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Operating Room Or Concert Hall?

Professor of Surgery and Pediatrics
University of Florida College of Medicine Jacksonville campus
9-2-2 Senior surgeons remember the days when an operation began with the surgical resident helping the anesthesiologist induce the depth of slumber that would enable effective operative intervention. The “help” usually involved keeping a finger on the patient’s pulse to assure it stayed there! Much has changed since those days of open drop ether and explosive anesthetics. Anesthesiologists correctly believed that good surgeons deserved good anesthesia, and less talented surgeons required it. Thus, the process of induction, which was the real start of a surgical procedure, was invariably conducted in a quiet, calming, confident environment designed to focus wholly and completely on the patient and assure safe passage to “surgical” anesthesia. This same focus carried over to actual performance of the procedure which demanded intense concentration, anticipation of findings, and complete environmental control. Since those days, surgical science has advanced, technology has evolved, and miniaturization has compressed what used to require a room full of computer storage onto a microchip half the size of a postage stamp, and probably half the cost! It would have been outlandish to bring the Beatles’ White Album into the OR, key up the needle, and operate to the tunes of “Hey Jude”. Yet today a surgeon can bring the entire compendium of the Beatles’ career into the OR in his or her scrub suit pocket. In fact, sometimes it seems that more time is spent devising the playlist than preparing the surgical site. On top of all of this a debate has emerged about the role of music in the OR. Does it soothe the savage beast and facilitate cognitive function? Does it lower operative stress, for both patient and surgeon? Can the patient actually hear what is being played, as some anecdotal data would suggest? In other words, is all this symphonic support an enhancement or a distraction?     If 99.9% of the time it was an enhancement, would the other 0.1% be a problem? According to some, that missing 0.1% would translate to 500 incorrect surgical procedures per day.1 Most of us would consider that a problem, especially if we or our family were among the unlucky five hundred. Back in the days of the surgical resident keeping a finger on the pulse, operative surgery was complex. Today it is even more so, especially with the addition of limited access and robotic technology. This is the primary reason the OR has adopted the checklist strategy from the aviation industry. None of us would willingly get on an airplane captained by a sleep-deprived pilot who was working on the in-flight music selections while the flight attendants were out checking the hydraulics and tire pressures. Yet, in many operating rooms, that is exactly what goes on, as the nurse struggles to get everybody’s attention to confirm that the guy lying on the table in the middle of the room actually belongs there, and for the right reason!     The take home message is very simple. Whether you are an advocate of an intra-operative symphony or not, the operative clinical mission is among the most complex in history and deserves the surgeon’s undivided attention and leadership, from point of preparation, through execution, and for immediate review thereafter. By definition, the complexity of the modern operating room is a forest of distractions. Checklists enable the surgeon to traverse the forest safely and effectively. Whether the surgeon is humming a tune or listening to rap is immaterial, as long as the music’s presence is accounted along with all the other potential distractions, and the team’s focus stays on the patient and procedure, where it is supposed to be. Who is responsible for leading this process of safety assurance? Who is the navigator that assures that all distractions are accounted and controlled? That would be the same person to whom the patient has entrusted confidence and hope for efficacious surgical care. Spending at least as much time assuring that all real and potential distractions are controlled as is consumed by picking a playlist is not an option. It is a mandate that has been part of our culture since the days of Hippocrates.       References: 1. Marino, Sal. Is ‘good enough’ good enough? Industry Week. February 3, 1997.  http://www.industryweek.com/articles/ is_good_enough_good_enough_1713.aspx 2. Leape, LL. Error in medicine. JAMA 1994;272:1851-7 3. Quinley, KM. 99.9% may not be good enough:   beware of “statistical insignificance” defense. http://www.claims-portal.com/nlps/story.cfm?  nlpage=557 4. Gabel, N. Is 99.9% good enough? Training Magazine. March 1991. http://www.maaw.info/ ArticleSummaries/ArtSumGabel91.htm