The OR Team
Case: 40 year old G0 with a history of infertility, regular menstrual intervals every 29 x 3-4 days, a normal hormone evaluation with an encouraging ovarian reserve (based on basal FSH and estradiol concentrations), a normal semen analysis, a normal postcoital test, and a normal hysterosalpingogram (normal uterine cavity and bilateral tubal patency) desires a pelvic evaluation (laparoscopy and hysteroscopy) to identify and treat possible pelvic pathology that is reducing her reproductive potential.
Question: Are all operating rooms (ORs) equally equipped to perform this sort of fertility surgery?
Operating rooms differ widely in terms of the tools that they have available for operative laparoscopy and hysteroscopy.
Over time, each fertility surgeon will develop a routine that works well for him (or her). This routine will include an orderly sequence of events (from transporting the patient into the operating room to delivery of the patient into the recovery room), decisions on specific surgical tools to be used to accomplish the desired surgical goals, coordination of the efforts of various members of the OR team, and troubleshooting.
Making available the surgical tools that the fertility surgeon is comfortable with is an initial variable that the surgeon must consider when choosing an OR for his cases. The highly specialized tools that a fertility surgeon may prefer to use are often extremely expensive and may only be available in a small number of hospitals. If a CO2 laser capable of superpulse or ultrapulse power settings is not available in a specific OR then a fertility surgeon may not consider using that OR for elective fertility cases.
Another variable that is important to the fertility surgeon is the training and experience of the operating room personnel (nurses and anesthesiologists) specifically with respect to the sort of fertility cases that are being performed. Advanced operative laparoscopy with a CO2 laser and operative hysteroscopy with a resectoscope are highly specialized procedures that may be unfamiliar to the OR personnel. In some operating rooms a particular set of nurses with experience in fertility surgery is available. Having experienced personnel in the OR is beneficial for all parties involved with the surgery.
Case: 32 year old G0 with unexplained infertility (after the completion of a basic noninvasive diagnostic evaluation) is planning a pelvic evaluation (laparoscopy and hysteroscopy) with her fertility doctor. The patient expresses a strong desire to have her surgery at one particular hospital (since it is closest to her home and her primary physician has given the hospital “glowing” reviews) whereas her fertility surgeon expresses a desire to perform the surgery at a different hospital (since he is most familiar with that specific OR and their nursing staff knows his preferences and routine thoroughly).
Question: Is the experience of the operating room personnel (nursing staff and anesthesiologist) with respect to a specific fertility surgeon’s routine for advanced operative laparoscopy and hysteroscopy important?
The experience of the OR team with a specific surgeon’s routine can be very important.
Fertility surgeons often use highly complex equipment that requires a lot of training to operate. Nurses in a particular OR may be far better trained (or experienced) with this equipment than in another OR which does not perform this type of surgery routinely.
An experienced OR team may be able to coordinate the complex intraoperative needs of the fertility surgeon easily whereas an inexperienced team may have difficulty with these same tasks.
Whenever a surgeon expresses a strong desire to use one particular operating room over another operating room the patient should understand that this is an important recommendation.
Case: 43 year old G0 desires to become pregnant, has a basic noninvasive infertility evaluation which is normal and indeed suggests a good ovarian reserve, and decides to have a pelvic evaluation to treat any pelvic factor that might be identified. While she is waiting in the holding area (to be transported into the operating room) a nurse reviews her chart for completeness and states to the patient that she (the nurse) does not believe that women over 35 years of age are meant to get pregnant.
Question: Is it appropriate for the OR nurse who is reviewing the chart (to assure that it is complete) to express her own personal perspective concerning who should and who should not become pregnant?
Answer: The personnel in the OR must always maintain a certain level of professionalism.
Nurses reviewing the chart for completeness generally ask patients about such things as allergies to medication, height and weight, chronic medical disorders, their understanding of which procedures they consented to have performed, and remaining unanswered concerns or questions.
The medical chart has a great deal of personal information that the patient may not desire to make public. Great care should be exercised to protect the privacy of a patient when discussing their medical issues. There should be a guarantee of confidentiality.
Medical personnel should also be nonjudgmental. Patients come from all walks of life and often have diverse cultural and social backgrounds. It is not the role of the medical care provider to instruct the patient on the proper way to live.
Sometimes a nurse or doctor will try to “make conversation” or “break the ice” by expressing an opinion on an issue of mutual interest. Generally it is best to keep these conversations centered on issues that generally have no emotional charge (such as the weather).
The expression of a strong negative opinion by a health care provider that opposes a patient’s stated opinion is rarely appropriate. In this case, stating that it is immoral or inappropriate for women to be interested in fertility when they are over a certain age is just not appropriate. Many women over 40 years of age try to conceive and many do so successfully.
If a hospital has a certain policy concerning conception, based on either religious or other beliefs, then the fertility surgeon should decide whether to use the hospital as an appropriate facility to perform procedures. Additionally, if members of the OR team express their own strong “ethical” beliefs to patients (that may make the patient uncomfortable) then this should also be considered.
Case: 40 year old G0 is undergoing a pelvic evaluation (laparoscopy and hysteroscopy) to identify and treat a pelvic factor that is reducing her reproductive potential (fertility). The fertility surgeon is preparing the instruments that have been set out on the sterile field to be used for the case and finds that one of the sterile instruments to be used is damaged and not working properly.
Question: How should the surgeon and operating room personnel respond to this discovery?
Answer: Every operating room (OR) must have a clear protocol to assure that every instrument that is provided for a case is in good working condition and is properly cleaned.
When implementation of this protocol breaks down and this breakdown is identified there needs to be a review of the working system. In this case, the person responsible for checking the instruments before providing them to the surgeon should be alerted that a damaged instrument escaped their detection.
The surgeon needs to assure himself (or herself) that the equipment to be used is appropriately cleansed and in good working condition before proceeding with the surgery. Many experienced surgeons check their instruments before proceeding with surgery.
In an OR that has personnel familiar with the specialized instruments that are used for fertility surgery the risk of handing the surgeon a non-working instrument is minimized.