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Communication & Conflict in the OR

February 27, 2009
No, Im not a hippy. But, my parents were.

No, I'm not a hippy. But, my parents both were. And I live on the Left coast.

Talking with some friends about “tense moments” in the Operating Room, I was reminded of a particular experience. We all know and fear mistakes caused by laziness, lack of skill or preparation, and most obviously, miscommunication. Problems arise, but they can often be prevented, or handled in a way that minimizes the negative impact.

Usually, health care providers work extremely well in team-environments. It’s what we are trained for, and if we don’t get along, how can we depend on each other to do our jobs? The OR is often a very friendly, relaxed environment. Everyone does their part to get through the day happily, and we get to know a little more about each other in the down time.

There are rare occasions when conflict arises. Often, it originates in patient safety issues. One person’s advocacy for the patient may not be accepted as appropriate by another person. Egos might get roaring, and the environment can be quite uncomfortable.

On an anesthesia rotation, I witnessed such a conflict. First case of the day, patient prepped and ready to receive the general anesthetic. No one had seen the surgeon. We got word from the OR desk that he was running late, but said he was in the change room. A few minute later, he still wasn’t there. A nurse was dispatched to find him. He wasn’t in the change room. They waited, and a few minutes later, saw him coming out of the elevator, car keys in hand, still wearing his street clothes. Just arriving for the morning. A bit late.

While gets changed, we put the patient under. He arrives. The conflict begins. First, it starts calmly, but it escalates. When the circulating nurse is trying to do a surgical pause so we can start the case, she can’t hear her own words over the yells of the anesthetist and the surgeon –  “I’m going to report you. It’s not that you were late, it’s that you lied and said you were in the hospital and you weren’t; what if you hadn’t made it?” “You’re not my mother!” “The patient would have been under and you wouldn’t have been here to do the procedure.” “I’m going to report all the anesthetists, every time they are one minute late!” “That’s not the point!! The point is . . . ”

The nurse tries again to get us to focus on the surgical pause. I’m sitting quietly on the anesthetists chair, monitoring the vitals and noticing the patient is a bit light. In a whisper, worried I’ll trigger another outburst if I speak too loudly, I ask the anesthetist if I can give some more fentanyl. “Yep, 100’s ok.” I do. A minute goes by, and the surgeon feels the urge to exchange a few more words. I walk over to the circulating nurse, and quietly tell her I’m really uncomfortable that we are proceeding with this case, and that I wish I could ask that we all focus on the patient for now… but I don’t have the balls to say it. She suggests it better for me not to say anything. “Agreed.” And the case goes on.

Being the lowest on the totem pole, I didn’t know how to (or if I should) step in. The situation settled and we got on with the case, but the surgeon was admittedly on edge the whole day, speaking with the Chief between cases. If I were the patient, I wouldn’t really want a grumpy surgeon operating on me, but to his credit, the technical aspects of the surgeries that day seemed to proceed smoothly.

That was moons ago. I’ve had plenty of training in communicating with patients, participated in sensitivity/conflict scenarios, and attended a conference (on my own accord) about working with other disciplines of care. However, I’ve never been taught anything specific to the Operating Room, other than what I’ve been able to glean from my dad who is an OR nurse. With his help, it’s been easier to figure out what a nurse might want or need from me, how I can work together with them in a polite (rather than demanding) way, and what I can learn from them.

There are many good articles about conflict resolution in the OR, like “A Systems Approach to Resolving OR Conflict – operating room,” and from the Anesthetist’s perspective: “Conflict and Its Resolution in the Operating Room.” Although it doesn’t apply directly to the case I described, I recently stumbled across this great presentation by Dr. Lorelei Lingard about communicating effectively for OR teams.

I’m still at the bottom of the totem pole, but as I grow more and more confident (and more and more senior) I will recognize when it is appropriate for me to intervene, and do so without worry. I hope!

3 Comments leave one →
  1. March 1, 2009 10:31 am

    Oy. I envy your medical school training if conflict like that is unusual in your ORs. I often left drenched in sweat, in search of a stiff drink. I settled for Diet Coke and penny candy from the gift shop. We didn’t call our hospital “The House of Pain” for nothin’! It wasn’t constant, but the environment was generally so toxic that if things went well and everybody was jovial I left the operating room rather euphoric. Ah, good times, good times. Hope the rest of the rotation goes well.

  2. dtotzkay permalink
    April 7, 2009 8:35 am

    As I read your comments, I was impressed with your emotional intelligence and concern. In the face of distracting conflict, you identified the “problem” (patient safety) and set aside emotion (e.g. “You’re not my Mother.”). Your key role was to ensure that the patient maintained adequate ventilation, perfusion, and pain management. You did not lose site of this purpose. You sought out timely guidance.

    Demonstrating this commitment to patient safety speks well of your leadership skills. The fact that you wisely listen to your Father’s suggestions will serve you well, as will your quest for self-improvement. I would love to work with someone of your caliber and passion!

    • April 8, 2009 3:52 am

      wow, thanks for the kind words; i’ve encountered numerous problems while working on elective in Cambodia and Vietnam, and dubbed myself “the OR police” with Operation Smile, and just today approached the Cho Ray (Saigon) electives coordinator with a concern for patient safety lack of appropriate drugs for intubation, also beta-blockers not stocked in ER for MIs/arrythmias, etc.).

      Where are you working, Deborah? Since it seems we are like-minded, it sounds like you will always be the patient advocate on whatever team you work with. It’s tough, but someone has to do it, right? And your patients and their families will thank you. Or not. But you’ll have done something important regardless.

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