Perspective: Attending Peds Cardiothoracic Surgeon

How do you prepare for major complex cases?

Almost all of my cases are major and complex because peds heart anatomy is so much different than adults - it has the biggest range in difference between adults and children than any one organ and that’s why you won’t see any cross-over between surgeons and even top first-assists between adult and peds CT surgery. I like to draw procedures out visually before the case, which allows me to walk through the steps of the surgery in great detail and discuss the potential pitfalls that we could run into due to unknown anatomical issues. I run through all of the possible issues that could be ran into - you can’t just have a ‘plan B’ - you need a ‘plan B’, ‘plan C’, etc. - it could be endless. I owe it to my patients and their families to be prepared for anything and we definitely discuss as my way of letting them know that I am the right surgeon for their child. At this stage of my career, I rely more on peer-reviewed journals and other medical publications on techniques than I do on textbooks. The complexity of the cases I see these days is often far beyond the reach of most textbooks. When I arrive in the operating room, I take time to speak to the different team members about the case to make sure we are on the same page and I like to sense whether they understand all the issues in-play. I speak to the perfusionist, scrub nurse/tech, and circulating nurse. I definitely like speaking to the anesthesiologist the most as the interplay that we need to have is immeasurable. For the team, I have no issue taking the time to draw the procedure out for them as I have visualized it - it’s a great way for me to reaffirm and for them to see what I am seeing.

What are the characteristics of an A-Team First Assist in CT Surgery?

I think an A-TEAM First Assist is one who goes beyond knowing their table, instruments. One who knows the surgeries, including  the steps of the surgeries, the variations within a case, to be two steps ahead. To keep their calm in a crisis. Rarely turn their attention away from the surgical field. To know what instruments are needed by watching/knowing the case such that the surgeon doesn't have to  ask for each item. One that takes pride in their work, cares about the patients and the outcomes. I've had the pleasure of working with some A-TEAM First Assists. One even would go to the ICU and follow up on "their patients". I loved that. I expect my First Assists to manage down during the case, which includes the scrub nurse and scrub tech, circulators, and sometimes even perfusion. It’s critical that my First Assists be able to stay focused on the field, but also make sure that everything is flowing that I don’t see as I have my head buried in ‘the zone’.

I often have a resident / fellow in the First Assist role, but for our highest risk cases, I actually prefer one of our talented PA’s (Denise). I have worked with her a lot - throughout my fellowship and into clinical practice. She is young, but knows her stuff and how to handle herself during the most high-risk cases. She is a no-nonsense member of the team who knows how to help me manage the temperament of the room. She is so thorough in everything she does and is not afraid to challenge me or others on the team:

• Surgical prep and draping: Denise is always involved in the prep, positioning and draping of our patients prior to surgery - this is so critical especially in children who often have significant anatomical considerations that need to be acknowledged and factored into the operative steps, which Denise is intimately familiar with.

• Stylistic Conformity: Denise knows exactly what instrumentation I prefer, when I like it, and how I like it. All-too-often, a First Assistant will hand you the right instrument at the right time, but in a manner where it’s not easily applied in the field, which actually negates a lot of the anticipation. For any surgeon working in delicate, high-risk cases, each of us knows the value of how instrumentation flows on the table and Denise understands this as well as anyone.

• Pre-Op Briefing: For our highest risk cases, I always try to have a pre-op briefing with Denise (as FA), other attendings, our anesthesia team, and perfusion. Denise often runs these briefings and knows the key items to be asking everyone to ensure all are on the same page and understand the expectations for the next day’s case - I really appreciate her diligence in the preparation process.

• Acute Resuscitation: Denise formally worked as our Lead APP in the CVICU so she is intimately familiar with the continuum-of-care. This comes into play in several ways. She is very familiar with crisis situations, including unexpected intraoperative cardiogenic shock, or even full arrest. She is also extremely thorough in our ‘hand-off’ process between surgery and the CVICU at the end of the procedure. This is such an under-valued process and Denise is the best and most comprehensive at articulating the issues encountered during surgery, key items to look out for, and any complications that she / we may foresee during the early stages of post-operative recovery.

• ‘Whatever it takes’: Denise does whatever it takes to facilitate outcomes in the Operating Room. She is never standing around looking for things to do. Sometimes, I’ll scrub in and the scrub nurse is busy with prep and it’s not uncommon for Denise to actually gown-and-glove me - it’s just a small example of a larger mentality, which is about not letting ‘job descriptions’ limit one’s ability to make the process smoother and more efficient for all.

• Compassionate Heart with Technical Excellence: Unfortunately, we do have adverse outcomes on the table and if Denise is the FA, I always ask her to accompany me to talk to the family. She has very high emotional IQ and complements me in these awful discussions. She knows how to talk to families in a way that is authentic, genuine and does not go down into the technical jargon of surgery that many families do not understand nor want at that time. I love her commitment to both the surgical (technical) side of our partnership together, but also the non-technical relationship with our patients’ families.

What type of Personal Protective Equipment (PPE) do you wear for your cases? Does it ever vary based on the type of case?  Any tips for long, grueling procedures?

I wear the same personal protective equipment for every case. Standard sterile gear - I like the surgeon’s hat, gloves, gown and loupes that provide eye protection. I don't vary per type of case. I like cloth gowns as they breathe better and we’re usually in marathon cases. I do not like to ‘heavy glove’ due to the tiny sutures and very small fields that we are in. I do think it is important to try to have as an ergonomic posture as possible. I recommend  standing on a padded mat if possible and wearing support socks for long cases - your back will thank you. I eat a protein packed breakfast that morning (usually eggs) and hydrate just enough to keep me fresh, but not too much to make me feel bloated or heavy during the case. When you are the surgeon in a grueling case, you won't notice your hunger, exhaustion, thirst, or your neck, back and feet pains, until you are done. I always like to give your assistants breaks when possible, but sometimes the cases are so tenuous that I like the consistency of everybody being present.

What type of etiquette do you like followed for your operating room?

I think it is important to communicate clearly and concisely. I set high expectations for the performance of the entire surgical team and I make sure they know that mediocrity is not going to fly on my table. I try to be respectful and do unto others as you would have them do unto you. Treat all with respect to help everyone succeed because that means a good outcome for the patient. I  would like to think no one wakes up and intends to do a bad job or cause harm, so treat them as such. I require everyone use closed-loop communication (no exceptions) - this involves repeating a command back from the person who made it to ensure that there is uniformity in the understanding of what needs to happen - this prevents errors. I do expect myself and all other physicians in the room to be addressed as “doctor”. I don’t believe in very rigid hierarchies, but I do believe that part of respect is addressing people with the titles that they have studied and trained for decades to achieve.

What is one of your biggest pet-peeves from your first assists?

I am definitely known to have high expectations of my first assists and make that clear before we ever get into a major case together. I expect the case to be on-time, but most importantly I demand my first assists be prepared. Preparation is shown to have direct correlation on surgical performance. This means that they know each operative step, the derivations of those steps, have a firm understanding of the patients’ anatomy and anomalies (i.e., adhesions from a previous sternotomy), and what complications we are most likely to encounter at which stages. I need my first assists to be able to keep up with me, which comes with thorough preparation. I need my first assist and I to work as many say…like a symphony - we complement each other’s maneuvers rather than work to correct them. I can tell within the first 10 minutes after incision whether my first assist has done the necessary prep work to be adequate for the case. I hate raising my head from the field so I expect the first assist to coordinate the team in a manner where I can be squarely focused with my headlight in the chest. My other pet-peeve would be how instruments are handed to me - I expect them to be handed to me in the position that makes my use of it natural. If I keep getting handed instruments in a way that I can’t immediately maneuver to use them, I will have that person replaced.

Do you have any unique policies in your operating room?

I take the role of the first assist very seriously and believe it is a privilege for all of us to be in that field. If the first assist is not prepared, I will give them one warning - and am very clear about that. If they continue to underperform after that one warning, I will ask that they be dismissed from the case and will have my second assist step in. That may seem harsh but our patients deserve nothing but excellence, and that’s how I want my ‘standard of practice’ to be seen. I make sure and touch-base with the person after the case so they know exactly why they were dismissed and so that they know what it takes for them to be at my table - you have to provide coaching and you can’t it personal nor punitive.

What do you think is best practice for dealing with underperforming team members during high acuity cases?

First off, establish relationships with your team, long before the toughest cases. Understand their strengths and what they aren't as  comfortable with. Get to know the individuals on the team and what motivates them. This takes time. I think making your team more  tense by snapping at them does not help them do better in that case. Disciplining in the moment is not helpful, I find, but speaking with  an individual privately is professional and more productive. If you have concerns about the conduct of the operation, discussing it may be  appropriate in the debriefing at the end of the case. With all this said, the dynamics on every team is different and what works well for  one, may not work for another. Be respectful, even when firm, never make it personal. Communicating well, informing the team before  you start and setting clear expectations will hopefully decrease the number of times people aren't performing at their best.

Hopefully rare, but how do you handle intraoperative codes from both a mental and spiritual standpoint? How do you keep  control of your team in such tense situations?

I think it is the surgeon's obligation to remain calm, focused, be a good leader, direct the team in a clear manner and do what you have  been trained to do - run the code, save the life if at all possible. You should be able to maintain control of the team, especially during a  crisis. If you are not confident, and know what you are doing, you won't be able to be an effective leader. Make sure you are prepared for  that responsibility. I am grateful to God for being there for me and helping me get through hard days.

Due to the high-acuity of your cases, do you feel a need to maintain an emotional barrier with the patient? Do you think 'cold'  CT surgeons can be more effective by disconnecting any type of emotion from the task at-hand?

I do not believe in maintaining an emotional barrier with my patients and their families. But for every individual surgeon, what works for  them will be different. I personally find the relationships with my patients and families is one of the most rewarding part of my career. I  am able to remain objective and make appropriate hard decisions when needed, yet stay connected to the family. I don't think one  means you can't do the other. My advice to anyone who feels they may not be able to be objective in any given situation, ask your  partners what they think. Get an objective opinion.