Every so often, a wee media firestorm erupts over surprising issues. Consider surgeons, for example, who sing in the operating room. The latest eruption happened locally with the dismissal of an official complaint from a Canadian patient offended by his eye surgeon’s vocals in the O.R.
According to a report of the hearing published in The Vancouver Sun, the unnamed patient filed a complaint to the College of Physicians and Surgeons of British Columbia after the eye surgery in May, 2011. The patient (awake for his entire procedure) could hear everything. He not only objected to his surgeon’s singing during the operation, but also the fact that he was casually chatting with others in the O.R. about, for example, his plans to take home the hospital’s linens “so he could wash his car with them.”
The complainant described the surgeon’s singing and chatter as “unacceptable, arrogant, disrespectful and shameful.”
But the College dismissed the complaint. And when the patient appealed to the B.C. Health Professions Review Board, that board dismissed it, too, with both agencies referring to the patient’s complaint as “trivial”.
A spokeswoman for the College claimed that the patient’s care was not compromised by the surgeon’s conduct, although she did add that the regulatory body must still “remind doctors that they have to be professional in all interactions with patients.”
But it turns out that both the College and the review board might have been mistaken in their assumption that patient care was not affected, according to a study on O.R. distractions published in The Journal of the American College of Surgeons recently.
As reported in Fierce Healthcare, the Kentucky researchers found that background noise in the operating room, such as loud surgical tools, talkative team members or music, can “significantly impair communication among the surgical team.’
In the presence of background noise, surgeons’ speech comprehension worsens when discussions include important details that are unpredictable – especially when music is playing, according to the study. Interrupting questions caused the most problems, followed by sidebar conversations among the O.R. team.
Now, I’ve never had eye surgery. I’ve never even been to Kentucky. But I have been in my fair share of operating rooms, diagnostic labs and hospital clinics where I’ve felt uncomfortable about the medical team’s behaviour.
For example, it’s surprisingly common for a medical team to “talk over” the patient, almost as if the patient were merely a piece of meat on a slab – but worse, an invisible piece of meat who just happened to be the 10 o’clock procedure, the obstacle between staff and their next break.
As a heart attack survivor with ongoing cardiac issues, I’ve had several opportunities to lay there on the gurney feeling not only frightened about what was going to happen next, but also as if I’d inadvertently crashed a private party while the medical staff overhead chatted about their weekend plans, laughed, cracked in-jokes – and yes, sang along with that ever-present (often hideous) O.R. music.
Once the anaesthesia takes effect, I don’t mind being treated like this – because I’m out like a light.
But this Kentucky study suggests that perhaps patients should actually be more concerned about all that ambient noise that’s distracting our surgeons even while we are under.
For example, the study authors warn:
“In a setting in which crucial tasks are performed continuously, distractions and barriers to communication can result in harm to both patients and O.R. personnel.
“It was found that the impact of noise is considerably greater when the participant is tasked. Surgeons demonstrated substantially poorer auditory performance in music.”
To prevent communication breakdowns and medical mistakes, the researchers recommend turning music off or lowering the volume, and limiting background conversations in the operating room
The Kentucky findings build upon previous clinical research (here and here) about the importance of an O.R. environment that fosters good communication and patient safety.
Another previous 2012 Oregon State University study published in JAMA Surgery found that surgical residents committed significantly more surgical errors when distractions and interruptions were introduced than during an uninterrupted procedure – in fact, eight times more errors when there were common disruptions in the O.R.
And in an interview done by the American Academy of Orthopaedic Surgeons, U.S. Army surgeon Col. Daniel White describes O.R. distractions as reaching “epidemic” levels:
“Nurses texting and playing ‘Words with Friends’, anaesthesiologists surfing the net, and alarms and notices throughout the case. All of it can be quite a distraction.
“The patient monitors and the necessary noises are enough. The louder it gets, the harder it is to communicate effectively.
“Teaching observers in the O.R. also has a distracting component, but patient safety must trump all distractions, including ‘intended distractions’ like teaching.”
In the same interview, Dr. William Robb, founder of the Illinois Bone and Joint Institute, listed a number of recommendations from an American College of Surgeons position paper on operating room safety:
- leave pagers and cell phones outside the O.R. or turn them to silent mode
- no web surfing, text messaging, or cell phone conversations in the O.R.
- no loud or distracting music
- only pertinent conversation from the anaesthesia team related to the case (the banter between the anaesthesia, surgery, and/or nursing teams needs to be related to the surgical care)
- limiting all non-essential conversation to maintain the central focus of the surgical team (non-essential conversation degrades the environment and is distracting)
Already, I can imagine the dismissive harrumphing* from some surgeons reading this, particularly as it’s delivered by a lowly patient who’s fast asleep during much of our relationship.
But as The American College of Surgeons once advised med students considering a surgery residency:
“Thoughtful reflection on the outcomes of your decisions and those of others will give you the most important quality: good surgical judgment.”
So while you’re thoughtfully reflecting on the recommendations of the Kentucky study among others, and thoughtfully reflecting on whether it’s time to dial down all preventable noise in your O.R., here’s a question related to both common courtesy and patient safety:
Would it be too much to ask that at least one – not everybody, but even just one – team member be assigned the bedside manner role of placing one reassuring hand on the patient’s shoulder, actually talking and listening to the patient in the midst of all the team socializing going on around us – at least until the anaesthesia kicks in?
You know, as if the patient were a living, breathing, human being just like the people standing over us, singing?
.
* harrumph: verb \hə-ˈrəm(p)f\ “To grumpily express dissatisfaction or disapproval.”
See also:
- “Distracted Doctoring” – updating your Facebook status in the O.R
- Smartphones make Top 10 Health Tech Hazards List
- Dr. Sherry Turkle: “I share, therefore I am”
- Why you should put that damned phone away
- The lost art of common courtesy in medicine
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The Ethical Nag 
The safest O.R.s always use checklists.
Absolutely correct. Thanks for the useful link.
From personal experience I know this to be true. I will send to our operating room manager.
Great – thanks Anne!
I’m a retired OR nurse. This study is just the tip of the iceberg. I spent years – YEARS – horrified by the chatter, singing, laughing and NOISE that goes on over the body of the unsuspecting patient during surgery. In the rigid hierarchy of OR politics it sure wasn’t up to me — a lowly nurse — to tell The Great Surgeon to shut up and focus on what he was doing to the patient instead of entertaining the room with his LOUD stories of hilarious weekend escapades. I finally transferred to another non-surg unit where docs actually pay attention to the PERSON in the hospital bed. Thankyou for this article and important message that’s rarely acknowledged by OR staff.
Thanks so much for your perspective here. Maybe your insider’s take on this issue may cause others to take note and make some improvements.
I believe that the patient care is compromised in that the patient is NOT cared for in a healing environment. There needs to be reassurance, patient asleep or otherwise (they can still sense); a respectful atmosphere, a kindness, a human touch. All these will, I believe help greatly in the successful recovery of the patient. That part seems to be lost in the current lack of duty of care medical environments.
And Cell Phones, Texting, in the OR? Horrors. And I have to turn off my cell phone whilst in the interminable waiting rooms of hospitals. Sick.
P.S. Is the cell phone sterilised?
Hi Lily
Your PS is a good question. In fact, mobile phones were listed for the first time ever in 2012 in The Top 10 Health Tech Hazards List – not because of lack of sterilization (although I’m guessing that few if any scrub or autoclave their smartphones en route to the O.R.) but because of “caregiver distraction from smartphones and other mobile devices”.
From my experience in the OR, the environment is incredibly professional and attentive whenever there is an observer. This can be a professional from outside or it can be a member of the patient’s family. From what I’ve seen, nothing brings everyone to their best behavior faster than an observer and no observer does this more effectively than a family member.
I suggest that every person who needs to have a surgery first obtains consent to have someone in the OR with them. Then find someone to be that person. (NOTE from CAROLYN: see Bev’s subsequent comment below about the reality of asking her surgeon if she could have another person in the OR with her).
At the outset, this would be unusual, especially if there aren’t special concerns. Many people might be rebuffed. In time, though, if everyone, everywhere will ask for consent and follow through, it will become less and less startling to surgeons until it is virtually expected. This might be the easiest and most effective way to rebuild the expectation that professional behavior is what is expected the OR and to remind all that the patient’s well being, and good surgical outcomes are the ONLY reasons that they’re there
P.S. About germy cell phones, the only things in the OR that are sterile are things the surgeon may need to use in performing the surgery. Most are found either 1) on the table with the other instruments, ready for the scrub tech/nurse to hand (wearing sterile gloves) to the surgeon (also gloved), 2) in the surgeon’s hands, ready to use, or 3) lying on the patient’s sterile drape. One thing we don’t have to worry about is whether electronic devices are sterile.
Thanks Bev – I love this idea of having a personal observer in the O.R. But frankly, I can’t see surgeons agreeing to this, though – can you?
Only with difficulty, but that’s right now. There are always willing-to-be-bold people in the world. I’m one of them.
Once this notion is in the minds of folks, some patients-to-be will ask others if they’ll come with them into the OR, or else someone who’s willing and knows the situation will offer. Those early pioneers will pave the path and surgeons will begin getting used to it.
I’ve done it, although being a nurse probably made a big difference, and I still had to do some convincing. Note, however, that in the OR during a Cesarian Section delivery, it’s STANDARD PRACTICE for the dad or other family member to be seated by the mother’s head. Doctors will even look around before starting the C Section and if they don’t see a father or someone with the mother, they’ll ask “Is anyone coming? Should I wait?”
I say, if it can be standard for one surgery, why not for every surgery?
Maybe some could see if a hospital policy could be changed? One which reads something like, “One family member or other close individual may accompany the patient during the surgery.” Maybe we should ask for 2 at the outset, so they have something they can win with. “No, two observers is too many. You may have 1 person in the OR only.”
Most people don’t want to be in an OR, so while I hope that would change, (remember, you don’t have to watch – take a magazine!) some will be willing to go and thus “help” OR staff pay attention to what they’re doing. Assuming there’s not a hospital policy change, when we go through the surgeon, and everyone gets used to us being in the OR, it will get easier for all, and much, much easier to gain consent. We have to start somewhere and then take it by steps.
I really like Bev’s comments. It’s not enough to just show what’s wrong….giving a solution is the other half of the equation and Bev has done so. Kudos!
But oh, how sad it is, to have to have supervision needed, to keep Professionals focused. An operation, no matter how minor, is not playtime.
I know that music and humorous quips are just ways for a surgeon to cope under the stress of performing surgery, and as long as it gets the job done..fine. But if it’s not doing the job, then it doesn’t belong in the OR.
But having conversations about their personal lives, cell phones and texting? There’s no excuse.
I agree Joanne – if having an observer present can improve behaviour, it somehow suggests that staff know perfectly well what’s appropriate and what’s not.
Reading this brought back a vivid memory of my time in the cath lab during my heart attack.
I remember a crazy flurry of activity in the ER when I arrived. Once I was wheeled to the cath lab, everyone left and the room was absolutely still and quiet. I think I was alone for a mere five minutes, but the absolute silence was a little unnerving. The doctor popped his head over me & introduced himself, said I could call him by his first name, and then assured me “We can fix this.” I trusted him completely in that moment.
The room remained absolutely quiet after that. I had no doubt my doc was completely focused on what he was supposed to be doing and for this I am extremely thankful.
Hi Angela – that is just the kind of patient story I like to hear!
Hi Carolyn Thomas. I am an operating nurse in Australia and we have been significantly concerned about noise and distractions in the operation room. So concerned in fact that a fellow nurse and I developed a language based safety tool called ‘Below Ten Thousand’ that is designed to :
-Flag critical phases of flight (Surgery).
-Create team situational awareness.
-Created directed focus at the task at hand.
-Create immediate and unquestioned quiet when required.
We have been having amazing success with using this iconic term of reference and many health care facilities have began to use it in their own organisations.
Best of all…….It is all TOTALLY FREE to use!!!!
Here are some useful links.
http://www.belowtenthousand.com/
https://www.facebook.com/belowtenthousandcom-134525700051119/
Thanks John – I love this patient safety initiative (and nurse-driven! you have to love that!) Best of luck with convincing other O.R. teams to adopt Below Ten Thousand themselves.
regards,
C.
Hi Carolyn. Again thanks for taking the time to address this very real and concerning issue of distraction and noise in the operating room.
I would like to let you know of our recent success in promoting this innovative idea and celebrating the uptake of this simple yet effective tool.
Dr Frank Sweeny, the creator of the ‘Straight Talk MD’ Podcast, has delivered for us a free plug right across America!
You can find Frank’s one minute sound grab from his interview with Michelle Feil, Senior Patient Safety Analyst with the Pennsylvania Patient Safety Authority about ‘Distracted Doctoring in the OR’
We have also just been published in the UK ‘Journal of Perioperative Practice‘ under the heading “A pathway to clinician-led culture change in the operating theatre “
We thank you again for flagging the very real issue of noise and distraction in the operating room.
Kindest Regards,
John Gibbs
Congrats on these two successful awareness opportunities, John. Do you know if the Journal of Perioperative Practice paper is available for free?
Thanks Carolyn for the great comments. The journal is very popular and lots of hospitals will subscribe to it, so you may find it in your academic resource department.
Here is a hyperlink to the actual article, however again, it appears that the user must pay a fee to download it.
Take care and kind regards.
John
Meanwhile, please let me know if/when this paper is available to the general public.
Hi Carolyn,
Sorry for the belated reply. As far as I know, the online article is only available as a pay for view document. However The Journal of Perioperative Practice has a very high circulation rate worldwide and I would assume that most hospitals would subscribe to it. Indeed our own organisation does and we now have the pleasure of having an article written and now sitting on the shelves of our own resource room.
Take care and thank you for the comments, and indeed your own continued efforts to improve the provision of the highest quality health care that ever one deserves. Not only for patients, but for staff.
Kindest Regards.
John
Thanks for trying to track down the (free) copy for me. I love these photos of seeing your paper published! Congrats!!
Here I am getting scheduled for a (minor) surgery and the surgeon is one who would have a COW if I asked if someone could be there with me! And I was so cavalier about getting someone to accompany you to surgery! I have absolutely zero idea about how this OR team behaves during surgery. Cross your fingers!