A Matter of Trust

To work in surgery, you need to have a certain level of confidence. This is helpful when you scrub or circulate in procedures that you don't see very often or procedures that may force you to combine your knowledge from various specialities. You have to be ready for ANYTHING.

How about when you need to be confident enough to handle working with a surgeon whose skills you don't trust?

Every now and then, I am assigned to work with Dr. A, one of many orthopedic surgeons on our roster. Short in stature, he is in his early to mid-forties with hair almost completely gray. A pleasant man outside of the OR, he is tense and nervous during procedures, often speaking to himself out loud as well as reminding everyone to "relax."

During a Total Knee Replacement...
Dr. A: "OK, can you hold the leg this way?"

As the scrub nurse, I comply with his request.

Dr. A: "Great..."

While I'm holding the patient's leg a certain way, Dr. A fiddles with the trial components until he is satisfied with their fit.

Dr. A: "OK... Now just relax... Everyone RELAX..."

My co-workers and I look at each other knowing that we're not the ones who need to relax!!!


Dr. A operates at Medium Suburban Teaching Hospital at least once a week, although it seems like he is increasing his time in our OR. The procedures that I have scrubbed and circulated for him are mostly total joints (knees and hips) and ORIF's (open reduction internal fixation - fixing broken bones with plates and screws). The other day, I was the scrub nurse for a Knee Arthroscopy with him.

Knee arthroscopies or "knee scopes" are simple procedures compared to doing a total knee or hip replacement. Basically, a small incision is made, a "trocar" or a port is inserted, followed by the camera. Two bags of sterile saline (3000ml/each) are hung and connected via sterile tubing to the trocar along with sterile suction tubing. The fluid allows the surgeon to have a clear picture of the knee (almost like using CO2 on laparoscopic cholecystectomies). The surgeon takes a look around and then determines where incision #2 will be made based on what he or she needs to do. A spinal needle is then inserted to determine location. The surgeon can visualize the needle via the image on the screen. One he or she chooses the location for incision #2, the cut can be made. For simple scopes, two incisions are sufficient --- one is for the camera, the other is for the probe or shaver.

When I was assigned to work with Dr. A, I did not know that he hasn't done many "scopes." Having worked with other orthopedic surgeons on a regular basis, most scopes are simple and straightforward making it feel very routine. In fact, I have seen many residents perform these procedures with minimal guidance from an attending. Dr. A's inexperience became evident when the rep showed up to demonstrate uses of the equipment. Uh, shouldn't that be reviewed PRIOR to the procedure??? Oh, geez... Here we go...

With Dr. A, everything seems to be a big production. Even positioning the patient requires the same intensity as the procedure. Dear God, why me??? I won't get into the minutia of positioning, however, I will say that I was exhausted even before incision was made.

Like the other ortho docs, Dr. A felt the patient's knee, located the proper landmark and made his incision. Then the fumbling began. Based on my experience and training, I had already put all the necessarily equipment on my mayo stand. I handed him the trocar that all the other docs use. He asked the rep if this was the right one to use, etc. The rep was there by his side to talk him through every single move. It was making me crazy.

What made me even more cuckoo is that Dr. A kept changing his mind on the port location making more incisions than necessary. Ouch ouch ouch! My poor patient! I don't know if it was because he was having a hard time seeing where he was since, duh, the camera wasn't in focus. Or was it because he didn't let me touch anything so I couldn't prime the tubing before he connected it to the trocar? (You have to prime the tubing for the saline - meaning let it run until there are no air bubbles - since bubbles get in the way of your view.) I kept my mouth shut and let the rep do the talking. After all, I've only been an ortho nurse since July. What did I know?

Once the rep showed him how to focus the camera, we were in business. The next step was to make Incision #2. I had the spinal needle ready in my hand when he grabbed the scalpel off my mayo stand. I cringed to think that he was going to just make an incision by guessing. Sure enough, that's what he did!!! Yikes. I wanted to run. I had a bad feeling about what would follow.

As it turned out, the incision was not made in the proper location, so he had to determine the correct one. Three or four incisions later, he found the spot. At one point, he didn't know if he broke through enough tissue layers to be able to insert a probe, so he took the scalpel (which happened to have a #11 blade on it - btw, it's the SHARPEST of all the regular blades), stuck it in the patient's knee, and wiggled it around a little. Ouch, ouch, ouch... What the heck is he doing???

Shortly after that, my relief showed up. I was so happy that I was out of there. It's one thing to work with a surgeon that you don't particularly like. But when you have to work with someone whom you don't think should be operating? What do you do? It's tough to refuse to work with someone. We're short-staffed not to mention the politics in the OR is terrible. The last thing I want to do is get a reputation for being a princess. But patient safety comes first. I have to do SOMETHING.

I was actually thinking about writing an anonymous letter to someone in the administration - not sure who - just so that this surgeon won't be able to do this to someone else. Is that the right move? I don't know... I feel terrible that I did not know how to advocate for this patient while I was scrubbed in surgery. I don't feel right about doing nothing. That's not what I signed up for when I decided to become a nurse. People trust me with their lives and I take that responsbility seriously. Maybe my team leader will know what to do. Let's see what she says.