Annex A > Chapter 14 - Care in the Operating Theatre and the `Learning Curve' > Care in the operating theatre > Performance of the team: a surgeon's perspective
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Performance of the team: a surgeon's perspective
23 Mr Dhasmana discussed teamwork in the operating theatre and the way in which operations at Bristol were conducted as compared with those he had witnessed in Birmingham when he went to observe the consultant paediatric cardiac surgeon, Mr Brawn, in the following exchange:
`Q. What was it about his team that was better than your team?
`A. Well, he had a dedicated paediatric cardiac surgical assistant in a way. My assistant, even though he could be a Senior Registrar, may not be a dedicated paediatric cardiac surgical assistant, may not have seen that many paediatric cardiac surgical cases and I have no other option but to take his assistance at that time to help me.
`So in a way he would not automatically move in the same way or anticipate my move as it was being done in Birmingham. Similarly, nurses in Birmingham, they had almost everything ready on the table. They knew when he was going to require a suture, it was almost as if he is not looking, he is just doing that, he is getting it.
`I used to really say in theatre that "we are not running a relay service here" because that is what I was noticing. Most of the time I am saying "4 O" then somebody else is in 4 O then somebody is getting from there and obviously by that time I would look at what is happening and this is all distracting.
`That was one of the problems, that sometimes some of the nurses in theatre were very uncomfortable with me because I did not like that type of - it is not service to me, I thought it is service to the patient, and that was lacking and I think it was lacking because these nurses were on the same day dealing with an elderly gentleman, another person where probably such things do not matter that much at the time, but here it did.
`Q. Again you are picking up I think on two or three factors there: one is that the consequence of having a "relay" operation, one person turning to another to another to another, is a further delay in the time it would take you to complete your operation?
`Q. Secondly, it indicates that if you needed something very quickly you might have to wait for it and that is not a good thing?
`Q. Thirdly, it indicates, does it, that you reacted to the nurses, telling them off for running a relay operation for the reasons you have explained, which I think you have told us sometimes affected the atmosphere in the theatre?
`Q. If you have an atmosphere in an operating theatre I suppose that the whole team does not function quite so well; it is inevitable, is it not?
`A. By "atmosphere" I do not really mean it should be pleasant with music going and all these things. I feel it should be professional and I felt it is not professional that, you know, things are not there. I mean the list is already out, you know what we are going to do. In a way it should be professionally ready for you and that is where my in a way criticism was.
`As far as the pleasantness is concerned, I was very pleasant outside operating time, but during the operating time, I did not want chit-chat, I wanted things done and that somehow was not popular with many nurses.
`Q. So for the reasons you have given, you could be cross and irritable in the operating theatre, could you?
`A. I never realised that I could be, but yes, it would be seen that way.
`Q. If you were telling nurses off for a relay operation as you have described it, your need to do that would be a distraction, would it, of you from focusing upon the particular job that you had to do with the patient?
`A. I think when one uses the word "telling off", it sounds harsher than what it really was. I do not think I was "telling off" because when you are telling off that means you had stopped doing things, what you were really doing. I was not stopped from doing anything really, I was just in a way hurrying up, if you like. It could be seen that way, or it could be interpreted, but I did not realise I was telling anybody off.
`Q. But you said you found it distracting?
`A. To me, yes, because I am operating here, looking at this, and then I ask for a suture and it is not there. So it is not there. I look this way and you have got magnification on all those things, all focused. Then you go back on there, it takes a little time, a millisecond, but you have gone out from there. To me, especially when you are doing a very minute vessel, I think it is a little bit - you know.
`But I did have actually a few nurses who were very good and mostly they used to work with me and I had no problem with that.' [28]
24 Mrs Armstrong commented in the following exchange:
`Q. Did you ever have the impression that excessive work was taking its toll on the surgeons?
`A. I think occasionally, particularly with Mr Dhasmana, I would know when he was tired because his temper would deteriorate.' [29]
25 The nursing establishment in the operating theatre for each case comprised three nurses: an anaesthetic nurse-assistant, a scrub nurse and a circulating nurse. In addition there was an allocated Sister-in-charge, although the Sister ordinarily filled one of these roles and was rarely supernumerary. [30] Each member of the team had their own specific tasks to perform in assisting the medical staff, although each was also aware of what the other members of the team were doing so that they were able to cover for each other. [31]
26 Mrs Mona Herborn, a cardiac theatre sister at the BRI, explained each of the three nursing roles as follows in her written evidence to the Inquiry:
`As a scrub nurse one stands next to the main surgeon performing the operation, to anticipate what equipment the surgeon will need at the various stages in the procedure, and hands it to him. As scrub nurse one needs to have a thorough knowledge of the operation being performed and be able to anticipate what equipment will be required. There is no time limit on the training to become a scrub nurse, which is carried out on the job and under the close supervision of an experienced scrub nurse.
`As an anaesthetic assistant one prepares the anaesthetics room which involves checking all equipment, laying out the required drugs and monitoring equipment. When ready, one calls for the patient, checks the patient's identity etc. The patient has usually been given a pre-med on the ward. An anaesthetic assistant's main role is concerned with the general safe keeping of the patient on the operating table.
`Once the operation starts the anaesthetic assistant has time to return to the anaesthetic room and tidy up, to get ready for the next patient. The patient is left in the care of the anaesthetist who stays with the patient at all times. The anaesthetic assistant is at the call of the anaesthetist if he needs any further equipment, for example syringe pumps or drugs. If there are any problems with the equipment during the operation it is the anaesthetics assistant who sorts it out or calls the necessary help to sort it out. At the end of the operation the anaesthetic assistant informs the ICU that the patient is about to arrive and ensures that the patient's notes, blood form, blood bags and all things that have come with the patient or been acquired during the operation go to the ICU with them ...
`As a "runner" one has to know all the aspects of what is going on and is usually interchangeable with the scrub nurse in terms of skills and experience. The runner's role is to give the scrub nurse anything extra required that is not on the trolley, for example more sutures. The circulating nurse has to be quick on her feet.' [32]
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Footnotes
[30] WIT 0132 0041 Mrs Armstrong
[31] WIT 0132 0042 Mrs Armstrong
[32] WIT 0255 0001 - 0002 Mrs Herborn