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Is the premium surgeon still the captain of the ship?
Maintaining a physical or mental checklist will help the surgeon keep order in the OR while delivering the best outcomes for patients.
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With the mounting pressures of state and federal guidelines and the added burdens of local hospital and ambulatory surgery center bureaucracy, the question remains: Are premium surgeons still in charge in the OR setting?
Overcoming bureaucracy
The decisions on whether to use trypan blue to stain the anterior capsule, to use capsular tension rings/hooks in pseudoexfoliation cases or to open the extra viscoelastic tube to avoid endothelial trauma are all examples in play when trying to achieve the best outcome for our patients, but administrative pressures to keep costs down and be compliant with the “standard of care,” which varies to great degrees geographically, push the limits to keep us from going overboard as captain of the ship. Interestingly, there is a legal doctrine named “captain of the ship,” which holds that during an operation in an operating room, “[the] surgeon of record is liable for all actions conducted in the course of the operation.” This legal doctrine was coined in McConnell v. Williams in 1949 in which the Supreme Court of Pennsylvania ruled that “it can be readily understood that in the course of an operation in the operating room of a hospital, and until the surgeon leaves that room at the conclusion of the operation … he is in the same complete charge of those who are present and assisting him as in the captain of a ship over all on board, and that such supreme control is indeed essential in view of the high degree of protection to which an anesthetized, unconscious patient is entitled.”
Obviously, interpretation of this law can vary, but in reality, once that time-out is called, the surgeon is the captain of his or her ship until that case ends. Unlike commercial airlines that have a co-pilot who could take over in an emergency, most ophthalmology outpatient situations do not have a co-surgeon in the OR wing waiting in case of emergency. We must take all measures to be perfect from the start, and the adage that perfect practice makes for perfect results holds true.
Keeping a checklist
Not unlike a commercial airline pilot, I will typically review my mental checklist before each surgical procedure, no matter how many cases I have performed in the past. A 10-year study conducted by OMIC revealed that IOL power calculations represent the single largest malpractice risk to a practicing ophthalmologist. With the progression of technology to intraoperative aberrometry, most staff can inadvertently put in the wrong axial length online preoperatively, which would give an aberrant outcome in terms of IOL power selection. This is just one example in which I review all preoperative inputs on the aberrometer screen in the OR before starting the procedure.
With most practices venturing into electronic health records, it is easy to not have immediate access to an IOLMaster (Carl Zeiss Meditec) or Lenstar (Haag-Streit) IOL printout in the OR. My solution is to simply print out all my IOLMaster pages for each patient for that surgery day and bring in the appropriate sheet for that case into the OR for IOL verification with or without the use of intraoperative aberrometry. I also only keep IOLs in the operating suite that I would consider implanting into that patient on the OR table — an in-the-bag IOL, a sulcus/optic capture IOL and an anterior chamber IOL, if high risk for such. Our consignment of IOLs remains just outside the OR so no IOL mix-up can occur once the power is verified by the surgeon.
One other common mistake is toric IOL axis alignment and/or astigmatic incision axis alignment errors. I will typically print out my vector analysis calculations page for a specific case and have it hanging in the OR for axis verification for manual/femtosecond astigmatic incisions and/or toric IOL alignment, even if intraoperative aberrometry is being used.
In the end, a simple repeatable checklist, physical or mental, in the OR, will maintain our ability to be captain of the ship. Despite the bureaucracy that surrounds us, it is our responsibility to keep the ship calm, orderly and free of adverse outcomes for our patients.
Stay tuned for my next premium channel column — Participation in clinical studies: Premium or priceless?
References:
Blumenreich GA. AANA J. 1993;61(1):3-6.Brick DC. Surv Ophthalmol. 1999;doi:10.1016/S0039-6257(98)00052-6.
Scott EW. Vill L Rev. 1962;7(2):283-286.
For more information:
Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Avenue, Suite L, Lake Villa, IL 60046; 847-356-0700; email: mjlaserdoc@msn.com.Disclosure: Jackson is a consultant for Carl Zeiss Meditec.