“If I had some duct tape, I could fix that.”
The above is one of the favorite lines of Angus MacGyver, a secret agent, scientist, and protagonist in the eponymous television series.1,2 Known for his ability to solve complex technical problems with everyday items such as paper clips and chewing gum, the verb “macgyver” has entered the American lexicon to describe simple, imaginative fixes to technical problems.
Medicine, and particularly anesthesia, is known for individuals who have advanced anesthesia practice by designing or adapting existing objects to solve knotty clinical problems. Sir Ivan Magill, for example, invented the first endotracheal tube so that inhaled anesthetics could be given to patients with facial burns.3 Arthur Guedel and Ralph Waters further modified Magill’s invention by adding detachable cuffs that sealed the airway. The laryngeal mask airway was the 13th patent of the prolific inventor and anesthesiologist Archie Brain, whose diary entry “Better, use a loop fitting into the anatomic loop of space surrounding the larynx” ultimately revolutionized the practice of outpatient anesthesia.4
Such inventions are only the tip of the MacGyver iceberg, and many other creative solutions have helped the anesthesiologists to navigate their clinical environment. Many anesthesiologists use tape, IVs, gauze, tubing, and other “common” operating room items everyday in a nonstandard fashion to solve problems. Readers of a certain age will recall that an almost mandatory aspect of anesthesia delivery in the 1990s was to constantly monitor lung sounds using an esophageal stethoscope connected to an earpiece. However, moving around the room while tethered to the patient was cumbersome. After some experimentation, one of the authors (KJR) glued a Luer lock adapter to a microphone and attached a small FM transmitter, allowing him to wirelessly monitor the breath sounds using a small FM radio and an earphone. Problem solved!
In this issue of Anesthesia & Analgesia, Dayan et al5 describe a novel method of repairing a pilot balloon by using a 22-gauge intravenous catheter to splice a new pilot balloon onto an endotracheal tube. They first present a case in which their repair helped them to avoid reintubating a ventilator-dependent patient. They then describe their repair in detail (including pictures). Finally, they test their approach by comparing cuff pressures and tensile strengths of the pilot tube between intact and repaired tubes under laboratory conditions.
The repair is ingenious and the data convincing. It is likely that a broken pilot balloon can in fact be repaired this way. However, such a finding invites as many questions as it answers. Should all pilot balloons be repaired using this technique? If not, under what conditions and in which patients should this repair occur? How should this repair be documented in the chart (if at all)? Most importantly, should such nonstandard repairs be permitted in modern clinical practice? Viewed through a safety lens, such a repair clearly carries inherent risks. Respiratory therapists, nurses, and other personnel unaware of the repair might not correctly diagnose its failure, especially late at night or during low staffing periods. In this situation, the authors’ decision to strengthen the repair with tape might paradoxically hide the problem. In addition, clinicians may be tempted to perform this repair rather than changing the tube in low-risk situations where a new, intact tube would be easy to insert. Finally, should a culture of safety allow such repairs? Although the authors clearly had an admirable goal of avoiding reintubation in a patient with a difficult airway, would they have been liable if the repair had failed and the patient were harmed? As an analogy, if a vital hydraulic hose in an airplane were repaired in a similar fashion, and an adverse event occurred, the nonstandard repair would come under intense scrutiny whether or not it was directly related to the event.
The questions that this article raises are highly topical. “Maker culture” is a relatively new, technology-based “do-it-yourself” subculture that combines robotics, computers, and 3-dimensional printing with traditional craftwork. Many millennials now entering medical school are enthusiastic makers and may well decide to simply build something to solve a clinical problem rather than seeking a hospital- or government-approved solution. Using 3-dimensional printers to prototype medical devices is no longer just a theoretical possibility; 2 gastroenterologists recently designed and printed a “capsule odometer” to aid investigation of the small bowel.6 Anesthesiologists are also using this technology to develop new solutions to old problems, describing in 1 recent case report 3-dimensional printing an adaptor allowing a Smartphone to be attached to a laryngoscope so a remote instructor can view the image in a “do-it-yourself” form of telemedicine.7
When is it better to pursue a nonstandard repair rather than using an US Food and Drug Administration-approved piece of equipment? Is it still permissible to build a patient care device in a garage or break room? Might rules forbidding such experimentation delay the next great invention? There are no good answers to these questions other than to advise extreme caution when building a medical device from spare parts. Sometimes, as in the situation described by Dayan, a home brew solution may be the best one, and in this case, it worked. As MacGyver himself has noted, “Well, when it comes down to me against a situation, I don’t like the situation to win.”1
Name: Keith J. Ruskin, MD.
Contribution: This author helped write the manuscript.
Name: Avery Tung, MD, FCCM.
Contribution: This author helped write the manuscript.
This manuscript was handled by: David Hillman, MD.
3. Nosker GS, Swan KG. Sir Ivan Magill: the right physician in the right place at the right time. J Trauma. 2007;62:10561059.
4. Brain AI. The laryngeal mask—a new concept in airway management. Br J Anaesth. 1983;55:801805.
5. Dayan AC, Epstein RH, et al. Structural integrity of a simple method to repair disrupted tracheal tube pilot balloon assemblies. Anesth Analg. 2016;123:11581162.
6. Karargyris A, Koulaouzidis A. Capsule-odometer: a concept to improve accurate lesion localisation. World J Gastroenterol. 2013;19:59435946.
7. Lee DW, Thampi S, Yap EP, Liu EH. Evaluation of a smartphone camera system to enable visualization and image transmission to aid tracheal intubation with the Airtraq® laryngoscope. J Anesth. 2016;30:514517.