Simple Steps To Improve Teamwork In The OR

Oh insomnia! How I do have a love/hate relationship with you. During most of my middle of the night periods, there is sheer loathing on my part knowing that the rest of the world is asleep and I am wrestling there in bed like the late Steve Irwin trying to hold the crocodile in a full roll.

Just very occasionally, insomnia becomes my friend and has given me great gifts, like the one time I got hooked on a golf club infomercial and bought that perfect club. I used it the first time out and whammo, it set me up for an eagle put of five feet from 215 yards out. (No, I did not make the damn putt!) “OK, birdieman,” you now say, “maybe my old friend insomnia will bring me a perfect putter one of these nights allowing me to combine the two for that magical eagle I so desperately want.”

Now the other night, the demons woke me up at about 3:30 a.m. (They are very consistent. The atomic clock people in Boulder, Colorado are negotiating with me right now about using this as a backup system to their clock’s precision in case an atom goes rogue and splits or something that atoms do). This time, I was wrestling two crocodiles. After about 20 minutes, I did the Roberto Duran thing and cried out “No mas!”

Violently flipping open the lid to my laptop, I started out looking at the news and then one of those pop-ups revealed itself on the right side of the screen. Most of the time, I am able to compartmentalize these pop-ups as less than a distraction. Usually, I completely disregard them but given my fuzzy, sleep-deprived mind at the time, I was slightly intrigued. It was an advertisement on how to get more out of life, have more fun and become a better person. The ad also had a really attractive, albeit clothed, lady making the proffer. My mouse wandered over the screen like an Ouija stylus and boom, I clicked on the ad. 

The ad was about organization: A new system. I am starting to think to myself now that this could be better than the golf club that is now rusting out in the garage. I would like to say that I am organized but that would be an outright lie. There are some areas in which I am highly organized such as scheduling travel and such, and then, well … there is the rest of life. There is also surgery. We are pretty good at what we do and I seem to have less stress in the OR than anywhere else except Napa Valley, Calif. (If you do not get that reference, think about the god Bacchus and you might get it).

Now that the cobwebs started to clear, the crocs were becoming more docile and the noodle started burning some high octane, I had some time to read about this offer. I immediately thought about how we could get better at something that we were pretty good at already. However, that is never enough for a surgeon who has an unending passion in trying to make outcomes better. 

So, let us talk about surgeons for a minute. Some folks idealize them and many surgeons idealize themselves. Two quick jokes come to mind.

1. How do surgeons commit suicide? They climb to the top of their ego and then jump off. (Now some specialties have a much longer freefall than others and you can determine them with fair ease).

2. What is the difference between a surgeon and God? God knows he is not a surgeon.

The fact of the matter about surgeons is no matter how great or gifted they are, they are nothing more than members of a team. Think about that for a second. Surgery is a team sport, my friends. The circulator, the OR scrub tech, the anesthesiologist, the scheduling people in the front office, the materials manager, the folks who sterilize instruments and the sales rep are all very important members of the team. Each person is vital as a member of the team but individually, except for maybe the sales guy, no one is really that special. Try doing the simplest procedure with the patient wiggling about because of poor anesthesia, not having the right implant, poor retraction and a distracted circulator who is never in the room, and you get the picture right away. Disaster. Absolute disaster.

Now is that poor patient going to get the best ideal outcome? Probably not. Fortunately, though, in most cases, patients get an adequate outcome, which is satisfactory but not truly great. The human body is amazing in how it can usually overcome what is sometimes a surgical assault. I want a truly great outcome and none of my colleagues want anything less.

Emphasizing Chemistry, Checklists And Communication Among The Surgical Team

How can we make the team better and surgical outcomes better? Two things: chemistry and checklists.

Now as a pilot, I get checklists and I would never think about taxiing my airplane without doing a complete preflight checklist. But how many times do you use a checklist in your surgical endeavors? Oh yes, you say you do a time-out on every case but I am talking about a much more precise and comprehensive checklist. Pilots basically have three phases when they use checklists every time: preflight and takeoff, inflight, and landing. Then there are the checklists that are available when the feces hits the fan, such as fires, smoke in the cockpit or engine failure. Surgeons, like pilots, are bright people but when there is constant distraction or chaos, even these highly revered neurons can become scattered. Now checklists for surgery are not a new idea but surgeons seldom use them globally. 

As delineated in Atul Gawande’s excellent book: The Checklist Manifesto: How to Get Things Right, a Johns Hopkins psychologist named Bryan Sexton, PhD, has done some fascinating research on the dynamics in the operating room. Interestingly, he found that in large facilities where there are many personnel who are not always on the same team but scattered among different specialties and times, more often than not, the personnel did not know the names of the people they were working with. Pretty incredible, huh? Members of the “team” were solely isolated players trained to do their jobs.

As a result of this, folks took the following steps to improve surgical outcomes. First, the folks in the room (call them the players) from the surgeon to the scrub tech used a checklist and one of the first things on that list was introduction of everyone in the room. Additionally, another point was for the surgeon to brief the entire team on the surgical plans and that was hugely empowering in many ways. Anesthesia was better because the anesthesiologist had a fairly good expectation of how long the case was going to last, which is better for the patient in many ways. The rest of the team knew what was going to happen. They could suggest a better instrument set that could save valuable time during the case rather than have the circulator constantly running around fetching different items needed for the procedure.

The introduction point on the checklist can help build that necessary team chemistry quickly, even though it takes a much longer time for a team to really coalesce. However, some effort in this regard is better than none.

That brings me to my concluding point: management guys, desk jockeys or whatever you want to call them have no clue whatsoever about the true beauty of a mature surgical team and the majesty of its function. No, they say “pool” nurses are just as good. No, they are not but when you have a surgery scheduled for you or your wife, let me know and I will make sure we get some of the “pool” for you.

For a great read and something that might incite you to take action, read The Checklist Manifesto: How to Get Things Right by Atul Gawande. It will be time well spent.