This morning I had just about made up my mind that I really ought to talk to the chairman before going to these surgeries; but at the last minute, he didn’t round with us as I had expected, and I didn’t have the courage to catch him in the hallway and force the topic. So, I just went.

I had underestimated the inefficiency of all ORs other than the one at the downtown trauma center. I had thought their scrub techs were sometimes absent-minded, sometimes ill-prepared, and their supplies sometimes located an inconvenient distance away. Big surprise. At my favorite hospital, the surgeons complain if it takes more than 20 minutes to turn over a room between cases. At the tiny suburban hospital, it took 45 minutes after the scheduled time to get the first case of the day going – and they were only running four rooms. It took them an additional 45 minutes between cases to turn over and get the patient settled in. This effectively destroyed my hopes of being first assist for any length of time. The two attendings knew the arrangements at this hospital very well, and thus, although their three cases were scheduled to conflict very thoroughly with each other, they in fact realized that each one would run so far behind that they could do each case together, and then move on to the next one.

The older surgeon was inclined to inquire cheerfully but closely into my presence. The younger one deflected him, and advised the ceiling over the scrub sink, “I never said this, especially if anyone asks, but in case someone should ask, you might say that we two gave you permission to come here, and it didn’t occur to you to ask anyone else. That way you won’t get your chief in trouble.” (leaving unsaid the fact that properly, the two of them ought to have equal authority with the chairman on a team that is billed as having four attendings – not just one: the chairman) No one paged me today, so I’m fairly hopeful that the chairman didn’t take it into his head to leave his office to look for me, and tomorrow is the last real day of the rotation, so we should be safe.

The first two cases were open. I mainly stood and looked over/at their shoulders, as previously, but the older one did leave to start the second case, so I got to help close: thrilling to stand on the first assistant’s side of the table, but not much accomplished otherwise. The younger attending was very nice and friendly, and talked about his residency program (completed more recently than I had thought), and discussed pros and cons of big and small surgery programs. Then he went to help with the second case, and I figured it would be extremely redundant to scrub in there too, so I hung around making friends with the OR staff and encouraging them to move the room along. He had promised I could do things in the next case, a lap roux-en-Y, if we got started before the other one finished.

One of the best things about the day was that I was at a strange hospital, in a different system, but I managed not to get very lost or nervous, and looked enough as though I belonged that all the nurses happily showed me where I needed to go, without questioning my credentials. I was also able to help set things up in the OR. So it’s a hopeful sign that I’m growing up, and will be able to adjust to the different environments I’ll have to work in.

On the other hand, one of the nurses in the room was new, orienting to the OR. We talked a little, but the conversation broke down when she explained that she had recently divorced her husband, a surgery resident who graduated from my school. The only thing I could think of to ask was whether it was a surgical personality or the demands of the residency program that had broken them up, and obviously one can’t ask that on first acquaintance.

 The last case of the day went smoothly right until the end (including me putting in two trocars before the second attending managed to scrub in), when suddenly every piece of equipment needed to wrap things up seemed to be either broken, or located in a store-room ten minutes away, or else completely unknown to the OR staff, although the surgeons use it every day at the big hospital. We spent half an hour, while the scrub-tech student tried to supply everything called for while her mentor ran around trying to find all the missing objects, and not succeeding. The surgeons ended up exercising a good deal of ingenuity, and controlled themselves very well under the circumstances, only requesting pointedly that every missing object be carefully added to their list of requirements for future days.

Main lesson: This little hospital is the only medicare-approved site in town for bariatric surgery, because it has qualified as a “Center of Excellence,” which I believe means they’ve done 150 cases. Although they’re working on it, the bariatric surgeons haven’t done that many yet at the big hospital. But does “Center of Excellence” mean that you get better, or even equivalent, care at the small hospital? Far from it. Their circulating nurses and scrub techs are so used to low volume and slow days that they are very inefficient at every step of the OR process. Their supply room is located far away from the operating room. Thus, if bleeding unexpectedly occurs, and the surgeon asks for a silk stitch which wasn’t listed in the official necessaries of the scheduled case, he has to wait while someone runs to this supply room, finds the suture, and brings it back. At the big hospital, all the operating rooms are located around a central clean core. Hundreds of different sutures are kept in each room, and if a different one is needed, it will take thirty seconds for an experienced nurse to find it. At the big hospital, even if the individual techs and nurses have not participated in 150 of a certain case, they are so well versed in surgical procedures that they can think ahead with the surgeon, based on what they see him doing, and the few words he says, and can ask for supplies and set their tools up so that the surgeon can move quickly when he wants/needs to. And that’s without even addressing the anesthesiologists, who don’t like to extubate obese patients in the OR (unlike the big hospital doctors, who are very comfortable with this), or the PACU nurses, or the ICU nurses, accustomed as they must be to a much lower level of acuity than the trauma hospital.

QED: Medicare and its standards of excellence, and by extension all government programs to ensure “quality,” are very likely to focus on non-material standards which have no real impact on patient care or outcomes, and compensation should definitely not be tied to this inadequate and inaccurate measurements.

But the suburban hospital definitely has prettier walls and waiting room furniture, if that makes a difference.

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