Working together to ensure quality patient care - Opinion

AORN Journal,  Jan, 2004  by Adam Frederic Dorin

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For many patients, few aspects of surgery are more frightening than the OR itself. Negative experiences in the OR may set into motion a lifetime of fear and neuroses about bodily damage, mutilation, and loss of control. As an anesthesiologist and an occasional surgical patient myself, both in childhood and as an adult, I have a special interest in the emotional environment patients encounter in the OR.

Although patients of all ages may develop a host of emotional tools to prepare for and deal with the trauma of surgery, children may be particularly vulnerable to fear. Many psychology theorists believe that the period between ages four and six and the period just before and during the onset of puberty (ie, ages 10 to 13) can pose marked psychological hazards for surgical patients.' Children try to frame the world in a way that makes sense and, even more importantly, secures a sense of bodily safety and comfort. The surgical experience can shatter this secure framework before a #10 blade is even placed on the Mayo stand.

Even as we move into adulthood, surgery can create conflicting feelings. Our mature, adult minds remind us that surgery is necessary and beneficial, but our unconscious minds ruminate on many troubling issues, including anesthesia, loss of control, exposure, evaluation and possible criticism of our bodies while we are asleep and naked, sharp objects cutting the body, and scarring.

During the years, I have noticed a few things that happen in the OR every day. Some of them are helpful and some are harmful in their effects on a patient's emotional well-being. These behaviors can be demonstrated with two different fictional scenarios, each of which has individual components we all have seen at various times throughout each day of our working lives.

THE NEGATIVE OR

Rock-and-roll music is blaring as the 79-year-old patient is wheeled into the OR for her hip fracture repair. The scrub person is audibly swearing because he cannot find a #48 screw to fit the plating system. He yells out to the circulating nurse to get the plating system's manufacturer's representative on the telephone. Meanwhile, the circulating nurse, who is having an affair with the surgeon, is busy flirting in the central core and comes running in when she sees the charge nurse begin to position the patient for transfer to the OR bed. The anesthesia care provider is reading the Wall Street Journal and is distracted as he mumbles stock quotes to himself. The patient, now thrown into a rapid supraventricular tachycardia, is well on her way to an intraoperative myocardial infarction.

It is a bit amusing to read this scenario, but only because we all have seen parts of it in our workplace. I bet that all of you had a little smirk on your face when reading the last paragraph.

THE POSITIVE OR

As the four-year-old patient, who is having tympanostomy tubes placed, is carried into the surgical suite by his mother, the anesthesia care provider notices that the suction is not yet hooked up. He forgot to check it earlier, but now quietly motions to the circulating nurse as they both greet the patient with smiles. As the anesthesia care provider helps the patient get comfortable on the OR bed, the scrub person and the surgeon present a glove balloon with a smiley face to the distracted, but still nervous, child. The mother is comforted by the warm, quiet room, and the anesthesia care provider, now reassured with functioning suction tubing and a Yankauer suction tip, is ready to go.

In this second, positive scenario, there still are some problems and distractions with which to contend. The environment in this OR, however, is much more patient friendly with only a modicum of additional effort.

PATIENTS AND SEDATION

The most important time to consider a patient's emotional well-being is at the beginning of the procedure, when the patient has been given little or no amnesic anesthetics. When a patient has been given a good maintenance general anesthetic, there usually is plenty of time for staff members to socialize and speak at will during a procedure. Regional anesthetics and local sedation procedures, however, require that staff members exercise additional restraint because many patients will remember conversations and events that took place, even if midazolam has been administered. Likewise, the emergence phases of general anesthetics classically are times when patients remember comments and distractions as if they occurred during the procedure itself. A surgeon's comment about a nurse may be interpreted personally by a patient and could create disturbing memories.

PATIENT-CENTERED CARE

Operating rooms are very intense and stressful places to be, even for those of us trained to be there day in and day out. A good set of reminders regarding behavior for surgical team members in the OR should include the following items.

* Limit nonprofessional, case-related conversation when greeting patients and during induction and emergence.

* Limit all nonprofessional, procedure-related conversation during regional or IV sedation anesthesia.