Sunday, March 27, 2011

Multitasking in the OR? We're fooling ourselves!

I was in the middle of a case in the OR on Friday when a conversation caught my ear.  Apple’s iPad 2 was being released that day, and the anaesthetist and his resident were excitedly talking about it.  I’m coveting an iPad 2, so I’ve also been looking forward to its arrival.

But, as much as I would have loved to share the excitement with them, I was a wet blanket.

“Hey, guys.  No iPad talk in here”, I said, semi-jokingly.

Without an objection, they stopped their conversation.  A little later, the anaethetist asked (semi-jokingly) why he couldn’t mention “that thing we can’t talk about.”

I explained that I was so interested in the iPad gossip that I thought it would likely distract me from a tricky part of the procedure that I had been starting at the time.  After the case was finished, we compared notes on how we each planned to acquire the new toy.

My request to change the topic of conversation had been slightly tongue-in-cheek, but I had noticed I became slightly distracted when they dropped the i-bomb.  I don’t insist that the OR theatre be silent during all my cases, but there are times when it is appropriate, in order to let the team focus on critical activities.

As I thought about that situation, which was somewhat light-hearted, I recalled another recent situation in which the OR team’s attention may have wandered from the prime task: patient care.

We were transferring an anaesthetized patient from the operating table back to a stretcher at the end of the surgery.  At this stage, patients are usually still unconscious and completely reliant on us to safely move them.  The anaesthetist is in charge of this patient movement as they control the patient’s head, neck and airway.  Once everyone is ready, the anaesthetist will signal “On 3”, and then count to 3.  The team will move slide the patient from the table to the stretcher.

It seems simple, and usually is, but involves a coordinated effort to make sure the patient is safe and also that any attached tubes and IVs don’t get dislodged.  There was a conversation going on between some of us and not all the staff heard the anaesthetist’s countdown.  The patient was moved safely, but it wasn’t the usual smooth transfer we’re used to.

No harm was done, but as I commented to 2 medical students who were observing in the room, I thought it could have gone better if we were all concentrating on the important task.  Also, I told them that I should have addressed it with the OR team right at the time but, frankly, wasn’t sure how to raise the concern without offending anyone or seeming overly picky.  (I hasten to admit that I have been guilty of participating in distracting side conversations also.)

Most non-medical conversations in the OR are positive – they promote a good team relationship, and often relieve tension during a long or difficult procedure.  None of us maliciously distract our teammates in the OR, but it’s easy to fall into a habit of chatting during critical times.  We may not even identify them as critical times because they are routine to us (e.g. patient transfers, induction of anaesthetic). 

I would like to think of critical times in the OR in the same way as critical times in aviation.  (Note: this is total fantasy on my part, as I have no aviation experience!  If any readers have such experience, or know someone who does, please leave a comment to correct any misconceptions I have.)  I’m sure that in the cockpit during takeoff, landing and turbulence, the conversation is sparse and professional.  But, while at cruising altitude, the pilots likely swap a yarn or two.

What’s the difference between the two situations?  The difference is culture – the mutual understanding and unspoken agreement of how we behave at work.  The pilots likely have it drummed into them from the start of their career about the importance of attentiveness during critical maneuvers.  They would have to agree on what those maneuvers were.  They likely also have some shorthand way of telling each other that something critical, yet unexpected, is happening.  The fact that there are only 2 of them in the cockpit, likely reduces the complexity of communication. 

I’m not sure that we all agree on what points during surgery are critical for everyone’s attention.  But, we’ve made a start with checklists.

We’ve taken a page from aviation safety with our surgical safety checklist.  Prior to every case in the OR, the surgeon, anaesthetist and nurse review a list of items important for the safe and efficient care of the patient.  It’s lead by the surgeon, who has the responsibility to make sure that the other team members are participating.  Sometimes, the anaesthetist may be in the middle of starting an IV, or giving a medication, or checking the patient’s chart and will give me a wave saying, “Go ahead, I’m listening”.  At the risk of offending my colleague, I usually decline to start and invite them to finish the important task at hand before we complete the checklist.  One anaesthetist told me “Go ahead with the checklist. I can multitask.”  Really?  (Here’s a brief AORN Journal commentary on “multitasking” in the OR.)

A stumbling block in the OR is communication (surprise!).  And, as the surgeon leads the team, a big part of the responsibility for open and appropriate communication lies with me.  If I’ve allowed myself to get stressed, I tend to speak sharply.  I get annoyed when the flow of preparations doesn’t go the way I envision it (as if the team should be reading my mind!).  I don’t always speak up in situations where I think team members should be avoiding distractions.  And, I don’t invite feedback on how my own behaviour affects the rest of the team.

If you have any suggestions on how to get these important conversations going safely and productively, please leave a comment.  When we’ve let it slide for so long, it seems so hard to get started.  But, for our patients’ sake, I would like to try.


  1. Right on with the checklist, and the analogy to aviation use. In his new book, "The checklist manifesto", Atul Gawande stretches this parallel even further, noting that in aviation there are "normal status" checklists, much like the three-parter WHO checklist now being implemented worldwide. But there are also many many more "emergency status" checklists that only get invoked when something is (or seems to be) amiss. It IS drummed into pilots to automatically revert to checklists as their SOLE form of communication when that happens. Their checklists are all stored electronically, can be quickly searched, and come up automatically on a screen (what happens when the emergency affects the screen?).

    But Atul concludes his book with one more telling comparison. Every "adverse event" in aviation (near miss, crash, loss of a system in flight) is rigorously investigated until resolved, and the results are most often revised checklists. Isn't that a model that medicine should aspire to emulate?

    Dave Wells, New Brunswick Access and Utilization Network

  2. Thanks, Dave. The aviation analogy is a strong one.

    Thanks also for setting me off on my next post about checklists...

  3. As an anesthesiologist, I too have been guilty of distracting conversations - sometimes because what is the quiet routine time for me is the critical time for the surgeon. A perfusionist said it best when he reminded me that "Every patient deserves our undivided attention". A gentle comment on the need to focus now on the work or patient is sufficient. I have also witnessed adverse events that I thought were partially due to the passionate nature of the conversation, resulting in an unhealthy "emotional temperature" in the room. We have lots to learn from other industries and sciences - the Checklist is a great start.

    Joy Dobson, your biggest fan

  4. Hi, Joy. "A gentle comment... is sufficient" - thanks for this great advice!

  5. Hmmm...does an advisory from your profession's regulatory body count as a "gentle comment"? Check out this item from National Post that also appeared in our Leader-Post...

    No more talking hockey in the operating room, B.C. surgeons warned

    British Columbia medical officials are warning surgeons to skip the hockey chit-chat in operating rooms to avoid upsetting patients. With the NHL playoffs just around the corner, the College of Physicians and Surgeons of B.C. has issued an advisory to the province's 11,000 doctors, reminding them that talking about things other than the surgical task at hand in the operating room is unprofessional and inappropriate. The matter arose after the college received a complaint from a patient who heard his eye surgeon talking hockey with the scrub nurses during a procedure for which he had been given a local anesthetic. The patient, who was awake the whole time, said he worried the hockey talk would disrupt his surgeon's concentration and possibly cause him to make a mistake. College registrar Dr. Heidi Oetter said in an interview that the surgery was successful, but the complaint serves as a useful reminder for doctors to be discreet.

  6. Thanks, Greg. It really makes an impression when we hear about how our patients perceive what we consider to be innocent behaviour.

    And, of course, this fueled another post.