Annex A > Chapter 14 - Care in the Operating Theatre and the `Learning Curve' > Care in the operating theatre > The role of the surgeons
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The role of the surgeons
11 Mr Wisheart told the Inquiry:
`In the operating theatre the surgeon is the lead figure and has the ability to determine the prevailing atmosphere.' [10]
`The anaesthetic team will consist normally of a consultant, a Senior Registrar or Registrar and a nurse. In addition to their own internal communications they need to maintain a good level of communication with the surgeons and with the perfusionists and finally with the laboratory. As the surgeons, perfusionists and anaesthetists know each other, these communications do not need to involve lengthy conversations ...
`The surgeons need to maintain a good level of communication with the anaesthetist, with the scrub nurse and with the perfusionists. Again, because the parties know each other, many of these communications may be unspoken. This is particularly the case with an experienced and efficient scrub nurse, who anticipates the needs of the surgeon ...
`[The anaesthetic nurse's] work is chiefly with the anaesthetic doctors, but he or she will frequently have a role of keeping the Ward informed of the progress of the operation and from time to time will interact with the nurse who is the "runner"...
`[The scrub nurse] relates most closely and importantly to the operating surgeon and his team, but she also interacts frequently and importantly with the nurse who is the "runner" who provides the scrub nurse with any instruments, disposables, implants or other equipment, which she may need. The scrub nurse has some interactions with the perfusion team with regard to the provision of disposables which the surgeon uses in establishing cardio pulmonary bypass.' [11]
13 Dr Stephen Pryn, consultant in anaesthesia and intensive care, said of Mr Wisheart and Mr Dhasmana in the following exchange:
`A. They were never in theatre scrubbed ready to go when we came in from the anaesthetic room. Quite often, especially with Mr Wisheart's cases, the child would be anaesthetised on the operating table, the case would be started by his Senior Registrar, and the Senior Registrar would then get ready to place the lines to go on to bypass and the operation would then stop, as the nurses madly phoned around to try and find where Mr Wisheart was and ask him to come down, and we would basically be twiddling our thumbs for quite a long time before we could progress.
`A. Maybe half an hour. That never happened with Mr Pawade. [12]
`Q. What about Mr Dhasmana? Had that been a problem with him?
`A. He was not present when we brought the cases into theatres, but he was often present at the start or shortly after the start of surgery, so not so much a problem waiting to go on bypass with him.' [13]
14 Mrs Kay Armstrong, Cardiac Theatre Sister at the BRI, stated in her written evidence to the Inquiry:
`Weekly meetings also took place between theatre sister, manager, surgeon, anaesthetist and perfusionist to discuss day to day problems, including the punctuality of surgeons. This was a big issue because we would bring a patient into theatre, anaesthetised. They would then be prepared for surgery by the registrar ready for the consultant surgeon to put them on bypass. However, there would sometimes be a long wait before the Consultant arrived which I felt was dangerous. Mr Wisheart was the main offender. Mr Dhasmana would usually come when he was asked.' [14]
`We were often kept waiting for a surgeon to appear in theatre despite several attempts to inform him that the registrar had the patient ready to go on bypass.' [15]
15 Mr Wisheart commented in his written reply:
`There is a practical problem in that the time taken to anaesthetise and place the patient on by-pass was extremely variable, and could range from a little over one hour up to three hours. I was always in the hospital at or immediately after 0800, but did not feel that I could simply spend the time waiting in the theatre suite. Therefore I sought to do something useful waiting to be called when needed.' [16]
`In order to be in theatre when needed I expected to be called a sufficient time ahead to enable me to get to theatre, change and scrub. This did not always happen and I do recall asking to be called earlier on quite a number of occasions ...
`If this was perceived to be a major issue, it was not drawn to my attention at the time in those terms by either the nursing or anaesthetic staff.' [17]
16 This issue was further explored with Mrs Armstrong in the following exchange:
`A. The variability in time should have nothing to do with it. The point is that we would never send for the surgeons until we were ready for them to come. When we sent, it was how quickly they responded to us sending for them.
`Q. But the variability, the length of time it took to put the patient on bypass is completely irrelevant because the surgeon would always be there before the patient began to go on bypass?
`A. Yes, but not before - when I say "put the patient on bypass", there is a good half an hour's surgery that takes place before that.
`Q. I do not think we are at odds.
`A. (To the Panel): You understand, yes? So someone else opens the patient up. Someone else may well put the "purse strings" in. When we are at the point when the heparin is being given and we are putting the "purse strings" into the patient, then we would call for Mr Wisheart or Mr Dhasmana to come to theatre to put the patient on bypass.
`Mr Dhasmana would always come straightaway, but Mr Wisheart would take some time to come and we would often need to call him two, maybe three times.
`Q. Who would call the surgeon?
`A. Whoever was the circulating nurse on that day.
`Q. How much warning would a surgeon reasonably need, do you think, to be told and able to get to the theatre and change and get himself ready?
`A. I would think they would need 10 to 15 minutes.
`Q. So do you understand Mr Wisheart's comment ...?
`A. No. I do not feel that the time taken in the anaesthetic room is relevant because we would not send for him until we were ready for him.
`Q. He does say ... that if this was perceived to be a major issue, nobody told him that it was a major issue?
`A. It was brought up frequently at the meetings. We used to have meetings where there was myself or Sister Herborn, the theatre manager. There would be the chief perfusionist and Mr Wisheart and punctuality was often on the agenda.
`Q. So he is wrong about that?
`A. I believe him to be wrong about that.' [18]
17 Mr Dhasmana commented in writing on Mrs Armstrong's statement that he `would usually come when he was asked':
`I feel that this is a vague statement and may impart unfairly on me. In cases of complex and other major paediatric operations and in all emergency operations, I would always be waiting for the patient to arrive in the theatre from the anaesthetic room ... However, during many routine adult operations, some paediatrics like ASD and isolated VSD and [a] few other paediatric operations in older children the senior or experienced Registrar would start the case and I would then be called in when it was ready to go on bypass. I would like to add that this is a common practice in adult cardiac surgery amongst cardiac units in the UK.' [19]
18 Mrs Armstrong commented further in the following exchange:
`A. He [Mr Dhasmana] was always present in theatre if we had an emergency such as a dissection or something like a TAVPD ... Our instructions were to bleep him when the patient was brought into theatre. Those were always our instructions. We would bleep him. He would respond to his bleep, and then he would come to theatre. That process would probably take between 15 and 20 minutes.
`Q. Just a little longer than the time-frame you mentioned a moment ago? [20]
`A. That is correct. I did say that Mr Dhasmana would usually come when asked.
`Q. You say Mr Wisheart was the chief offender?
`A. That is correct.' [21]
19 Mr Wisheart told the Inquiry subsequently that there were occasions when a surgeon was late arriving in theatre. [22] He explained his approach:
`So I, in general, sought to use the time some other way and asked the theatre to inform me in good time so I could stop what I was doing, change, scrub and join the operation.
`The problem that seemed to arise is that when they informed me they really wanted me in 10 minutes rather than in 20, if I may put it that way. I am not saying I was never at fault myself in any other way, but that was a common issue and it arises directly out of this sort of background; how long does it take to get going, and one never knew.' [23]
20 Mr Wisheart was asked by Counsel to the Inquiry in the following exchange:
`Q. ... if it is the case that it was a late call by the theatre to you when you were quite appropriately doing something else, can you help with why the comment should be directed more at you than at him [Mr Dhasmana] because one would have thought that it ought to have been equal?
`A. I cannot comment. I mean I cannot contribute anything to that, I am sorry.' [24]
21 Dr Sally Masey, consultant anaesthetist, told the Inquiry about the organisation of the theatre in the following exchange:
`Q. In the theatre there was a change, was there not, in 1994 in the organisation of the theatre in that surgical assistants were appointed?
`A. Two part-time surgical assistants were appointed, but I do not know the date.
`A. I do not know the reason why the change was made.
`Q. What was the professed reason for it?
`A. I cannot recollect professed reasons - reasons given for it, but I can think of reasons why this move was made.
`A. The reason would be that the surgical assistants would be able to perform operative tasks that at that time were being performed by surgical Senior House Officers. This would free up those SHOs for other duties, if these duties could be performed by surgeons' assistants.
`Q. What was your attitude to this change ...?
`A. I felt it was a positive move.' [25]
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Footnotes
[10] WIT 0120 0170 Mr Wisheart
[11] WIT 0120 0169 - 0170 Mr Wisheart
[12] Consultant paediatric surgeon from 1995
[14] WIT 0132 0009 Mrs Armstong
[15] WIT 0132 0014 Mrs Armstrong
[16] WIT 0132 0067 Mr Wisheart
[17] WIT 0132 0067 - 0068 Mr Wisheart
[19] WIT 0132 0024 Mr Dhasmana; see Chapter 3 for an explanation of clinical terms
[20] `10 to 15 minutes'; T59 p.63 Mrs Armstrong
[21] T59 p.64-5 Mrs Armstrong; see Chapter 3 for an explanation of clinical terms