Originally published in the June 2015 issue of Veterinary Practice News
Being efficient in the OR is much easier when you prepare well ahead of the procedure. To quote the great Benjamin Franklin, “by failing to prepare, you are preparing to fail.” So how can we prepare for a successful surgery? We asked several board-certified surgeons to share their favorite tips to nurture an efficient and effective surgical team.
Clear communication with your client during the consultation is of the utmost importance to avoid misunderstandings. This is the time to discuss the medical and financial aspects of the procedure. What is the (presumptive) diagnosis? Are there non-surgical therapeutic options? What are the options during surgery? What are the pros and cons of each one? What is the prognosis? Which ancillary tests are required? What are possible complications?
Being realistic, upfront and thorough with the client will help make decisions quicker during surgery. Consider, for example, a patient who has advanced or potentially inoperable cancer. Will you recover the patient, obtain a biopsy, debulk the tumor, remove it, or possibly prepare for intra-operative euthanasia while the patient is under anesthesia? Will the client want to be present? Time is of the essence in these situations, and a lot of time can be saved by discussing such details preop rather than making a lengthy phone call intraop.
What can you possibly do the day of the consultation that will save time the day of surgery? Could you draw blood and urine samples? Could you take radiographs? Could you take specific measurements, for example, to make sure you have the right size splint?
Saving time starts well before the patient is dropped off on the day of surgery. Staff members should anticipate the needs of both the patient and the surgeon.
Should any special medications or equipment be ordered? Have any of the drugs you will need expired? Do you have enough?
Do receptionists know when to interrupt you during surgery and when to save information for later? You probably don’t need to know that Ms. Smith’s toy poodle finally had a bowel movement in the midst of performing brain surgery. If you expect a specific phone call, then let the receptionists know exactly what to do.
You also may want to consider having a receptionist call clients the day before surgery to remind them of their drop off time, of the need to fast their pet, of the importance of allowing access to water overnight, and of dropping off food and medications.
Photos Courtesy of Dr. Phil Zeltzman
Will you be able to close the skin after excising this fibrosarcoma on the caudal thigh of this 7-year-old cat?
Early drop-off of patients is critical to having an efficient system. The consent form should be correctly prefilled by the staff (with the correct side of the procedure specified if needed) and signed by the owner. Any remaining questions should be answered. Make sure you have a reliable phone number to reach the client. A deposit should be secured. Medications and their last time of administration should be discussed and documented.
Timely drop-offs allow your team members to draw blood work if needed, take radiographs, place IV catheters, and start IV fluids and CRIs.
Having a surgery team pow-wow allows everybody to be on the same page. You can discuss details of each procedure, the correct surgical site (left versus right), unusual IV fluid rates, clipping instructions, patient positioning, timing of medication administration (e.g. metronidazole, insulin) etc. If an unusual procedure is on the agenda, take that opportunity to educate the staff.
If you have several surgeries, discuss the order in which they should occur. Experience, outpatient versus inpatient procedures, risk levels and patient health status will help determine a logical order.
Also, discuss staffing — who should do anesthesia, who should scrub in, who will be left to work on the next patient?
Morning huddles may seem like they are time-consuming. In fact, when done correctly, they are huge time-savers; they help avoid mistakes, and they improve the chances of a successful outcome.
Ideally, the OR should be restocked the night before a procedure. Vaporizers can be refilled, oxygen tanks and soda lime are changed as needed, and suture material and instruments are prepared ahead of time (laundry baskets or plastic containers are great for that purpose). The morning of surgery, appropriate-sized tubes and bags can be fitted on anesthesia machines (after cleaning and drying). Turn heating devices on. Leak-test anesthesia machines. Double-check equipment — suction, cautery, lights, room temperature, etc.
Surgeon Preparation Part One
You may feel like a super hero who doesn’t need to follow the rules, but the fact is that getting a good night's sleep, starting the day with a nutritious breakfast and drinking enough water will help you keep a sharp mind throughout the day. Whether coffee makes you quiver like a post-prandial, shunt-affected, canine flea medication laden, Valium-deprived kitten, or prevents you from shaking like a leaf, is a decision only you can make.
Take care of urgent phone calls and bodily functions before surgery in order to free up your mind.
Before you perform an unusual or complicated surgery, be humble and devote time to review the procedure, either in a book or by discussing it with a more-experienced surgeon. If at all possible, practice on a cadaver. Review the anatomic structures relevant to the procedure. Think ahead and make a plan. Even better, have a plan B and a plan C in mind in case of complications or misdiagnosis. For example, if you cannot save the leg, is the hair clipped enough to convert to an amputation? What if the “routine” enteroromy turns into a resection-anastomosis? What if you can’t remove the urethral stones? What if you can’t close the skin after removing a mass?
And then, there’s Murphy’s Law… Anticipate technical difficulties, such as instrument malfunction or contamination. What if you accidentally drop a critical instrument on the floor? What if the battery of a power tool dies? What if you run out of nitrogen?
The surgical procedure to be undertaken should be appropriate for your level of training. Know when to ask for help. Know when to refer. Know when a patient will need overnight care. Be prepared to deal with complications.
Surgical experience speeds decision-making.
Kelly Serfas, a Certified Veterinary Technician in Bethlehem, PA, and Zee Mahmood, a veterinary technician in Reading, PA, contributed to this article.
The authors wish to thank the generous suggestions of Drs. Justin Harper (Texas Specialty Veterinary Services in Boerne, Texas), Myron Downs (Athens Veterinary Surgery Center in Athens, Ga.), Denis Marcellin (North Carolina State University’s College of Veterinary Medicine) and Mitch Robbins (Veterinary Specialty Center in Buffalo Grove, Ill.).