Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?
If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.
John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.
Respectfully, I disagree.
The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.
On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.
Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.
Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases? No.
Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.
Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.
These things take time
Let me tell you a little about what goes on behind the scenes during a typical case that I do quite often: anesthesia for lung surgery. The surgeon’s goal is to remove all or part of a patient’s diseased lung, often because of cancer.
The first step involves my interview and physical examination of the patient. Next, I start the IV if the patient doesn’t already have one, and give appropriate premedication — for example, to help the patient relax, or to prevent nausea. Then the nurse and I bring the patient into the operating room, assist the patient in moving from the stretcher to the OR table, attach appropriate monitors for heart rate and blood pressure, and position the patient comfortably with warm blankets. While I’m busy with these tasks, the surgical team is setting up the operating room, counting instruments and making sure that all the equipment is ready. All this takes at least 20 minutes, often longer. None of it requires the surgeon’s presence.
At this point, I give the patient oxygen to breathe through a mask and I start the appropriate medications to induce anesthesia, taking into account any underlying health problems the patient may have, such as high blood pressure or heart problems. As the medications go into the IV, the patient stops breathing and I take control of the ventilation. Then I insert a special breathing tube into the airway. This tube, called a double-lumen tube, allows each of the patient’s lungs to be ventilated separately. The lung with the cancerous tumor needs to be collapsed and motionless while the surgeon operates on it. The other lung is ventilated. I have to position the tube precisely with a fiberoptic bronchoscope so that it functions properly — allowing full collapse of one lung and effective ventilation of the other, and making sure that the patient receives plenty of oxygen.
Once I’m happy with the position of the double-lumen tube, I may need to place other lines — perhaps a larger calibre IV, or an arterial line to measure the patient’s blood pressure continuously. The nurse may need to insert a urinary catheter.
When we’re done, we call for help to position the patient for surgery. This involves coordinating a team of operating room staff to turn the patient safely all the way onto one side, right or left depending on which lung needs surgery. We pad all the bony prominences — hips, knees, elbows — for comfort, putting pillows between the knees and positioning a padded axillary support to protect the nerves in the “down” arm. The nurse cleans the surgical site with antiseptic solution, and the surgical technician covers the rest of the patient’s body with sterile drapes. I recheck the breathing tube’s position with the fiberoptic bronchoscope.
Now we’re ready for the surgeon.
Team may work better with surgeon elsewhere
Surgeons remind me sometimes of racehorses. They are eager for the event to start, and impatient with anything that keeps them from bolting out of the starting gate and laying knife to skin. They’re perfectly willing to acknowledge that all the preparatory activities I’ve just detailed need to be done, and that the people doing them can’t be rushed too much or harm to the patient could result. But surgeons hate to stand around and watch — they pace, and mutter, and consciously or not, they put pressure on the OR team to move faster so the operation can start.
Everything goes more smoothly when the surgeon is happily occupied in the case next door. Experienced teams know how to stagger the starts so that the surgeon is in the key portion of the first case during the preparations for the second.
Once the critical work of the first case is complete, the surgeon can leave safely to begin work on the second one. The surgical technician and nurse begin the precise count of all the surgical instruments, needles, and sponges to make sure nothing is left inside the patient, while a surgical resident or fellow, or one of the surgeon’s partners, begins to close the wound. Once that’s done, members of the surgical team apply the dressing and reposition the patient for the wake-up from anesthesia. I make sure the patient is breathing well and all vital signs are stable, and then I remove the breathing tube. We move the patient from the OR table to the stretcher, and transfer the patient to the postanesthesia care unit. All these activities at the end of the case take time as well, and none of them requires the presence of the chief surgeon.
Often, the team is more efficient and at ease when the surgeon is occupied elsewhere while the patient wakes up and everything is done to move the patient safely out of the operating room. Then the operating room must be thoroughly scrubbed down before set-up can begin for the next case.
Better for shorter than longer cases
In most instances where I’ve seen surgeons running two operating rooms at once, safely and efficiently, the key surgical portions of the case are relatively short while the preparation time is long. A good example would be total joint replacements, especially hips and knees, where it takes time to set up complex equipment and place regional anesthetic blocks before the surgical team is ready for the surgeon.
What about long spine cases, such as those detailed in the Boston Globe article? Whether scheduling those cases concurrently is a good idea isn’t as clear cut. It would depend on the specific situation. In surgical groups where partners have comparable skill and experience, it often doesn’t matter much which surgeon is listed as the primary surgeon and which one is listed as the assistant. They may work together consistently, and when they run two rooms, the quality of care is no different. In fact, it may be better in the sense that they can each perform the parts of the work that they do best, and relieve each other for brief periods during especially long cases.
Should patients be told that surgeons have scheduled two operating rooms? Of course they should. And in my experience, they are. I’ve seen patients next to each other in the preoperative bays, chatting about the skill of their mutual surgeon and congratulating each other on their choice. They understand that the OR runs more efficiently when cases are staggered, and have confidence that each of them will have the surgeon’s full attention at the appropriate time.
It’s important to recognize, too, that no one can become an excellent physician without years of training. That training can’t happen just by watching. Residents and fellows need to perform surgery under supervision, just as anesthesia residents and fellows give anesthesia and do procedures under my supervision. As long as supervision is appropriate, a recent study has demonstrated that quality isn’t in jeopardy.
Reporters and the public shouldn’t rush to judgment about the wisdom of scheduling concurrent surgical cases. It’s important to understand how this long-standing practice may contribute positively to the overall performance and efficiency of the surgical team, and to the safety and well-being of our patients.