Minimizing premature closure and diagnostic error in the Operating Room

Cliff Hughes 1
  • 1 Clinical Excellence Commission, Level 13 227 Elizabeth St, Sydney, New South Wales 2000, Australia
Cliff Hughes

Abstract

The Operating Room does not leave time for scholarly reflection before action. Old ways of managing the risk of Premature Closure under stress need re-appraisal and perhaps a new paradigm. Is it time to say farewell to the autonomous surgeon?

This reminds me of something I have never seen before

-Bruce Leckie, Cardiothoracic Surgeon 1927–2012

Bruce Leckie was an exceptional surgeon. Largely self-taught he invested in his trainees and his colleagues. He pioneered cardiac surgery in Sydney with his colleagues and brought to bear many techniques that he had borrowed or copied from his experience as a truly general surgeon. It was Bruce who encouraged me to continue my interest in surgery of the thoracic outlet and of the thyroid as a young cardiac trainee.

It was 1985 when I took the call in the Operating Room (OR). A former trainee, now head of a prestigious unit overseas, explained his urgent problem. The patient was the wife of a member of Cabinet and related to a High Court judge. She had had an aortic valve replacement several years earlier and two other surgeries for recurrent aortic valve endocarditis. She had represented with a pulsatile mass pointing through the third and fourth intercostal spaces to the left of the sternum. Not just pointing but weeping small drops of blood! Transfer to Sydney was clearly neither practicable nor safe. He needed help. As I was preparing to catch the next plane I talked through the possibilities with my three senior colleagues. None had seen anything quite like this. The most important advice came from Bruce – “think outside the box!”.

Twenty-four hours later, the anesthesia began. I was in a strange hospital six thousand miles from home and facing a unique and critical situation. CT scans and interventional radiology were not available and even cardiac ultrasound was in its infancy. I did have one advantage – the entire team had trained in our unit at Royal Prince Alfred several years earlier and had built their unit as a replica. They used the same instruments, perfusion equipment and protocols. Better still, they understood my Aussie accent! We had discussed our approach as soon as I arrived and on their advice we prepared for bilateral femoral cannulation. They noted that, despite her age and size, her vessels were quite small. My concern was cerebral protection.

Recalling my general training with an endocrine/vascular surgeon with four or five thyroidectomies each week I exposed both carotid arteries and applied vascular snares to each. At the same time the host team proved that they were right. The femoral vessels were tiny. But with both sides cannulated we established reasonable flows. Opening the chest cavity was like chiseling through concrete and at no stage did we see any normal aorta nor even the heart. Both were encased in dense fibrous tissue with no landmarks to guide me. Under moderate hypothermia and total circulatory arrest, the carotid snares were tightened and the false aneurysm opened directly. There was a one-inch diameter defect leading directly into the ascending aorta. There was no sign of active infection and it was a simple task to apply a patch, irrigate the area with antibiotics, and eventually return the patient to the intensive care unit. I have not seen anything like it since!

Surgeons regularly meet new challenges in frightening situations. There is no time to consult the textbooks, to search the literature or for a prospective randomized double blind control trial. Even “Simulation” is unlikely to prepare us for the rare. It is in such moments of stress that surgeons have to quickly balance the conflict between what Daniel Kahneman has described as fast and flow thinking [1].

That day in South East Asia I learnt some valuable insights. First we must be able to think outside the box. The pulsatile mass was not the issue, control of the carotids was. Second, I learnt the value of teamwork – I did not have to think about the anesthetic, perfusion or equipment. My team knew how I thought and even pre-empted my needs. Third, experience is a great teacher. All those thyroid surgeries gave me confidence to stray well above my usual comfort zone, the thorax. Fourth, expect the unexpected. Of course we were all looking for pus and necrotic tissue. That was why the local team did not want to operate at all. But there was none. The blood cultures and all specimens collected at operation did not show any organisms or active infection. Fifth, local knowledge is a marvelous source of intelligence. Their experience with this patient predicted the need for a different (bilateral) approach to groin cannulation. Finally, more measured reflection has taught me the need for shared experience. We need to move away from the concept of the “autonomous” or “independent” surgeon and embrace “interdependence” and “team work”. After all, who would fly in an A380 with only one pilot and no engineering back-up? Read “QF 32”, the amazing story of the plane that should have crashed on take-off from Singapore in August 2012 [2].

Like it or not surgeons mostly base their art on pattern recognition. They know the anatomy and its common variations. They know how disease presents and its most frequent treatments. But even the simplest case is but a small distraction away from a potentially unmanageable crisis.

Recent studies have shown that humans performing even the most complex tasks can be easily distracted as often as every 4–11 min [3]. And it can take as long as 25 min to get back on track [4]. Furthermore more than half of these are self-initiated [3]. We all know the feeling of arriving at a destination to realize we can’t remember the last few minutes of the drive while we were thinking about our family, our tax return or the dreadful performance of our favorite football team. As surgeons we must recognize our humanity and put in place protections for both our patient and ourselves. The team can both minimize distractions and help us back on track with timely advice and prompts. Of course, practice does not make perfect but it does improve performance.

Previous generations of surgeons were able to practice their procedures in the autopsy room or anatomy laboratory, but both are now rare opportunities. The capacity to simulate the unknown requires a different approach. The aviation industry provides the obvious example and almost all teaching institutions provide simulation training for at least the most common surgical conditions and for the introduction of new technologies. However, even these “staged” resources cannot possibly prepare the surgeon for every situation, and yet, the surgeon will be held to account, and will indeed hold himself to account, when he or she gets it wrong because of inexperience!

There are, however, threats to experience: increasing specialization, shorter general surgical training programs, shorter working hours and greater emphasis on work–life balance (good though it is!). All mean that experience has become a premium commodity. I have no doubt that this journal will provide many examples where experience turned a catastrophe into a survivor. But the first step will be to ensure we do not fall victim to premature closure. We must not unthinkingly apply techniques “just because we have always done it that way”. Premature closure is nothing more than “a closed mind”! For too long surgeons have practiced in isolation. But help is literally across the operating room table or as close as the phone. What a pity that we do not use the latter to get the former.

In 1975 my teachers had a broader vision. They established a truly cooperative practice and cardio thoracic surgery unit at Sydney’s Royal Prince Alfred Hospital. Despite the very strong characters, that practice survived for over 40 years. The principles that they taught us were simple yet profound. The first was that none of us knew everything. The second was that two heads are better than one. The third was the most important – it’s all about the patient! They also taught me that if experience is a great teacher how much more is shared experience our professor.

As an honest and open profession, we must believe that “I, the individual”, do not have all the answers. But, as a team, as perpetual learners, as perpetual teachers we can together perform miracles that will be otherwise impossible. The many Christmas cards I received from the Muslim lady were a testament to not one, not two, but three generations of surgeons working together. So it is time for us to rethink the out-dated concept of the autonomous surgeon. The team member, the team leader, the sharing team, the communicating team, the collegiate team, is what will minimize the risk of premature closure and diagnostic error in the operating room.

The challenges that I believe to be the emerging themes behind Professionalism and “best practice” Patient Care are: Communication, High Reliability Teams, and Integrated Supervision. Not just for the trainee or the young consultant but for all.

Conflict of interest statement The author declares no conflict of interest.

References

  • 1.

    de Crespigny R. QF32. Sydney, Australia: Pan Macmillan Australia Pty. Ltd., 2012.

  • 2.

    Kahneman D. Thinking, fast and slow. London: Allen Lane, 2011.

  • 3.

    Dabbish L, Mark G, González VM. Why do I keep interrupting myself?: environment, habit and self-interruption. Proc CHI 2011 Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. ACM Press, 2011.

    • Crossref
  • 4.

    Mark G, Gonzales V, Harris J. No task left behind? Examining the the nature of fragmented work. Proc CHI ACM Press 2005.

    • Crossref

If the inline PDF is not rendering correctly, you can download the PDF file here.

  • 1.

    de Crespigny R. QF32. Sydney, Australia: Pan Macmillan Australia Pty. Ltd., 2012.

  • 2.

    Kahneman D. Thinking, fast and slow. London: Allen Lane, 2011.

  • 3.

    Dabbish L, Mark G, González VM. Why do I keep interrupting myself?: environment, habit and self-interruption. Proc CHI 2011 Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. ACM Press, 2011.

    • Crossref
  • 4.

    Mark G, Gonzales V, Harris J. No task left behind? Examining the the nature of fragmented work. Proc CHI ACM Press 2005.

    • Crossref
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