apparently forgot that a patient was receiving one of the most dangerous drugs around.

The Times article described a malpractice case from Colorado. It involved a neurosurgeon who was making personal phone calls during an operation which left the patient partially paralyzed. Where were the OR staff and the anesthesiologist while all these calls were being made? I doubt that I could even make one personal phone call during a case in my OR without the supervisor, the medical director and risk management being notified.

There is no question that electronic devices can be addicting and distracting if you let them. So can many other things like thinking of sex, which men apparently do at least 19 times a day or so a recent study says.

I will admit that it annoys me when I am talking to a resident or PA and she pulls out her phone to read an incoming text. And I certainly agree that 99.9% of all emails do not need to be viewed immediately.

That does not mean we should electronic devices from hospitals. I think the ability to look up a drug instantly or review management of a problem on UpToDate at a patient’s bedside far outweighs the potential for distraction.

I wonder if the same debate took place when radios were first placed in automobiles?

iPads approved by FAA for use by airline pilots, not passengers

As reported by The New York Times and ZDNet last week, iPads are now approved by the FAA for use by pilots. iPad flight charts replace about 35 pounds of paper charts. Another story says that the iPads, which weigh about 1.5 pounds, will save some $1.2 million worth of fuel a year.

Supposedly fearing disruption of avionics equipment, the FAA has yet to approve iPad use for passengers when the planes are below 10,000 feet. Yet if I interpret the FAA correctly, pilots, using iPads while sitting directly next to the avionics, present no threat.

This reminds me of the still on-going controversy about the use of cell phones in hospital intensive care units. Cell phones have been said to interfere with monitors and ventilators. Many hospitals still have signs prohibiting cell phone use.

Research (e.g., here, here and here) shows that cell phones do not cause clinically important interference with medical devises unless placed within a minimum of about 3 feet, although a Dutch study claimed otherwise. However, that study used certain European cell phones which emit three times the energy of American phones. It is likely that iPads and other tablets do not cause problems either.

Yes, I realize that being unable to use one’s iPad for 30 minutes of an airplane flight is not really that big a sacrifice. And I would hate to be subjected to three hours of 200 people talking on their phones in a space as confined as an airliner. But one could make the same argument as that use regarding the replacing of paper flight charts with iPads. Let’s say 200 passengers brought iPads, Kindles or Nooks aboard instead of books. Wouldn’t that save a lot of weight and fuel too?

If it’s about being distracted during critical take-off and landing sequences, then the flight attendants should make all passengers put down their non-electronic books during those times too.

Bottom line: Rules that are irrational cause people to lose faith in authority. If this rule is not rational, people think maybe other rules [e.g., the 55 mph speed limit] are not rational either. As respect for authority decreases, chaos ensues.

UPDATE 12/26/2011:
New York Times reports electronic devices do not emit significant energy and are highly unlikely to affect avionics.