[SPEAKER_02]: Hello and welcome back to Accraack.
[SPEAKER_02]: I'm Jed Wolpa and I am excited to be able to play for you today the audio of our live episode from the Anyshesiology Annual Meeting in San Antonio, Texas.
[SPEAKER_02]: So without further ado, here is the recording.
[SPEAKER_02]: Well, hello, everyone, and welcome to an ACRAC podcast.
[SPEAKER_02]: We are live and anesthesiology 2025 here in San Antonio, Texas.
[SPEAKER_02]: This recording will be released both on the ACRAC feed and on the ASA Central Line podcast feed.
[SPEAKER_02]: So you'll be able to find it there in the weeks and months to come.
[SPEAKER_02]: I'm very excited to be here and really grateful to all of you for coming to listen.
[SPEAKER_02]: we are going to have an exciting talk today.
[SPEAKER_02]: I've got with me Dr. Joyce War.
[SPEAKER_02]: Dr. War was a cardiac anesthesiologist, practice at University of Michigan for 20 plus years, and then transition into the patient's safety space where she really made a name for herself.
[SPEAKER_02]: in patient safety.
[SPEAKER_02]: She published a paper that was called one of the best papers of the decade in the 2010s on patient safety in the cardiac ORs.
[SPEAKER_02]: And she continues even though she's mostly retired from practice to speak and advocate for patient safety.
[SPEAKER_02]: She's giving the severing house lecture on Tuesday talking about cognitive errors, why they happen and how we can maybe start to think about preventing them.
[SPEAKER_02]: And that's what we're going to talk about today.
[SPEAKER_02]: I'm thrilled to have her here.
[SPEAKER_02]: Dr. War welcome to the show.
[SPEAKER_01]: Thank you for having me.
[SPEAKER_02]: Excited to be here and thank you all for coming as well.
[SPEAKER_02]: So the structure will be that we'll chat for about 25, 30 minutes and then we will open it up to audience Q&A.
[SPEAKER_02]: So, Joyce, let me start by asking you how did you get interested in cognitive error prevention?
[SPEAKER_01]: So in 2002, left University of Michigan because my husband, who's here today, left cardiology and moved to Minneapolis to start medical devices.
[SPEAKER_01]: So I took a little bit of a sabbatical during that time, not working at the University Hospital.
[SPEAKER_01]: I did go back to Minnesota, but
[SPEAKER_01]: a little bit of time and was asked to chair the SCA, Society of Cardiovascular and Assisiologist Foundation.
[SPEAKER_01]: And they had a major project that they were wanting to kick off with Peter Poon of Oost, looking at patient safety in the cardiac operating rooms.
[SPEAKER_01]: And that was
[SPEAKER_01]: where I started and I started reading all the books, James Risa and human error, all the James Risa books and then branching out into some of the other books not written by anesthesiologists but written by cognitive psychologists.
[SPEAKER_01]: Here's how we think.
[SPEAKER_01]: Here's how errors arise and I was amazed at the information that's available out there that most people do not have.
[SPEAKER_01]: We do not know
[SPEAKER_02]: Yeah, I mean, that's kind of wild to think about.
[SPEAKER_02]: In our specialty, errors can be the difference between life and death, and we don't really have a great feel for how they happen or how to prevent them.
[SPEAKER_02]: So you've taken an interest in this.
[SPEAKER_02]: Let's talk about the difference between system 1 and system 2 thinking.
[SPEAKER_02]: Now, some people may have read thinking fast and slow, but for those who haven't, maybe just give us an idea of what is system 1, what is system 2 and how do they differ?
[SPEAKER_01]: Right.
[SPEAKER_01]: And of course, we all know that we work on two different planes, the unconscious and the conscious.
[SPEAKER_01]: We tie our shoes without any conscious attention.
[SPEAKER_01]: But Kahneman and his partner, Amy Staversky, who he always gives people credit to, unfortunately, Dr. Taversky died quite young of a malignant melanoma.
[SPEAKER_01]: So we'll just talk about Kahneman.
[SPEAKER_01]: But he really put it into this system one in system two.
[SPEAKER_01]: And he acknowledged they're not really different systems, but it's a useful construct.
[SPEAKER_01]: So system one, fast, automatic effortless, subconscious is what lets you drive a car at 70 miles an hour on a busy freeway while you're conscious deliberative, deductive,
[SPEAKER_01]: Brain is trying to figure out how you're going to manage that very fragile, mitochondrial re-gird patient tomorrow.
[SPEAKER_01]: And the two work pretty independently, but they're never isolated.
[SPEAKER_01]: So when you see a traffic jam up ahead, system two stops thinking about that patient and starts thinking about, how can that what other route can I take to get to work on time?
[SPEAKER_02]: So a system one is kind of the autopilot.
[SPEAKER_02]: Is that a fair way to think about it?
[SPEAKER_02]: Right.
[SPEAKER_01]: We do not even know.
[SPEAKER_01]: what system one is doing.
[SPEAKER_01]: We just get in the car and we drive, right?
[SPEAKER_01]: And all of that is some conscious, and it's, I think it's just absolutely incredible, amazing, spectacular, what system one does on an everyday basis.
[SPEAKER_01]: It's 99% of what we do every single day.
[SPEAKER_01]: It's how you walk,
[SPEAKER_01]: And system one gets that because from the time you're tiny, you're absorbing, saving.
[SPEAKER_01]: all these sites, sounds, perceptions, actions, reactions, and by the time you're just even three or four years old, you have this incredible matrix of associative memories that system
[SPEAKER_01]: reach back into those associative memories, find a similar, stored mental model, and bring it forward and says to your conscious mind, oh, here's where you are.
[SPEAKER_01]: And here's what's happening.
[SPEAKER_02]: So.
[SPEAKER_02]: Does this explain why when I get in the car and it's Saturday morning and I don't have to work, and I'm supposed to be driving to my daughter's soccer game, and I realize halfway to work that I'm driving to work, because system one is doing what it thinks I'm supposed to be doing.
[SPEAKER_01]: And you probably don't even know what you're doing.
[SPEAKER_01]: And when I talk about system one errors, these are errors we can't predict.
[SPEAKER_01]: we can't prevent and very often we don't even perceive them until you're almost at work right you didn't even perceive you were making that error right okay now is there a way to say how do I get system to stop me from doing that
[SPEAKER_01]: No.
[SPEAKER_02]: No.
[SPEAKER_01]: No.
[SPEAKER_01]: There is no way to really, you could have system to consciously pay attention to every action sequence you're doing, but that's really impossible.
[SPEAKER_01]: System 2 requires effort.
[SPEAKER_01]: Right?
[SPEAKER_01]: It's an effortful deductive process.
[SPEAKER_01]: You don't have that much reserve for effort, and there are lots of competing things for effort, and in the operating room, disciplining yourself to not snap at the obnoxious surgeon, also pulls from that same reserve of effort, you're physically busy, you do not have any bandwidth to bring
[SPEAKER_01]: kind to attention to every time you pick up a syringe or every time you swab an injection port, you couldn't possibly do it.
[SPEAKER_01]: You couldn't possibly do it.
[SPEAKER_02]: That's why we need this to one.
[SPEAKER_02]: Right.
[SPEAKER_02]: Yeah.
[SPEAKER_02]: So let's talk about eyewitnesses.
[SPEAKER_02]: You'd think an eyewitness would be the most reliable witness, right?
[SPEAKER_02]: They saw it.
[SPEAKER_02]: They were there.
[SPEAKER_02]: Whatever we're talking about, they saw it happen.
[SPEAKER_02]: They, in court, you know, you read a, you watch a trial on TV.
[SPEAKER_02]: I mean, the eyewitnesses there.
[SPEAKER_02]: They're giving testimony.
[SPEAKER_02]: But you would say eyewitnesses are not necessarily reliable.
[SPEAKER_02]: Tell me why.
[SPEAKER_01]: Right.
[SPEAKER_01]: And we're going to come back to this because we're going to talk a little bit about Trump's examic acid and bupificate.
[SPEAKER_01]: So when I said that system one is continually scanning what's out there.
[SPEAKER_01]: And then going back in, trying to find a mental model that fits this pretty well.
[SPEAKER_01]: system on his built for speed, not for precision, and so if it grabs the wrong mental model.
[SPEAKER_01]: And it doesn't quite agree with what's out here.
[SPEAKER_01]: It doesn't change the mental model to fit reality.
[SPEAKER_01]: It changes reality to fit the mental model.
[SPEAKER_01]: And so when you have two eyewitnesses who observed exactly the same event happening, each one of them, they have different associative memories.
[SPEAKER_01]: A lot are quite similar.
[SPEAKER_01]: What?
[SPEAKER_01]: different enough so that then when this, I witness a system once as, oh, here's the metal model that this one fits and presents that as reality.
[SPEAKER_01]: It can be different than what system one does in the person's standing right next to them.
[SPEAKER_01]: And we think, well, this must be new information, solely wrote the book Allusions in 1881.
[SPEAKER_01]: This idea that our subconscious counterfits immediate knowledge, that this is why we misperceive
[SPEAKER_01]: reflecting back to those mental models.
[SPEAKER_01]: And he was the first one that talked about this is why eyewitnesses are really unreliable.
[SPEAKER_01]: And then, Mr. Burr, early 1900s at Harvard,
[SPEAKER_01]: went back to that theme and he wrote a book on the unreliability of eyewitnesses and in the introduction he gave us about four court cases.
[SPEAKER_01]: One of them, these are court cases, transcripts of what eyewitnesses said.
[SPEAKER_01]: During the same event, the first eyewitness said it was drizzly in muddy, the second one said it was dry and dusty.
[SPEAKER_01]: So not minor little irregularities, major differences.
[SPEAKER_01]: How long was it between when that horn blew and the event occurred?
[SPEAKER_01]: One eyewitness, ooh, ten seconds, the other one upwards of ten minutes.
[SPEAKER_01]: major differences in what each one of them perceived as this is reality happening now considerably different.
[SPEAKER_02]: And so how much of that is just that our memories aren't great, right?
[SPEAKER_02]: So I don't remember, you know, it's hard for me to remember what happened back then.
[SPEAKER_02]: So I think it was about 10 minutes and how much of it is that in the moment we are actually perceiving different things.
[SPEAKER_01]: So it's both, and certainly, over time, our memory is definitely degrade.
[SPEAKER_01]: So things differences get, I think, greater and greater.
[SPEAKER_01]: But even at the moment, there's a powerful emotional component in it.
[SPEAKER_01]: So my husband was broadsided by a criminal trying to get away.
[SPEAKER_01]: It was a white car, and a certain model.
[SPEAKER_01]: I'm sure that if Dennis watched another broadside accident in his mind, it made very likely the color of the car may be remembered as white, because it has such an emotional context to it.
[SPEAKER_01]: And we don't even perceive that that's happening.
[SPEAKER_02]: And that is really wild, right?
[SPEAKER_02]: So you're saying that in the moment when a red car
[SPEAKER_01]: Well, that's a pretty big distinction, but if it was silver, easy to see it as white.
[SPEAKER_01]: So the closer they are to alike, the easier it is for system one to make those two line-up and agree.
[SPEAKER_01]: System one loves coherence.
[SPEAKER_01]: It needs a story that makes sense with everything else that's in the brain.
[SPEAKER_01]: And it will make sense of reality.
[SPEAKER_01]: Can I give an example?
[SPEAKER_01]: Yes.
[SPEAKER_01]: So this is a study done many years ago where test subjects were shown just a brief glimpse of a schematic of a bedroom.
[SPEAKER_01]: two rectangles, denoting twin beds, a square, that's the nightstand, and on the nightstand was a pretty large, old-time alarm clock with those little ringy dingy things on it.
[SPEAKER_01]: Everybody knew that that was a bedroom.
[SPEAKER_01]: They all owned it with the alarm clock.
[SPEAKER_01]: When they were asked, what time was on the alarm clock?
[SPEAKER_01]: Some said six, some said eight, some said five.
[SPEAKER_01]: And when pressed, they were very confident that yes, this was the time on the clock.
[SPEAKER_01]: There were no hands on the clock.
[SPEAKER_01]: system one does not have a mental model of a clock that doesn't have hands.
[SPEAKER_01]: So the only mental model that fits this scenario is an alarm clock with hands so that's the perception it presented to these test subjects and then of course
[SPEAKER_01]: the time of the hands naturally, it's the time you would see when you get up.
[SPEAKER_01]: So that's just one, it sounds like a funny, interesting story, but it's real scientific evidence that what gets presented to our conscious brain as reality is just a perception of reality.
[SPEAKER_02]: So there's the famous study where they took chest X rays and put a gorilla
[SPEAKER_02]: in the midst of the chest right a little gorilla and they showed them to a radiologist and the radiologist often didn't see the gorilla right and I'm imagining this must be because when they look at a chest x-ray it's so automated for them they have a schema of you know what this is and gorilla existing in the chest is not one of the things right and so they literally didn't see it right not like they decided to leave it out of the report they didn't see the gorilla
[SPEAKER_01]: Right.
[SPEAKER_01]: So there is another.
[SPEAKER_01]: It's a video tape.
[SPEAKER_01]: It must be 30 years old.
[SPEAKER_01]: Very interesting.
[SPEAKER_01]: College students.
[SPEAKER_01]: Half of them have on white t-shirts, half of have on black.
[SPEAKER_01]: And each team has a basketball.
[SPEAKER_01]: And they're passing back and forth between each other.
[SPEAKER_01]: And they're moving around each other in your job is to count the number of passes that the white team makes.
[SPEAKER_01]: And it goes on
[SPEAKER_01]: announcer says the correct answer is 15 passes.
[SPEAKER_01]: But did you see the gorilla?
[SPEAKER_01]: You rewind the tape and sure enough, at about past eight or nine, here comes a colleague student in a gorilla suit.
[SPEAKER_01]: He walks into this group passing the basketball.
[SPEAKER_01]: He turns, he looks at the
[SPEAKER_01]: but he wasn't in white and he didn't have a basketball.
[SPEAKER_01]: He didn't, he was not pertinent to the task at hand in any way.
[SPEAKER_01]: Your task was to count the passes the white team makes.
[SPEAKER_01]: Your system one didn't even tell your conscious brain.
[SPEAKER_01]: that that character was there.
[SPEAKER_01]: Same way with the chest x-ray.
[SPEAKER_01]: And I don't want to fight in people about oh my god I can't even trust what my eyes are showing me.
[SPEAKER_01]: I just can't trust my system one.
[SPEAKER_01]: We don't want to be fearful of system one.
[SPEAKER_01]: But I think the more we learn about how these errors can creep up, the more
[SPEAKER_01]: I'm not going to say, the more able we are to prevent them, we can't prevent them.
[SPEAKER_01]: The more accepting we will be, of those interventions that will prevent those very natural errors that are system on banks from reaching and harming a patient.
[SPEAKER_01]: So that we will refuse to hear our leadership say when there's been a bad medication.
[SPEAKER_01]: syringe swap.
[SPEAKER_01]: Just try harder.
[SPEAKER_01]: How many of you have had your pharmacists say if you just read the label, right?
[SPEAKER_01]: Just read the label.
[SPEAKER_01]: But the clock story tells us that you can't just read the label.
[SPEAKER_01]: So I'm going back to that view pivot case.
[SPEAKER_02]: So tell us that.
[SPEAKER_02]: So let's talk about how this exists in our specialty.
[SPEAKER_02]: So tell us about that track.
[SPEAKER_02]: Sure.
[SPEAKER_02]: We got some view pivot again.
[SPEAKER_01]: So I think most people know that over the past decade we've had 12 case reports are sold all around the world, certainly many here in the US, where a anesthesia provider doing a spinal for an ortho, case or for a elective c-section, the nurse brought and put an ampule of transexemic acid and an ampule of
[SPEAKER_01]: If you pivocaine on, you know, your medication, pray, and in the midst of doing the spinal,
[SPEAKER_01]: anesthesiologist picked up TXA and gave it in trethically, and most of those cases the patient dies.
[SPEAKER_01]: And whenever we have providers, practitioners who get caught in one of those terrible syringe swaps, very, very frequently they say, but I did read the label.
[SPEAKER_01]: I'm sure I looked at the label and I'm sure that they did,
[SPEAKER_01]: System One has no mental model of you doing a spinal where you put TXA into the CSF.
[SPEAKER_01]: So when you look at the vial, it says, no, you'd never have this doesn't match the story at all, and I think you actually see.
[SPEAKER_01]: you pivocaine.
[SPEAKER_01]: You're convinced that it's pivocaine, so when people say try harder, even when you try to bring your conscious brain to it, system one is so powerful about altering your perception and reality, that's extremely difficult.
[SPEAKER_01]: Now, there's an incredibly simple solution, right?
[SPEAKER_01]: Transexemic acid only gets supplied in a minibag.
[SPEAKER_01]: You'd never hook a minibag to a spinal, right?
[SPEAKER_01]: So that's such a simple solution.
[SPEAKER_01]: Completely effective.
[SPEAKER_01]: So easy to do.
[SPEAKER_01]: We ask for it at Minnesota.
[SPEAKER_01]: We don't have the money.
[SPEAKER_01]: We can't afford it.
[SPEAKER_01]: Our pharmacists doesn't have enough time to do that.
[SPEAKER_02]: Yeah, so that's such a great example.
[SPEAKER_02]: It's much like the silver and white cars, right?
[SPEAKER_02]: So those vials, they're pretty similar, right?
[SPEAKER_02]: If the Trans-Acamica acid one came in a bright red double-sized vial and the Bppppkin was in a blue small vial, it probably wouldn't happen.
[SPEAKER_02]: But they're similar enough that you're saying it's not that you accidentally picked up one and didn't read it.
[SPEAKER_02]: You're saying that the practitioner picks it up.
[SPEAKER_02]: looks at it and because in their mind the only thing that should be there is be pivicane while they're doing a final they actually see be pivicane and then they give it even though it's said training semi-gasm but their mind is just not able to see that in that moment and how tragic for that practitioner who is highly skilled, highly intelligent
[SPEAKER_01]: The last word you would use for them is careless.
[SPEAKER_01]: They care a great deal.
[SPEAKER_01]: Well, we just have to accept the fact that this is what happens and be willing to demand that we have those interventions.
[SPEAKER_01]: And I think sometimes our leadership gets away with saying we don't have the money, we can't afford it.
[SPEAKER_01]: We're sort of complicit in that because we think we can try harder.
[SPEAKER_01]: We think this is like an athletic competition where we can train and we can try harder.
[SPEAKER_01]: But system 1 doesn't allow for that.
[SPEAKER_01]: And again, I don't want us to be terrified of our system 1.
[SPEAKER_01]: So this is system 1.
[SPEAKER_01]: been doing cardiac anesthesia for maybe five, eight years, and we just finished urgent cabbage on a patient who had had a stemmy three days before.
[SPEAKER_01]: Dressing's are on this cardiac surgeon has gone next door to start the next case, and I go around to manage the playback, the chest tubes, and watch a horror
[SPEAKER_01]: as the plurvac literally fills with blood in the space of about two seconds.
[SPEAKER_01]: System one.
[SPEAKER_01]: Rocky don't break down the pump.
[SPEAKER_01]: We're going back on bypass.
[SPEAKER_01]: Gene the get your table up here right now.
[SPEAKER_01]: Deb called the blood bank calendar stay 10 units ahead.
[SPEAKER_01]: I run next door.
[SPEAKER_01]: I say, Mike, you've got to come now.
[SPEAKER_01]: He's exingonated into the chest tube.
[SPEAKER_01]: We've got to get on bypass or he's dead.
[SPEAKER_01]: Mike looks at me.
[SPEAKER_01]: and comes.
[SPEAKER_01]: By the time he gets back in the room, Deb already had a new gown and gloves open and ready for him.
[SPEAKER_01]: The surgical resident had the drapes off, splash, beta-dine on the chest, and was snipping the sternal wires.
[SPEAKER_01]: Rocky had his pump up, Gene had every table up and we were on back on bypass in about five minutes.
[SPEAKER_01]: And the patient walked out of the hospital neurologically
[SPEAKER_01]: That scenario would never have happened in System 2.
[SPEAKER_01]: You could never have gotten on bypassed.
[SPEAKER_01]: We only managed that because each of us had done those things hundreds of times.
[SPEAKER_01]: Previously, we didn't have to think about how to tie our shoes.
[SPEAKER_01]: My team has put in so many purse strings, so many arterial cannula.
[SPEAKER_01]: Rocky's gone back on pump again and again and again and again and we did it without thinking.
[SPEAKER_01]: So system one is capable of errors but it is also capable of what James Reeson calls heroic rescues.
[SPEAKER_01]: So we do not want a Hubble system one.
[SPEAKER_01]: We don't want to live in fear of it.
[SPEAKER_01]: We don't want to try to watch it all the time.
[SPEAKER_01]: Let's just put the barriers in place that we know are effective at capturing those inadvertent errors.
[SPEAKER_01]: Let's protect not just our cells, but our fellow practitioners from being devastated.
[SPEAKER_01]: people have committed suicide over having one of these errors, even when we had barriers, we could have used to prevent that from happening.
[SPEAKER_02]: Yeah, so it seems to me that what you're saying and what makes a lot of sense is we need system one.
[SPEAKER_02]: We don't want to say let's get rid of it.
[SPEAKER_02]: We need it for those heroic rescues, but we want to set things up so that system one can be successful.
[SPEAKER_02]: And so
[SPEAKER_02]: But the things you talked about, in other words, using a mini bag for trans-examigasin, making a connection so that the Bupivicane pump cannot be hooked up to the IV, would be another one, right?
[SPEAKER_01]: Right.
[SPEAKER_02]: And all they'd be hooked up to the epidural.
[SPEAKER_01]: that small more connectors than eq small more connectors so would we call these forcing functions as that with that term means they would be so certainly pin indexing anti-hypoxia valves when i started anesthesia you could forget to turn the oxygen on we didn't have pulse like symmetry we didn't have f i o two you could turn
[SPEAKER_01]: nitrous and an anacetic gas on and have no clue that you had just done that.
[SPEAKER_01]: They were right next to each other.
[SPEAKER_01]: They look very similar.
[SPEAKER_01]: So...
[SPEAKER_01]: Our cockpit on the right is a model of safety and forcing functions.
[SPEAKER_01]: We help all those things on the right in our in a seizure work station that prevent errors we might make like turning up the nitrous instead of the oxygen.
[SPEAKER_01]: We've prevented that from ever happening, computerization,
[SPEAKER_01]: Our left side, the medication administration side, looks exactly the way it did when I was a resident in 1981.
[SPEAKER_01]: We have things we can do pre-filled syringes.
[SPEAKER_01]: Great.
[SPEAKER_01]: For me, failure modes and effects analysis of everything that can go wrong.
[SPEAKER_01]: from starting preparation of a medication to administering it, 68 possible failure nodes.
[SPEAKER_01]: If you have pre-filled syringes, you will eliminate 20 of those error nodes.
[SPEAKER_01]: You guys all have pre-filled, every syringe in your medication tray is pre-filled.
[SPEAKER_01]: We have maybe one or two epinephrine, you know, some of it cold things, but they won't give us all of those others.
[SPEAKER_01]: And they won't give us trans-examic acid in any of them.
[SPEAKER_01]: In a mini bag.
[SPEAKER_02]: Stay with us.
[SPEAKER_02]: We'll be right back.
[SPEAKER_02]: All right, and we're back with our live episode.
[SPEAKER_02]: And the reason, as you said before, is that we get told, at least, is that it's too expensive, right?
[SPEAKER_02]: To put all these things in pre-made syringes, to switch over to a mini-mag, they'd have to hire extra pharmacists, it's too expensive.
[SPEAKER_02]: And yet the alternative is that these mistakes are going to happen, and we may lose practitioners because they may be so devastated by it that they leave medicine.
[SPEAKER_02]: We lose patients and that obviously is forable and tragic and comes with a lot of costs.
[SPEAKER_02]: So in the end, it probably makes sense to make the upfront investment in these forcing functions so that we prevent the errors from system one from happening.
[SPEAKER_02]: But how do we convince health systems to do it?
[SPEAKER_01]: Right.
[SPEAKER_01]: Well, and I wonder, so Elliot Grig is the one who came up with this concept on the right side, we've done it well.
[SPEAKER_01]: On the left side, we're using totally
[SPEAKER_01]: Um, we pretty much controlled the right side, right?
[SPEAKER_01]: We told the manufacturers what we had to have to make in a seizure safe.
[SPEAKER_01]: And they did it for us on the left side.
[SPEAKER_01]: We don't control that.
[SPEAKER_01]: We get the medications that pharmacy buys.
[SPEAKER_01]: we get our trays the way they prepare them.
[SPEAKER_01]: And so we don't control that very well.
[SPEAKER_01]: And again, I think that perhaps the reason pharmacy gets away with saying, try harder, is that we're a little complicit.
[SPEAKER_01]: But before I go there,
[SPEAKER_01]: I never let them say we don't have the money.
[SPEAKER_01]: I say, of course you have the money.
[SPEAKER_01]: You bought two surgical robots last year.
[SPEAKER_01]: Each of them costs $2 million.
[SPEAKER_01]: The service agreement on one of those robots is $150,000.
[SPEAKER_01]: Sounds like a pharmacist salary to me.
[SPEAKER_01]: Of course you have the money you have chosen to spend it elsewhere.
[SPEAKER_01]: But being complicit,
[SPEAKER_01]: We don't say to them, don't give me that.
[SPEAKER_01]: Of course you have the money, because I think in our own heads, we still believe we can try harder.
[SPEAKER_01]: We kind of think that I wouldn't make the mistakes that that person made.
[SPEAKER_01]: I'm a little brighter, I'm a little smarter, and I wouldn't make that mistake.
[SPEAKER_01]: And as long as we believe that that's true,
[SPEAKER_01]: we don't push what we know we should do.
[SPEAKER_02]: Yeah, well we've got future leaders here right in front of us who are going to be leading our health systems and they hopefully will have heard you talk and will.
[SPEAKER_02]: We'll make this change.
[SPEAKER_02]: I want to ask you to make a random recommendation and then I'll do the same and then we're going to open it up to the audience for questions.
[SPEAKER_02]: So, okay, what would you recommend people check out?
[SPEAKER_02]: Well,
[SPEAKER_01]: I'm a huge fan of Selena Gomez.
[SPEAKER_01]: I love her.
[SPEAKER_01]: You know, of course, she had a renal transplant.
[SPEAKER_01]: She went through significant medical issues.
[SPEAKER_01]: Got her kidney transplant and now is just doing so amazingly.
[SPEAKER_01]: So I love only murders in the building.
[SPEAKER_01]: And then for a very short one, only three minutes long, three to four minutes is John Mulvaney.
[SPEAKER_01]: There's a horse in the hospital.
[SPEAKER_01]: It is absolutely hilarious.
[SPEAKER_01]: He kind of starts saying, you know, we're all kind of on edge these days.
[SPEAKER_01]: We don't know what's going to happen, we're just kind of
[SPEAKER_01]: anxious and desperate.
[SPEAKER_01]: He says, I think about it like there's a horse in the hospital and nobody knows what the horse is going to do and it just gets better and better from there.
[SPEAKER_01]: So check that one out.
[SPEAKER_02]: Sounds great.
[SPEAKER_02]: I always at these events like to recommend something that you all can check out right here while you're in San Antonio.
[SPEAKER_02]: So I came in a little early because I gave a talk at the spot meeting Friday and I randomly found a little restaurant that is about a half a mile down commerce from here called Tokyo Cowboy and it was so good I had lunch there on Thursday and it was so good I went back for dinner last night it is fabulous.
[SPEAKER_02]: It's
[SPEAKER_02]: Asian Texan fusion small plates go with some friends you can share and get a bunch of stuff and it everything we had was absolutely fabulous highly recommend Tokyo cowboy down the street all right We're gonna open it up if you have questions for Dr. War come on up and ask and please introduce yourself Let us know who you are and what your question is
[SPEAKER_03]: Hi, I'm Thomas.
[SPEAKER_03]: I am a resident of Washington St. Louis.
[SPEAKER_03]: Thank you so much.
[SPEAKER_03]: I'm wondering, like, as you were talking about, like the just try harder mentality that we seem to be complicit in.
[SPEAKER_03]: To me, it feels like that starts really early in training.
[SPEAKER_03]: So, like, we're all trained in medical school to like taste these tests that reward quick thinking and decisive, like ABCD answers and that for anesthesia extends
[SPEAKER_03]: through to advanced.
[SPEAKER_03]: I'm studying for that now and it's the same thing.
[SPEAKER_03]: I'm trying to answer these questions that are really complicated within like 30 seconds if I can so that I have an uptime.
[SPEAKER_03]: And in thinking about that, I realize that I'm over relying on my
[SPEAKER_03]: taking the time to really think through it and it's successful.
[SPEAKER_03]: I'm having a lot of success in answering those questions as they're presented, but then I learn while I can just try harder with that and I'll get there.
[SPEAKER_03]: And it shifts us away from doing it the sort of slower way or thinking about the ways to sort of create those forcing functions.
[SPEAKER_03]: So
[SPEAKER_03]: I guess my question for you is how early do you think this starts and how can we then try to integrate these kinds of questions and explorations earlier in the process then when you're actually practicing.
[SPEAKER_01]: That's a really great and complex question because when you're trying harder with those questions, I assume you mean you're going to the books and you're studying more.
[SPEAKER_01]: You're putting it into mental models that you can access faster and faster because you've memorized all of them.
[SPEAKER_01]: You're still not using your deductive reasoning.
[SPEAKER_01]: And I'm one more story around deductive reasoning, a little test for you guys.
[SPEAKER_01]: System one can get in the way of your system two thinking in the same way it can present problems
[SPEAKER_01]: So here's a question, a bat and a ball together, cost $1.10.
[SPEAKER_01]: The bat costs $1.00 more than the ball, what is the ball cost?
[SPEAKER_01]: And I'm pretty sure the instant answer that popped into your brain really fast was 10 cents.
[SPEAKER_01]: It's wrong because if the back costs a dollar more than the ball than the back costs a dollar ten and together they cost a dollar twenty.
[SPEAKER_01]: Now your conscious brain could have done that if somebody had said don't give me the first answer work it through carefully you would have gotten there.
[SPEAKER_01]: but system one like speed, we like speed, cognitive work takes effort, we don't like effort full.
[SPEAKER_01]: And so again, system one intrudes on that thinking.
[SPEAKER_01]: So I don't think anybody has the answer to your question.
[SPEAKER_01]: Jerome Goopman, an internal medicine doctor of road, how doctors think,
[SPEAKER_01]: talk to you about how do we decide what disease a patient has and of course system one can tend to get in the way of that.
[SPEAKER_01]: You think that they are having X, Y, and Z, but they're not having this component.
[SPEAKER_01]: system one doesn't tell you, yes, I think that's the mental model, but they're missing this one thing.
[SPEAKER_01]: It doesn't.
[SPEAKER_01]: It just says, this is the diagnosis and it's confident of the answer.
[SPEAKER_01]: So tricks and tools that people use involve another person.
[SPEAKER_01]: this is what I'm thinking they'll have a different system one in a different model stored so they may come up with a different answer and the other thing is you know we kind of preach this okay you've got the first diagnosis named three other things that it could be at force yourself to come up with a few more and once you've got two or three others there then you can say oh yeah he's missing this one or that one and that can help you and then of course
[SPEAKER_01]: stand for emergency manuals.
[SPEAKER_01]: So these cognitive aids to help you in those moments of stress where you have to work faster, really relying on system 1, to save a patient's life, system 1 is going to tell you the first thing you need to do, you need to do it.
[SPEAKER_01]: mental model it comes up with, not necessarily the most accurate one.
[SPEAKER_01]: So that's where those cognitive aids, like the Stanford emergency manual, having that in every operating room, having it available at your fingertips, can help with that.
[SPEAKER_01]: I'm not sure how we can teach our conscious brain to
[SPEAKER_01]: be more careful and be really successful on it.
[SPEAKER_01]: We've got great tools to help us be safe.
[SPEAKER_02]: Yeah.
[SPEAKER_02]: Well, I'll add, you know, there's a fabulous, I don't if you all listen to the drive, podcast, Peter, it's a great podcast.
[SPEAKER_02]: And he recently interviewed one of the founders of Alpha School.
[SPEAKER_02]: And I recommend listening to it.
[SPEAKER_02]: I'm not going to summarize the whole thing, but
[SPEAKER_02]: Alpha school uses AI guided teaching to bring kids who are behind grade level up very, very quickly to a two grade level in above.
[SPEAKER_02]: And what they have found is that for kids who are below grade level in math, the number one thing that will help is they have to get the memorization part done.
[SPEAKER_02]: So they tend to not have ever memorized their timestables or all that stuff.
[SPEAKER_02]: And if they teach them that, which they can do pretty quickly,
[SPEAKER_02]: then they fly through a lot of the more advanced stuff and the reason is because this is what we've been talking about is that if you're doing let's say a calculus problem and you have to spend some of your mental energy you use some system to energy
[SPEAKER_02]: to do what is eight times seven, then you've got a little less of that energy left for the more complex stuff, but if eight times seven can be system one, then you do that.
[SPEAKER_02]: So I don't know if this applies as well in anesthesiology, I don't think it's been studied, but I do think there's probably some value in memorizing some of the stuff, not all the stuff, some of you don't need, but some of the stuff that's on the exams, because it probably does help in the crisis to have that stuff you don't need to look it up so you can look at the more advanced stuff.
[SPEAKER_02]: That would be my guess.
[SPEAKER_00]: Hi, thank you.
[SPEAKER_00]: I'm Ana Swanson and I was just wondering, there is a movement towards standardization for making things easy and fast like we like it.
[SPEAKER_00]: Standardization, both the kind of setup of the OR, all the anesthesia locations is when he is possible.
[SPEAKER_00]: And also kind of standardization in the anaesthetics incorporating eras and al-rass protocols.
[SPEAKER_00]: And I feel like that really shunts us towards the system one thinking in, if this is kind of power, it always is.
[SPEAKER_00]: Have you noticed any of that in your work?
[SPEAKER_00]: And then if so, how do you think we can kind of build in forces?
[SPEAKER_00]: that kind of make us think about questions where in a certain situation, we might need to do something different.
[SPEAKER_01]: Yeah, thank you, Anna.
[SPEAKER_01]: Certainly, standardization, automation is considered to be a forcing function.
[SPEAKER_01]: Standardization reduces a lot of errors.
[SPEAKER_01]: If you're thinking about it,
[SPEAKER_01]: The closer you pivicane and TXA are to each other in the medication tray, the greater the likelihood that you'll pick that up.
[SPEAKER_01]: Or if the medication tray is different every time you look at it,
[SPEAKER_01]: standardization also helps with speed, so that you can reach to one area and you know what to expect there.
[SPEAKER_01]: But it also reduces risk that you'll reach and pull out the wrong vial or the wrong ampoule.
[SPEAKER_01]: And standardization of protocols, I think it was Lucien Lee who said, every physician needs to know how to write a protocol.
[SPEAKER_01]: how to use a protocol and want to deviate from a protocol.
[SPEAKER_01]: So just because we are protocols and we've standardized things, doesn't mean that we don't have to use our conscious brain along the way to say, what about this protocol doesn't fit the patient in front of me?
[SPEAKER_01]: And bring that critical thinking every time asking yourself that question,
[SPEAKER_01]: What about this protocol isn't appropriate for this patient?
[SPEAKER_01]: And many times it's nothing, but sometimes then you'll pick something up.
[SPEAKER_02]: And I do wonder if, you know, let's imagine the scenario where all the anesthesia trays are standardized in a given hospital, except one area.
[SPEAKER_02]: And so in that area, the Zofran has been swapped with, you know,
[SPEAKER_02]: happen, right?
[SPEAKER_02]: So in that would be terrible because you would have been trained in every area, right?
[SPEAKER_02]: Your system one just goes.
[SPEAKER_02]: You go.
[SPEAKER_02]: You pick out those over and pick out those over and then you go to that other area and you go and you're going to think it's over.
[SPEAKER_02]: Right?
[SPEAKER_02]: So I think I would imagine that if a hospital is going to standardize, you really have to standardize.
[SPEAKER_02]: You can't just standardize some areas.
[SPEAKER_01]: Yep.
[SPEAKER_01]: So what we did at Minnesota, Mike Wall, I know Anna, you might have been involved in it.
[SPEAKER_01]: There's a basic anesthesia tray that is exactly the same for everybody.
[SPEAKER_01]: Peeds has still the same basic tray.
[SPEAKER_01]: It may have different concentrations, but the same man's are in the same location.
[SPEAKER_01]: And then you have the specialty tray.
[SPEAKER_01]: So, you don't try to create a tray for cardiac anesthesia that has happened in prodomine in the basic tray.
[SPEAKER_01]: You keep that out in a separate, this is an add-on for just cardiac anesthesia and the basic tray is the same in every single operating room, p's, OB, everywhere.
[SPEAKER_05]: Yeah, that's great.
[SPEAKER_05]: I'm Jack Wolfe.
[SPEAKER_05]: I'm a fourth year medical student.
[SPEAKER_05]: I wanted to thank you guys for this conversation and thank you as well as a someone trying to do a podcast as well in the medical space.
[SPEAKER_05]: You're an expert in our podcast progress notes.
[SPEAKER_05]: Let's up to you.
[SPEAKER_05]: So thank you for that.
[SPEAKER_05]: My question was a little bit more maybe looking at the neuro scientific side of things.
[SPEAKER_05]: Is there a electro-physiological evidence of these two systems one and two?
[SPEAKER_05]: Can we think of them kind of on a continuum like two different points or should we maybe think of them as discrete systems?
[SPEAKER_05]: That's kind of my question.
[SPEAKER_05]: Has somebody strapped sensors and someone's had making these decisions or using different systems?
[SPEAKER_01]: Yeah and I think that's one of the problems with for this conversation that we're having now
[SPEAKER_01]: It is really hard to understand what the sub-conscious is thinking and doing.
[SPEAKER_01]: No one has figured out how to tease out which part of the brain.
[SPEAKER_01]: It's throughout the brain.
[SPEAKER_01]: There isn't one part.
[SPEAKER_01]: You know, we have a limbic system, which is more for the emotions and things.
[SPEAKER_01]: And we can see it light up on a functional MRI.
[SPEAKER_01]: They haven't come up with anything that I know that can
[SPEAKER_01]: tell you this is system one, you're fast, unconscious, stored, associated memories at play versus your deductive reasoning.
[SPEAKER_01]: And we may be able to tell more about deductive reasoning.
[SPEAKER_01]: I don't know because it's effortful.
[SPEAKER_01]: And because it's effortful, you get more blood flow.
[SPEAKER_01]: So there may be some with our conscious.
[SPEAKER_01]: effortful brang, but I don't know of anything in the subconscious space.
[SPEAKER_04]: I just a practical question.
[SPEAKER_04]: As somebody who has practiced for many years and has been involved in the patient safety space, just for a personal opinion, what is the biggest step we take in in the patient safety, whether it's practical physical, I can mention the pin system, whether it's oxygen's ad probes, timeouts, in your opinion what's the biggest advance in the last
[SPEAKER_01]: Again, that's a great question.
[SPEAKER_01]: And I'm not sure I can come up with an answer for that.
[SPEAKER_01]: It's like we talk about what, if you're a, what's the value dome?
[SPEAKER_01]: You know, when they race bicycles around the, circuit, you know, they're almost going sideways.
[SPEAKER_01]: And somebody wants to shave six seconds off their time.
[SPEAKER_01]: There is one thing they can do to shave six seconds off.
[SPEAKER_01]: It's got to be six things that each take one second.
[SPEAKER_01]: So it's hard.
[SPEAKER_01]: depending on what the problem is, two syringes that look alike for nepotrarchsate and vincristin.
[SPEAKER_01]: That simple, vincristin comes in a mini bag.
[SPEAKER_01]: The solution to that will be very different than pre-filled syringes.
[SPEAKER_01]: I would say that one of the, perhaps the biggest thing that's happened in patient safety is that we're just talking about it.
[SPEAKER_01]: that we are just really now really aware of that and becoming I hope really conscious of the fact that it is not our fault if our system one gets in the way and creates an error, but we have to go to those forcing functions and we have to force our leaders to bring in
[SPEAKER_01]: unique small board connectors for niraxial for feeding tubes.
[SPEAKER_01]: And we have to say this is critical to our patients safety and well-being.
[SPEAKER_01]: And maybe leave you with us that Alan Mary talks about all the time.
[SPEAKER_01]: The difference between an error, which is an unintentional failure to complete a plan of action as you wanted, and a violation, which is a conscious decision to not employ those things that experts tell you are necessary for safety.
[SPEAKER_01]: And so, we often think this was an error, but you could have used this barrier.
[SPEAKER_01]: You could have had pre-filled syringes, but we didn't implement it.
[SPEAKER_01]: We thought we could try harder.
[SPEAKER_01]: That actually then becomes a violation.
[SPEAKER_01]: Dr. John Icorne, Rob's full thing, have told us what we need to do for medication safety.
[SPEAKER_01]: And yet, still in our hospitals, we're missing a lot of those barriers.
[SPEAKER_02]: I mean, it does seem I think too many of us who grew up with Paul Soximators that going from not having a Paul Sox to having one must have been a pretty big advancement.
[SPEAKER_02]: But I have heard people, you're interested here with you, you think, Joyce, but people who once practiced without them, who felt like, you know, you patients did okay.
[SPEAKER_02]: I mean, you paid close attention, you watched them carefully and, you know, it wasn't like patients were dying from my boxing left and right in the yard.
[SPEAKER_01]: almost of them did really, really well.
[SPEAKER_01]: Having had a friend who is in anesthesia who turn the nitrous on with no oxytun, that's a rare, rare, rare event, but it is horribly devastating to everyone.
[SPEAKER_01]: And I know they say, well, we've never been able to prove that pulse-accimiterus help.
[SPEAKER_01]: but nobody would ever go back to doing one.
[SPEAKER_01]: So I was at UCSF, John Severinghouse had in this closet a mass spectrometer and little tubing went up through the ceiling, you know, tubing from your elbow.
[SPEAKER_01]: up down to the mass-fac, and every 10 seconds you got a refreshed inhaled and exhaled oxygen, CO2, and inhaled gases.
[SPEAKER_01]: When I left Michigan, I'd done a year of head of seizure at Michigan.
[SPEAKER_01]: Our monitor showed us EKG blood pressure was all manual and there was no CO2, there was no pulse Accimator, we didn't know what RFIO2 was, which is why we could turn the nitrous up and have 100% nitrous and no alarm went off because they weren't even measuring the fraction of inspired oxygen.
[SPEAKER_01]: So
[SPEAKER_01]: having those devices, those tools when I then had to leave UCSF and go back to giving an a seizure with nothing, and I can't tell you of all the things we came up with, but if you feel right here,
[SPEAKER_01]: When you give it rough, that's more reliable than looking at chest rise, any place else.
[SPEAKER_01]: And all the things we try to come up with to prevent unrecognized, astrophysicial intubation, right?
[SPEAKER_01]: So, the one thing that probably has saved more lives than anything else is CO2 in every operating room.
[SPEAKER_02]: Yeah, fabulous.
[SPEAKER_02]: All right, I will ask one last question, which is if someone in the audience is thinking themselves, you know, Dr. War has had such an incredible career.
[SPEAKER_02]: She's made such an impact.
[SPEAKER_02]: I want to get involved in patient safety.
[SPEAKER_02]: What would you recommend?
[SPEAKER_02]: How can they get involved as either medical students or residents or young faculty in having a career like yours fighting for patient safety at the beginning for patient safety?
[SPEAKER_01]: So certainly, well, now there are actual online courses that you can do in patient safety.
[SPEAKER_01]: Quite a few of them, and they're very effective.
[SPEAKER_01]: They'll give you all of the basics.
[SPEAKER_01]: But also, definitely, when the APS-South newsletter comes in, anesthesia patient safety, foundation newsletter comes, read it, cover to cover.
[SPEAKER_01]: Because it will give you a lot of the things,
[SPEAKER_01]: that's happening in patient safety.
[SPEAKER_01]: And you could go back and read the seminal articles from Jeffrey Cooper.
[SPEAKER_01]: Jeff Pierce, all of those great leaders, many of them are archived on the APSF website.
[SPEAKER_01]: And it's a great thing to read an article here and there.
[SPEAKER_02]: Jeffrey Cooper was one of the first live accurate episodes except that was before we did it here so it was just me and him sitting in a room live But it was not actually on stage.
[SPEAKER_02]: So it was great to interview him and as you said he's not like just a giant actually well Thank you Dr. War.
[SPEAKER_02]: I want to say a big thank you to Marine Gagan and her team
[SPEAKER_02]: for making this possible to ASA, of course, and Dr. Wartier, you for taking the time to be here on the show and to our fabulous audience for taking the time to be here and your wonderful questions.
[SPEAKER_02]: So give yourselves a round of applause.
[SPEAKER_02]: And I'll end as I always do, and I really mean it by saying that you all are whatever stage you're at.
[SPEAKER_02]: Some of your medical students, some of your residents, some of your my residents, some of you may be already in practice, but what we do is tough, you're out there, you're working hard, you don't always get a lot of gratification, a lot of thank yous for it, but
[SPEAKER_02]: I hope that you know and I truly believe that what you are doing every day is truly important and so very valued.
[SPEAKER_02]: Thank you for doing it.
[SPEAKER_02]: Thank you for being here and have a wonderful rest of your conference.
[SPEAKER_04]: Thanks so much.