Before the Flight: Pre-op Checklist
Moshe Schein
“The pilot is by circumstances allowed only one serious mistake, while the surgeon may commit many and not even recognize his own errors as such.”
(John S. Lockwood)
Like any military or commercial pilot, prior to any flight, you have to go over a “check list”. In fact, the need to check everything obsessively is more crucial to you than to the pilot. For while a team of dedicated and well-trained maintenance professionals surround the pilot – you are not uncommonly surrounded only by jerks. We do not want to be abusive or rude but let us be realistic: at 2 a.m. your intern or junior resident is much more interested in his lost sleep than your pro- spective operation.And the anesthetist? Your emergency case is just a pain in his ass.
The sooner he or she can administer the gases,the sooner they can dump your “case”
in the recovery room or intensive care unit and the sooner they can crawl under the warm duvet – the place they yearn to be.And the nursing staff? Forget them! Not in vain today are they called OR technicians (> Fig. 9.1).
9
Fig. 9.1. “Doctor, show me your pilot’s license…”
So face it – you are alone; it is always a solo flight and you can count only on yourself.Regardless of how many people are buzzing around the patient – this is your patient, and you are responsible for the success, failure, morbidity, mortality, and potential lawsuit. The fate of your patient is in your hands. So wake up and go over the checklist.
The Checklist
Does he really need the operation?The cliché that it is more difficult to decide when not to operate than when to operate is mentioned elsewhere in this book.Va- riations of this aphorism are circulating around the world in many languages. But it is much more difficult to decide against the operation after the operation has been scheduled. So you decided to book the patient for appendectomy based on what the chief resident told you over the phone – that “the CT is compatible with acute appendicitis”– and now,when you arrive in the OR,you find the patient smiling and sitting in bed with a soft and non-tender abdomen. Do you want to operate on the CT or the patient? You do not need big balls (or ovaries) to book a patient for operation but you need large balls to cancel the operation and order the patient back to the floor (ward). You need huge balls to remove the patient from the operating table and giant balls to tell the anesthetist to wake him up… but if you palpate a large appendiceal mass after the induction of anesthesia and abdominal wall relaxation – what is the point of continuing?
Examine the patient before he is put to sleep. Never ever – we repeat – never ever operate on a patient without having examined him yourself; if you do then you are a butcher. That the endoscopist visualized a “bleeding ulcer”and the patient continues to vomit blood may be an indication for operation, but this is your chance to diagnose the large spleen and ascites, which were hitherto overlooked by the others.You do not want to operate on a Child’s C portal hypertension patient, or do you? (See > Chap. 16).
Look at the X-rays and imaging studies.Review all X-rays and imaging studies by yourself. Do not rely only on what the radiologist said or wrote.You may pick up findings, which may move you to cancel the operation or to decide on a different incision.
Position the patient. Already before you start you have to have a general idea what you are going to do or what you may have to do. This has an impact on your patient’s position. For example – does he need a Lloyd-Davies position, offering access to the anus and rectum? This may be needed during colorectal procedures – to insert a scope, to decompress the colon or to insert a stapler. You do not want to have to stop the operation and place the patient in the correct position or to send the intern crawling under soggy drapes looking for the anus. In whatever position 78 Moshe Schein
your patient is to be, check that all limbs are protected and well padded at potential pressure sites.Poor positioning on the OR table may result in damage to nerves,skin ulceration and compartment syndrome of the extremities – and a lawsuit.
Warm your patient. See that the patient is well covered and warmed. Hypo- thermia increases the likelihood of postoperative infections and contributes to intra-operative coagulopathy.
Think about preventing deep vein thrombosis (DVT): Prevention of DVT should be initiated before the patient is put to sleep – not after the operation.
Any abdominal procedure lasting longer than 30 minutes is associated with a moderate risk of DVT; you can add to this specific risk factors such as smoking, use of oral contraceptives, previous history of DVT, age, obesity, a cancer and so forth.
But instead of pondering too much – why don’t you provide all your patients undergoing an emergency abdominal operation with DVT prophylaxis? Whether it is in the form of subcutaneous heparin or calf compression depends on what your OR can offer. Bear in mind that anticoagulation is not good for an exsanguinating patient! We have seen young patients dropping dead from pulmonary embolism a few days after appendectomy and young women developing intractable post- phlebitic syndromes following appendectomy performed for pelvic inflammatory disease. Always think about this.
Is the bladder empty?Most patients undergoing emergency operations arrive at the OR with a urinary catheter in place; in the rest you will insert the catheter on the table. But if contemplating a lower abdominal procedure on a non-catheterized patient you have to check that the bladder is empty. When the bladder is full it may look to you like the peritoneum. Bladder distension may also mimic a surgical ab- dominal condition.
Think antibiotic prophylaxis(see > Chap. 7).
Document everything(see > Chap. 8).
Now you can go and scrub! You are the captain of the ship – behave like one;
the sight of a surgeon dramatically entering the room with his scrubbed hands held high in the air is pitiful.
“Poor judgment is responsible for much bad surgery, including the withhold- ing of operations that are necessary or advisable, the performance of unnecessary and superfluous operations, and the performance of inefficient, imperfect, and wrongly chosen ones.” (Charles F.M. Saint, 1886–1973)
“The surgeon, like the captain of the ship or a pilot of an aircraft, is responsible for everything that happened. His word is the only one that cannot be gainsaid.”
(Francis D. Moore, 1913–2001)
79 9 Before the Flight: Pre-op Checklist
