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Reducing stress in the operating room: stress relief for the patient

2023; Lippincott Williams & Wilkins; Volume: 49; Issue: 9 Linguagem: Inglês

10.1097/j.jcrs.0000000000001200

1873-4502

Robert H. Osher,

Hospital Admissions and Outcomes

This column is one in an invited series by Dr. Osher. The series highlights techniques that may be helpful particularly to young practitioners. This is the second article of 2 that is based on 4 decades of experience in learning to reduce surgeon and patient stress.1 This article will focus on the patient. Office Discussion The office experience sets the stage for the surgical experience. For my entire career, an educational video showing and narrating the cataract procedure is playing in the waiting room. I was among the first to incorporate video into my practice, which has been reported to reduce patient anxiety.2,3 The cataract surgeon must invest quality time in an information-packed conversation with the patient, delivered with empathy and sincerity. The words we choose are so critical that Dr. Jack Parker and I wrote a book on patient conversations, What I Say.4 Eye-to-eye contact is essential, and I personally am in favor of a gentle touch to the hand or shoulder when reassuring the patient that I am going to do my very best for them. I am also in favor of a little humor, when appropriate. For example, if the patient wants to know what is the worst thing that could happen during their surgery, I might answer, “For me to die!” I also like to reassure the patient that the surgery is easier than the comprehensive initial examination, and I often add that I am a “no hurting doctor.” One of my favorite quotations is that “patients don't care how much you know…until they know how much you care.” The compassion that the surgeon displays is the most important factor in reducing patient stress. Preoperative Greeting In our surgery center, the surgeon is encouraged to visit while the patient is being prepared by the nursing staff. This is an opportunity to welcome the patient and to offer an encouraging statement such as “Are you ready for a good operation today because I'm going to do an excellent job for you.” Again, I like to pat the patient on the shoulder because human touch is very comforting. I like to add that he or she has an “excellent, very experienced nurse” who will get everything ready for the operation. Family Support I never liked the impersonal feeling of a large recovery room, so our first ambulatory surgery center (ASC) was designed in the early 1980s with preoperative and postoperative private rooms and bays, which has expanded to 23 in our current ASC. The family is encouraged to remain in the room with the patient preoperatively and then reunite with the patient as soon as the operation is finished. I am always touched by the husband and wife who are holding hands when I enter. The presence of family plays a major role in relaxing the patient. Preoperative Medications Although the anesthesia team often favors a mild sedative to reduce anxiety, I've always preferred that the patient is awake, alert, and minimally sedated. I strongly believe that the best anesthesia is not general or local…it's vocal. A cheerful and optimistic disposition can outperform sedation in reducing patient stress. Operating Room Comfort The operating room is a strange and foreign environment for patients—unfamiliar people behind masks, unusual smells and sounds, uncomfortable drapes and beds, and often bitter cold temperatures. The best fix is some TLC—tender loving care. The circulating nurse will offer a warm blanket, and the anesthetist will place an oxygen tube so that it blows fresh air onto the patient's face with kind reassurance about “getting plenty of fresh air.” While I am adjusting the patient's head so that my access to the globe is optimal, the nurse will make certain that the patient's shoulders, back, and knees are positioned comfortably. A pillow under the knees is often appreciated, especially by patients with degenerative back disease. I have designed a drape that allows easy handholding, and I always explain that the drape around the eye is being placed for maximum safety and sterility. When the positioning and draping are complete, I always ask the patient if they are comfortable…and I recall one patient replying “Yes, I make a pretty good living!” I've already commented about the importance of music to reduce the surgeon's stress, but it is always surprising to me when so many patients comment that they enjoyed the nice, soft music.1 Introductions At this point, I will try to introduce the patient to my scrub technician who I say is highly experienced and one of my favorites. The patient has already met the anesthetist and the circulating nurse, but I will reintroduce them. This simple greeting is reassuring to the patient. When a resident, fellow, or visiting surgeon is observing surgery, I will always introduce this person and explain that he or she will be watching while I am performing the surgery. I will then ask whether I can explain what I'm doing to both the patient and the visitor, and the patient invariably grants permission. Constant Communication I like to make a few notes on my surgery plan, which hangs on the microscope and reminds me to ask the patient about a hobby or a relative on whom I've operated. This conversation lets the patient know that they are more than a mere number. I always emphasize that I am checking to confirm that the patient feels no pain before I start and I then say, “I'm working now, see how easy this is for you!” I tell the patient in a calm voice what I am doing, describing the anatomy of the cataract and what the buzzing sound is accomplishing. The script is automatic, so I am not being distracted, and it is loaded with reassuring words such as “that went perfect!” and “everything is going well.” While I enjoy camaraderie, I do not condone casual conversation among the staff during the surgery. Moreover, if the phaco machine fails, I will always tell the patient that there will be a slight delay because one of the machines or instruments is not testing perfect, so we are going to wait a moment until it is replaced to my satisfaction. I believe that patients can sense when something is not going well, and I am constantly reminding the team to be careful about what they say. If I have visitors or residents in the room, I will often ask whether they want to look through the microscope to see a “beautiful surgical result.” I am not bragging: these carefully chosen words are very reassuring to the patient. Should a Complication Occur As I stated earlier, it is inevitable that if you operate, you will eventually encounter a significant complication. Every surgeon must be prepared to deal with the unexpected and to manage a complication in the operating room. The patient and the family will experience high stress, unless the surgeon also properly manages the dialog during and after surgery. I am a strong proponent of being honest with the patient and the family. Although the surgeon should be as transparent as possible, the goal should not be to alarm but rather to reassure. It is critical to provide ample time to discuss both the complication and the corrective action. Rather than interrupt a busy day, it may be a better strategy to bring the patient and the family back for a more detailed conversation at a later time. Patients can forgive a complication that has occurred if they have been given an honest and sincere explanation with clear reassurance that everything will be done to rectify the situation. Not only is reassurance important but continued follow-up is also essential. Although we do not want to be reminded of a complication, it is this patient who should be seen or called most often. If a patient feels that he or she is being abandoned, the relationship between the physician and the patient will be compromised, which can lead to devastating consequences. Honesty, reassurance, a plan of action, and extra attention are the key ingredients to making the patient feel as comfortable as possible when a complication has occurred. Going Above and Beyond Although some patients are very calm and others are very anxious, all patients appreciate being able to connect with and ask questions of their surgeon. After all, eye surgery is frightening, and it is natural for the patient to feel some fear of the unknown. Immediately postoperatively, I like to reassure the patient and the family that the operation went smoothly. Then, I give the patient my personal cell phone number. This gesture, more than any other, seems to be appreciated by the patient who breathes a sigh of relief, knowing that they can reach their surgeon if something unexpected happens. Although I have received very few calls, I am trying to live by the principle that patients should be treated as if they were members of your own family. The sheer nature of cutting into one of the most valued sense organs can cause significant anxiety for the patient and elevated stress for a surgeon, especially a surgeon who truly cares and understands the gravity of what is being done. Stress is a normal, natural reaction to a high-stakes situation but, if managed poorly, can have detrimental effects in the short and long-term. I have tried to review several of the strategies and practices that should reduce anxiety for both stakeholders: patient and surgeon.1 It should be our constant goal to make the surgical experience a pleasant one for the patient, while allowing the surgeon to feel calm, relaxed, and acutely focused on the important work we are so fortunate to perform.