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While you slept: bad behaviour and recording in the operating room

CaptureA head-shaking story of operating room unprofessionalism has been making the rounds on news services and social media, as an unsuspecting patient inadvertently recorded audio during his colonoscopy, only to hear his person and personality belittled by the operating room staff while he was anaesthetized. The heat has fallen mostly on one anesthesiologist, but none has escaped rightful scrutiny.

The anesthesiologist of the day quipped to the newly asleep patient “after five minutes of talking to you in pre-op, I wanted to punch you in the face and man you up a little bit.” The OR team mocked a rash the patient had noted, alternately joking that it was syphilis or “tuberculosis of the penis”. “As long as it’s not Ebola”, remarked the surgeon. The case went to court and the patient was ultimately awarded $500,000US.

On reading the story and the clearly ghastly banter among the team, no doubt the first response would be along the lines of “they actually said those things?!”. I suspect, however, that more than a few surgeons’ gut reaction might have been “he heard what they were saying about him?!”, followed by squirming in one’s seat and the sudden recollection of a dozen blithe comments in one’s own ORs. This incident opens several proverbial cans of worms that merit some thought.

Clearly, this particular debacle is a no-debate-needed case of unacceptable behaviour, and the solution is simple: don’t do that! We have spent much energy in the past years establishing ground rules for online professionalism, but of course the rules of decorum have always applied in the material world as well. Recording or no recording, there is simply no place for mocking of patients, awake, asleep or in absentia.

As surgeons, and urologists perhaps in particular (with our warrant to investigate and operate on urogenital complaints), this provides a stark reminder about our own behaviour, when the audio isn’t being recorded. Ask yourself if you have openly lamented the challenges of operating within a morbidly obese patient’s pelvis or retroperitoneum, snickered or gasped at the enormity of a hydrocele or penile tumor, or glibly eulogized a torted or cancerous testicle.

A question then becomes, what is acceptable and unacceptable in the operating room? Are all off-topic conversations unacceptable? Given the intensity of surgery and the OR, is there room for joking and banter to decant some stress? My personal thought is that black-and-white dictates and zero-tolerance policies usually (read: usually) only serve to absolve us of having to actually think about issues, and that grey areas exist in most settings. Levity in the OR is no different, but caution and forethought are critical.

The other issue that clearly arises is that of recording within the OR during surgery. There are doubtless advocates of each extreme, from the sanctity of the theatre to full access to video and audio. We have all had patients bring recorders into the clinic room – does the Hawthorne effect improve our behaviour or our care, or does the added scrutiny lead to hedging, indecision or ambiguity on the part of the physician? You can see both sides play out in this post and its comments. Recording in the operating room is on a completely different level than clinic discussions, however. Aside from the content of conversation within the operating room, the complexities and individuality of each procedure and the thought of a second-by-second parsing of technical detail by non-expert patients seems to make this a totally unwieldy proposition. On the other hand, are the assumption of basic ethical standards and a post-op chat enough “data” for a patient to really understand all of the relevant details of their care? What about recording for skill development or assessment? Much has been written here as well.

The patient/plaintiff in this case was clearly subject to a debasement none of us deserves or would wish on ourselves. Reading and hearing this OR team’s contempt for their patient is a graphic reminder of what this behaviour can descend to unchecked, and hopefully a course-correction for surgeons, nurses and anaesthesiologists who hover on or over “the line”. As for its window into the merits of recording, the issue gets no clearer.

 

Mike Leveridge is an Assistant Professor in the Departments of Urology and Oncology at Queen’s University, Kingston, ON, Canada. @_TheUrologist_

 

 

Anaesthesia for robotic-assisted laparoscopic radical prostatectomy

Richard MoreyHere’s my technique for anaesthetising patients for robotic-assisted laparoscopic radical prostatectomy and I’d be interested to hear any thoughts, comments and ideas.

Pre-op. I try to fast the patients for as short a time as possible and also include pre-operative carbohydrate loading. This is in line with Enhanced Recovery After Surgery (ERAS) Guidelines for major bowel surgery and has been shown to reduce the negative nitrogen balance that occurs following major surgery. I use 200ml cartons of Polycal, which is clear and non-particulate, prescribed 12 and 3 hours pre-operatively. Clear fluids are encouraged up to 2 hours pre-op as this improves gastric emptying and minimises pre-operative dehydration.

Intra-op. I use a mixed technique of both general and regional anaesthesia. The general consists of a fairly standard technique with a Propofol induction and maintenance with Desflurane and a Remifentanil infusion. To reduce post-operative nausea and vomiting I use ondansetron, cyclizine and dexamethasone. The regional part is a spinal anaesthetic using 0.5% Hyperbaric Bupivacaine with additional intrathecal Diamorphine. Regional anaesthesia has been shown to reduce peri-operative DVT formation, probably by blocking sympathetic activity and improving blood flow through the legs, it also produces profound muscular relaxation enabling better pelvic vision and easier insufflation. In addition there is some evidence that appears to suggest regional anaesthesia may reduce the recurrence rate of prostate cancer. As the patients are positioned in a steep trendelenberg they are all intubated and ventilated with a small amount of additional PEEP to reduce pulmonary atelectasis.

Post-op. Intrathecal diamorphine usually provides 12-14 hours of good quality post operative analgesia. Intrathecal opiates act locally producing segmental analgesia and therefore do not produce the systemic side effects to the same degree as intravenous opiates. The ondansetron given peri-operatively may reduce the incidence of opiate induced pruritus as well as acting as an excellent antiemetic. Additional analgesia will be required but usually paracetamol and ibuprofen are sufficient. It is unusual for patients to require any additional stronger opioid medications and this is helpful in ensuring that gastric stasis and reduced gut motility do not occur. This enables the patients to be rapidly progressed on to a light solid diet that in turn further reduces the occurrence of a post-operative ileus.

Fluid Management. Using this starvation policy, patients should commence their surgery with only a minimum degree of dehydration. Remifentanil produces an extremely cardio-stable anaesthetic and with the patients being head down peri-operative hypotension is unusual.  Should this however occur blood pressure should be maintained with the judicial use of vasopressors and fluid if necessary. Post-operative urine output can be maintained if required with plasma expanders and diuretics.

 

Richard Morey qualified from MHMS in 1987 and has been a Consultant Anaesthetist in SE London since 1997. His particular interests are ERAS/ Laparoscopic Surgery along with ENT and Difficult Airways.

@morphthegasman

 

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