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Virtually Sensing the Future of Perianesthesia Nursing
INFORMATICS AND HEALTH INFORMATION TECHNOLOGY
Virtually Sensing the Future of Perianesthesia Nursing Matthew D. Byrne, PhD, RN, CPAN, CNE
HIGH ON A SHELF in her parent’s garage was a silver, black, and green Corona typewriter. It was bulky and heavy with sticky rusted keys whose obsolescence was betrayed by the length of time it had sat on its dusty perch. It was a marvel in its time, a mass-produced word processor that clacked out messages and papers now lost to time and memory. The arrangement of the keys on that typewriter remained largely unchanged. They were an echoing testament to a past in which they were organized to slow down the typist to prevent the keys from sticking. It was a technology artifact whose utility was predicted, whose usefulness was then outlived, and whose sentence was now to serve only as a curiosity. Even in the face of rapidly evolving technology, the nursing profession learned to evolve just as quickly. Visionary leadership at the right time in the nursing profession kept them from becoming yet another dusty artifact doomed only to be admired as a curiosity of a past time. Rachel did not miss all the different passwords she had scribbled on pieces of paper tucked behind her ID badge, which had also become obsolete. Biometrics and embedded sensors completely replaced those bygone irritations. She barely paused outside the hospital’s employee entrance as the security software scanned her retinas and read her fingerprints off the door handle in mere millisec-
Matthew D. Byrne, PhD, RN, CPAN, CNE, is Assistant Professor of Nursing, Department of Nursing, Saint Catherine University, Saint Paul, MN. Conflict of interest: None to report. Address correspondence to Matthew D. Byrne, Department of Nursing, Saint Catherine University, 2004 Randolph Avenue, Saint Paul, MN 55105; e-mail address: mdbyrne@ stkate.edu. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.11.003
64
Figure 1. A Futurist Perspective on Perianesthesia Nursing. Copyrighted by Dennis McElroy.
onds. She had long ago let go of the paranoia about the constant digital sensing of her proximity to people, devices, and doors in favor of the conveniences it provided. The churning of software algorithms constantly anticipated her needs, whether it was a lunch menu or a virtual consultation with the respiratory therapist. She saw Dr. Harbrook in the hallway struggling with her virtual reality gear. The thin and disposable cardboard mask had replaced the clunky but washable versions that they had been using until last year. The disposable virtually reality masks were the last step in the ‘‘touchless initiative’’ started by the hospital 2 years ago after multiple
Journal of PeriAnesthesia Nursing, Vol 30, No 1 (February), 2015: pp 64-67
INFORMATICS
Carbapenem-resistant bacteria outbreaks. The last major outbreak, at the hands of the bug known as Super Kleb, killed hundreds of thousands of patients and health care workers, nearly shutting down every hospital and care facility in the country. The federal mandate to dramatically reduce the number of patient care devices that actually had to be touched or that were reused multiple times included everything from keyboards to the virtual reality gear. ‘‘Good morning Dr. Harbrook, do you need some help?’’ ‘‘How embarrassing but I am so glad you happened by. I can get into the Hyper Medical Library (HML) but I can’t find my patient in there.’’ Some things never change. Rachel was transported back to earlier in her long career working with Dr. Harbrook when they would have to hunt down missing paper patient charts or wade through extensive patient libraries in the early generations of electronic health records. Rachel had always volunteered as physician support and now was helping physicians navigate the next iteration of information system. The virtual reality medical libraries put reference information, patient data, and even experts of every type at their virtual fingertips. ‘‘The sensor out here in the hall still needs some adjusting. Try taking two steps closer to the patient’s room. Usually that does the trick.’’ A smile spread across the physician’s face and Rachel could envision the wonders and vastness of the HML opening. As she walked away, Rachel could see Dr. Habrook motioning through the air almost like she was conducting a symphony, her voice combining with gestures to call up virtual files and images. Behind the odd-looking cardboard mask, she knew that images were being rotated, zoomed, and overlaid across the infinite fabric of virtual space. Data were transformed there into colorful bursts of light showing hot spots of problems and suggesting real-time connections between therapies and clinical data for customized risk-stratified care regimens. Dr. Harbrook’s favorite trick was to zoom far into the three-dimensional full body scan views and take virtual tours with the patient and their family to point out microsurgical treatment options. The pre-op waiting area was bustling as usual and she had to side step the ‘‘spray-tech’’ who was talk-
65
ing to a young boy. The notion of being sprayed with the grainy translucent skin coating was understandably unnerving to him. The tech applied some of the surgical skin solution to the back of the boy’s hand and explained how the grains were actually tiny little sensors that could read temperature, movement, and electrical activities. It was a good thing he left out the part about the embedded antimicrobial scrubbers, which probably would have been too much for the young boy to handle. Rachel grabbed her Comm-Goggs and her Compounding Machine for her first post-op patient of the day. She read the patient notes and summary data that floated across her field of vision courtesy of the technology-enhanced protective eyewear. A large exclamation point popped up in her view causing the slow scroll of patient data to pause and fade, a warning she recognized as a critical just-in time education alert. A demonstration video began to play heralding that more settings were being installed for the Bilevel and Continuous Positive Airway Pressure (BiPAP and CPAP) module of the Compounding Machine. She disliked that name, but it stuck despite the fact that it did more than just compound medications. It was an amalgamated infusion pump, medication dispensing device, and ventilator that could interact with the patient’s health care data in ways each of those individual technologies could not in the past. She knew it to be just another data feed to the patient’s health care data cloud. Almost every device, sensor, and provider activity was being cataloged in this way, eliminating the documentation burden and need to interact with germ carrying mobile devices and the mouse and keyboard. She wondered if this module upgrade was making the remaining respiratory therapists even more nervous. She remembered seeing them at the demonstration of the Compounding Machine’s ventilator and respiratory medication delivery systems. Their faces went from amazed to worried and rumor had it that they immediately had an all staff meeting to determine if the new device was going to put them all out of work. The nurse anesthetists had had to adjust as well. They actually were able to expand their regional anesthetic practice once the machines were being used for automated sedation delivery for almost all minor cases. Some of the nurse anesthetists from her
66
facility had even joined the rural surgery initiative that allowed for minor surgeries to be carried out in a recreational vehicle with ‘‘old-fashioned anesthesia’’ and an adventurous surgeon who was happy to operate with only some of the heavy duty virtual reality and robot-assisted gear. Through the Comm-Goggs, the anesthetist called for report and patched Rachel visually into the room through their own camera-mounted glasses. She could see that they were just about to leave the room. The Compounding Machine began its verbal verification processes, sensing the patient was en route. The nostalgia for the adrenaline rush while scrambling to settle the patient, document in the record, and listen to report were washed away by a red flash indicating imminent patient wake-up via electro-encephalographic (EEG) monitoring and actigraphy sensors embedded in the surgical skin sprayed on in pre-op. ‘‘Prep Fentanyl delivery, 25 micrograms.’’ The compounding machine silently prepared the medication and ran through the finely tuned series of cross-checks that were once performed by the fallible eyes and minds of nurses and doctors. By the time they had switched the patient’s lines and respiratory gear over to the deceptively simple looking machine, it was already notifying her that the medications were ready. ‘‘Confirm delivery of Fentanyl 25 micrograms.’’ The voice soothingly spoke through the earpiece built into her protective goggles. ‘‘Confirm.’’ Most of her colleagues were using the hand gesture option to confirm delivery, but she liked the satisfaction of hearing it out loud. As the operating room staff filed out of the postanesthesia care unit, the holographic projection of the vital signs began to convert to her preferred visualization formats. She listened to the quiet thumping of the patient’s elevated heart rate and watched as the green rise and fall of the respiratory rate began to slow. Her favorite part was watching the colors and sounds begin to harmonize including the shimmering river of translucent blues and greens of the EEG and capnography waves. She got lost for a moment in the simple beauty of a carefully controlled and predictable return to consciousness that had replaced the sometimes-wild wake ups of the past.
MATTHEW D. BYRNE
The nasally voice alarm from the sensor bed pulled her out of the enjoyment of a job well done, ‘‘Moderate bleeding detected.’’ The sensor beds were sometimes oversensitive and by policy, a visual assessment of whatever fluids it was detecting was required. The beds were made up of dozens of cushiony tubes that not only sensed and identified fluids but also monitored pressure zones as well, inflating and deflating to improve comfort and reduce pressure at hot spots. She pulled back the Envirosheets to get a better look. The sheets puffed and hissed at her in vain as they searched for the body temperature reading courtesy of the sensor-embedded surgical skin. ‘‘Confirm bleeding. Error correction. Large amount sanguineous drainage noted from incision site. Contact surgeon.’’ Her voice, captured by the microphone in her Comm-Goggs, was also recording the event to the patient’s data cloud and would most likely trigger an alert to the patient’s family. She had to trust that they knew that live feeds of a patient’s surgical course were sometimes anxiety provoking. The surgeon’s voice came over the line a few moments later. ‘‘I am in another patient’s HML but let me jump over. Patch me in visually please.’’ Unlike Dr. Harbrook, the surgeon was very used to the latest generation of technology. He appreciated the ability to quickly evaluate large amounts of data and to be visually aware of the patient circumstances no matter where he was. ‘‘Activate and share visual.’’ A small green light appeared in the virtual space within Rachel’s Comm-Goggs indicating a live shared video stream. ‘‘Just reinforce the site and keep a close eye on it. We have two units of pseudo-auto-heme ready if we need it.’’ Instantly, a double-helix symbol bounced across her peripheral vision. A soothing voice delivered the warning. ‘‘Genotype interaction alert. A genetic cross-check found that the risk for allergic response was above the set threshold for this future order.’’ With a slight hint of irritation, the surgeon’s voice broke in, ‘‘I will follow on up on the alert and see what the risk ratios look like. I am pretty sure it’s a false-alarm since the pseudo-auto-heme is
INFORMATICS
67
supposed to be a perfect genetic match. I am guessing it is a filler or a preservative triggering the alert.’’ With that, the surgeon signed out, and she could see that pulling the Envirosheets back and her conversation had rippled the waters of the patient’s EEG. The turbulence levels were low so she let the patient rouse and started to reorient them with the usual reassurances of a case gone well and all being fine.
report of how well the radio-active seed is working and how well the rapidly regenerating cells are working on your prostate. Nurse Bahmani said that you wanted to take a look at the surgical video and walk through the biopsy information again. I have also confirmed the order for bladder spasm medications. Do you want me to send that through to your 3D printer or have it delivered via pharmacy drone?’’
Rachel had seen the pharmacy techs load the genesequenced artificial blood product into her Compounding Machine earlier. She laughed to herself, thinking about a surgical patient from last week who could not wrap his head around the idea that the blood product had been genetically engineered and grown for him in case he would need it. He was the same patient that had also balked at the idea of using his smartphone’s chemical sniffer during her Phase 3D call with him after he had gone home the day of his surgery. She had not planned on covering the Phase 3D shift but one of the staff had hit their maximum virtual immersion time limit for the day.
‘‘Pharmacy drone is fine. It’s still a little creepy, though, that there is a hologram of you here in my bathroom.’’
‘‘Good morning Mr. Vang. My name is Rachel and I will be taking over for Nurse Bahmani.’’ The daylight was bright from his bathroom window so she toggled the camera views so she could see his face. ‘‘So you guys really want me to put my phone near the toilet? There just seems to be something wrong with that.’’ His face displayed skepticism and a bit of annoyance at the thought of it. The best part of Phase 3D postoperative shifts was that it was almost like doing real-life house calls and she, like many perianesthesia nurses, had embraced this newest evolution of their practice. ‘‘Yes, I know that sounds weird, but the chemical and radiation sniffers in the phone will give us a
‘‘Sorry about that. Let me switch to voice-only. I will patch the surgeon in when we have our second virtual visit later this morning. Otherwise, you can always call me before that if you need anything. In the mean-time, make sure you get a greenlight verification reading from your smartphone before you flush.’’ She chuckled to herself, slipping the virtual reality gear off and letting her eyes adjust to the lowered light of the workroom whose blinds had a fine layer of dust. She resisted the instinctive urge to reach for the keyboard to log in and write up some notes, a now obsolete task and instead wiped away a bit of the dust on the blinds. The dust-layered typewriter in her parent’s garage popped into her mind. She was glad her own usefulness had not been outlived and that her years of knowledge and experience were still valuable. The clunky functionality of the old systems, much like the frustration of sticky typewriter keys, had finally been pushed aside by new technologies. She sat back and listened as the lunch menu began to play quietly through her headset, sitting on the desk and marveling at the pace of such rapid change. The greater access to information and the sense of greater patient contact, despite increased technology, let her rest assured that the hard lessons of past technologies had finally been learned.
Virtually Sensing the Future of Perianesthesia Nursing Matthew D. Byrne, PhD, RN, CPAN, CNE
HIGH ON A SHELF in her parent’s garage was a silver, black, and green Corona typewriter. It was bulky and heavy with sticky rusted keys whose obsolescence was betrayed by the length of time it had sat on its dusty perch. It was a marvel in its time, a mass-produced word processor that clacked out messages and papers now lost to time and memory. The arrangement of the keys on that typewriter remained largely unchanged. They were an echoing testament to a past in which they were organized to slow down the typist to prevent the keys from sticking. It was a technology artifact whose utility was predicted, whose usefulness was then outlived, and whose sentence was now to serve only as a curiosity. Even in the face of rapidly evolving technology, the nursing profession learned to evolve just as quickly. Visionary leadership at the right time in the nursing profession kept them from becoming yet another dusty artifact doomed only to be admired as a curiosity of a past time. Rachel did not miss all the different passwords she had scribbled on pieces of paper tucked behind her ID badge, which had also become obsolete. Biometrics and embedded sensors completely replaced those bygone irritations. She barely paused outside the hospital’s employee entrance as the security software scanned her retinas and read her fingerprints off the door handle in mere millisec-
Matthew D. Byrne, PhD, RN, CPAN, CNE, is Assistant Professor of Nursing, Department of Nursing, Saint Catherine University, Saint Paul, MN. Conflict of interest: None to report. Address correspondence to Matthew D. Byrne, Department of Nursing, Saint Catherine University, 2004 Randolph Avenue, Saint Paul, MN 55105; e-mail address: mdbyrne@ stkate.edu. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.11.003
64
Figure 1. A Futurist Perspective on Perianesthesia Nursing. Copyrighted by Dennis McElroy.
onds. She had long ago let go of the paranoia about the constant digital sensing of her proximity to people, devices, and doors in favor of the conveniences it provided. The churning of software algorithms constantly anticipated her needs, whether it was a lunch menu or a virtual consultation with the respiratory therapist. She saw Dr. Harbrook in the hallway struggling with her virtual reality gear. The thin and disposable cardboard mask had replaced the clunky but washable versions that they had been using until last year. The disposable virtually reality masks were the last step in the ‘‘touchless initiative’’ started by the hospital 2 years ago after multiple
Journal of PeriAnesthesia Nursing, Vol 30, No 1 (February), 2015: pp 64-67
INFORMATICS
Carbapenem-resistant bacteria outbreaks. The last major outbreak, at the hands of the bug known as Super Kleb, killed hundreds of thousands of patients and health care workers, nearly shutting down every hospital and care facility in the country. The federal mandate to dramatically reduce the number of patient care devices that actually had to be touched or that were reused multiple times included everything from keyboards to the virtual reality gear. ‘‘Good morning Dr. Harbrook, do you need some help?’’ ‘‘How embarrassing but I am so glad you happened by. I can get into the Hyper Medical Library (HML) but I can’t find my patient in there.’’ Some things never change. Rachel was transported back to earlier in her long career working with Dr. Harbrook when they would have to hunt down missing paper patient charts or wade through extensive patient libraries in the early generations of electronic health records. Rachel had always volunteered as physician support and now was helping physicians navigate the next iteration of information system. The virtual reality medical libraries put reference information, patient data, and even experts of every type at their virtual fingertips. ‘‘The sensor out here in the hall still needs some adjusting. Try taking two steps closer to the patient’s room. Usually that does the trick.’’ A smile spread across the physician’s face and Rachel could envision the wonders and vastness of the HML opening. As she walked away, Rachel could see Dr. Habrook motioning through the air almost like she was conducting a symphony, her voice combining with gestures to call up virtual files and images. Behind the odd-looking cardboard mask, she knew that images were being rotated, zoomed, and overlaid across the infinite fabric of virtual space. Data were transformed there into colorful bursts of light showing hot spots of problems and suggesting real-time connections between therapies and clinical data for customized risk-stratified care regimens. Dr. Harbrook’s favorite trick was to zoom far into the three-dimensional full body scan views and take virtual tours with the patient and their family to point out microsurgical treatment options. The pre-op waiting area was bustling as usual and she had to side step the ‘‘spray-tech’’ who was talk-
65
ing to a young boy. The notion of being sprayed with the grainy translucent skin coating was understandably unnerving to him. The tech applied some of the surgical skin solution to the back of the boy’s hand and explained how the grains were actually tiny little sensors that could read temperature, movement, and electrical activities. It was a good thing he left out the part about the embedded antimicrobial scrubbers, which probably would have been too much for the young boy to handle. Rachel grabbed her Comm-Goggs and her Compounding Machine for her first post-op patient of the day. She read the patient notes and summary data that floated across her field of vision courtesy of the technology-enhanced protective eyewear. A large exclamation point popped up in her view causing the slow scroll of patient data to pause and fade, a warning she recognized as a critical just-in time education alert. A demonstration video began to play heralding that more settings were being installed for the Bilevel and Continuous Positive Airway Pressure (BiPAP and CPAP) module of the Compounding Machine. She disliked that name, but it stuck despite the fact that it did more than just compound medications. It was an amalgamated infusion pump, medication dispensing device, and ventilator that could interact with the patient’s health care data in ways each of those individual technologies could not in the past. She knew it to be just another data feed to the patient’s health care data cloud. Almost every device, sensor, and provider activity was being cataloged in this way, eliminating the documentation burden and need to interact with germ carrying mobile devices and the mouse and keyboard. She wondered if this module upgrade was making the remaining respiratory therapists even more nervous. She remembered seeing them at the demonstration of the Compounding Machine’s ventilator and respiratory medication delivery systems. Their faces went from amazed to worried and rumor had it that they immediately had an all staff meeting to determine if the new device was going to put them all out of work. The nurse anesthetists had had to adjust as well. They actually were able to expand their regional anesthetic practice once the machines were being used for automated sedation delivery for almost all minor cases. Some of the nurse anesthetists from her
66
facility had even joined the rural surgery initiative that allowed for minor surgeries to be carried out in a recreational vehicle with ‘‘old-fashioned anesthesia’’ and an adventurous surgeon who was happy to operate with only some of the heavy duty virtual reality and robot-assisted gear. Through the Comm-Goggs, the anesthetist called for report and patched Rachel visually into the room through their own camera-mounted glasses. She could see that they were just about to leave the room. The Compounding Machine began its verbal verification processes, sensing the patient was en route. The nostalgia for the adrenaline rush while scrambling to settle the patient, document in the record, and listen to report were washed away by a red flash indicating imminent patient wake-up via electro-encephalographic (EEG) monitoring and actigraphy sensors embedded in the surgical skin sprayed on in pre-op. ‘‘Prep Fentanyl delivery, 25 micrograms.’’ The compounding machine silently prepared the medication and ran through the finely tuned series of cross-checks that were once performed by the fallible eyes and minds of nurses and doctors. By the time they had switched the patient’s lines and respiratory gear over to the deceptively simple looking machine, it was already notifying her that the medications were ready. ‘‘Confirm delivery of Fentanyl 25 micrograms.’’ The voice soothingly spoke through the earpiece built into her protective goggles. ‘‘Confirm.’’ Most of her colleagues were using the hand gesture option to confirm delivery, but she liked the satisfaction of hearing it out loud. As the operating room staff filed out of the postanesthesia care unit, the holographic projection of the vital signs began to convert to her preferred visualization formats. She listened to the quiet thumping of the patient’s elevated heart rate and watched as the green rise and fall of the respiratory rate began to slow. Her favorite part was watching the colors and sounds begin to harmonize including the shimmering river of translucent blues and greens of the EEG and capnography waves. She got lost for a moment in the simple beauty of a carefully controlled and predictable return to consciousness that had replaced the sometimes-wild wake ups of the past.
MATTHEW D. BYRNE
The nasally voice alarm from the sensor bed pulled her out of the enjoyment of a job well done, ‘‘Moderate bleeding detected.’’ The sensor beds were sometimes oversensitive and by policy, a visual assessment of whatever fluids it was detecting was required. The beds were made up of dozens of cushiony tubes that not only sensed and identified fluids but also monitored pressure zones as well, inflating and deflating to improve comfort and reduce pressure at hot spots. She pulled back the Envirosheets to get a better look. The sheets puffed and hissed at her in vain as they searched for the body temperature reading courtesy of the sensor-embedded surgical skin. ‘‘Confirm bleeding. Error correction. Large amount sanguineous drainage noted from incision site. Contact surgeon.’’ Her voice, captured by the microphone in her Comm-Goggs, was also recording the event to the patient’s data cloud and would most likely trigger an alert to the patient’s family. She had to trust that they knew that live feeds of a patient’s surgical course were sometimes anxiety provoking. The surgeon’s voice came over the line a few moments later. ‘‘I am in another patient’s HML but let me jump over. Patch me in visually please.’’ Unlike Dr. Harbrook, the surgeon was very used to the latest generation of technology. He appreciated the ability to quickly evaluate large amounts of data and to be visually aware of the patient circumstances no matter where he was. ‘‘Activate and share visual.’’ A small green light appeared in the virtual space within Rachel’s Comm-Goggs indicating a live shared video stream. ‘‘Just reinforce the site and keep a close eye on it. We have two units of pseudo-auto-heme ready if we need it.’’ Instantly, a double-helix symbol bounced across her peripheral vision. A soothing voice delivered the warning. ‘‘Genotype interaction alert. A genetic cross-check found that the risk for allergic response was above the set threshold for this future order.’’ With a slight hint of irritation, the surgeon’s voice broke in, ‘‘I will follow on up on the alert and see what the risk ratios look like. I am pretty sure it’s a false-alarm since the pseudo-auto-heme is
INFORMATICS
67
supposed to be a perfect genetic match. I am guessing it is a filler or a preservative triggering the alert.’’ With that, the surgeon signed out, and she could see that pulling the Envirosheets back and her conversation had rippled the waters of the patient’s EEG. The turbulence levels were low so she let the patient rouse and started to reorient them with the usual reassurances of a case gone well and all being fine.
report of how well the radio-active seed is working and how well the rapidly regenerating cells are working on your prostate. Nurse Bahmani said that you wanted to take a look at the surgical video and walk through the biopsy information again. I have also confirmed the order for bladder spasm medications. Do you want me to send that through to your 3D printer or have it delivered via pharmacy drone?’’
Rachel had seen the pharmacy techs load the genesequenced artificial blood product into her Compounding Machine earlier. She laughed to herself, thinking about a surgical patient from last week who could not wrap his head around the idea that the blood product had been genetically engineered and grown for him in case he would need it. He was the same patient that had also balked at the idea of using his smartphone’s chemical sniffer during her Phase 3D call with him after he had gone home the day of his surgery. She had not planned on covering the Phase 3D shift but one of the staff had hit their maximum virtual immersion time limit for the day.
‘‘Pharmacy drone is fine. It’s still a little creepy, though, that there is a hologram of you here in my bathroom.’’
‘‘Good morning Mr. Vang. My name is Rachel and I will be taking over for Nurse Bahmani.’’ The daylight was bright from his bathroom window so she toggled the camera views so she could see his face. ‘‘So you guys really want me to put my phone near the toilet? There just seems to be something wrong with that.’’ His face displayed skepticism and a bit of annoyance at the thought of it. The best part of Phase 3D postoperative shifts was that it was almost like doing real-life house calls and she, like many perianesthesia nurses, had embraced this newest evolution of their practice. ‘‘Yes, I know that sounds weird, but the chemical and radiation sniffers in the phone will give us a
‘‘Sorry about that. Let me switch to voice-only. I will patch the surgeon in when we have our second virtual visit later this morning. Otherwise, you can always call me before that if you need anything. In the mean-time, make sure you get a greenlight verification reading from your smartphone before you flush.’’ She chuckled to herself, slipping the virtual reality gear off and letting her eyes adjust to the lowered light of the workroom whose blinds had a fine layer of dust. She resisted the instinctive urge to reach for the keyboard to log in and write up some notes, a now obsolete task and instead wiped away a bit of the dust on the blinds. The dust-layered typewriter in her parent’s garage popped into her mind. She was glad her own usefulness had not been outlived and that her years of knowledge and experience were still valuable. The clunky functionality of the old systems, much like the frustration of sticky typewriter keys, had finally been pushed aside by new technologies. She sat back and listened as the lunch menu began to play quietly through her headset, sitting on the desk and marveling at the pace of such rapid change. The greater access to information and the sense of greater patient contact, despite increased technology, let her rest assured that the hard lessons of past technologies had finally been learned.