Death on the Table

[ctsurgeryscrubrn]

We've had a couple younger patients expire on the table in the past couple weeks during high-risk aortic procedures (both were re-do's and we operated for 15 and 16 hrs, respectively, prior to expiration). It's been very difficult for me - scrubbing on the high-risk CVOR team comes with these types of outcomes and I know what I signed up for, but it is still heartbreaking.

They always say that high-risk CT surgery is where you, as a practitioner, need to maintain emotional distance from your patients. However, I've never subscribed to that idea and believe that in order to be the ultimate advocate, you have to build relationships with your patients no matter what they'll be on your table for.

Has anybody worked on a high-risk team where there have been more frequent D.O.T's than other surgical specialties? Any tips for coping and not facing emotional burn-out?

[FurBabyMom, MSN, RN]

Sent you a PM. I'm a neurosurgery nurse, but I understand completely. It's difficult to balance appropriate distance with what you have to do to be a compassionate advocate. I've experienced patients dying on the table and experienced my share of "abort and get the h*ll out of the OR - get this patient to ICU now before they code again" moments. For the ICU nurses who may be reading this, I promise it's not that we want to dump a trainwreck on you all...it's that families can be better informed and perhaps part of the decision making process if we send our patient to ICU.

If your facility has resources for staff - using them is helpful. My facility provides peer-support, the hospital employed chaplains will come talk to staff members if needed, we have a situational debriefing program (where all the staff involved in an incident are invited to participate) and we have an Employee Assistance Program which provides access to professional counseling if warranted.

I think the other thing that is important is remembering to care for yourself. Even without facing OR deaths there are studies that show that staff in ICUs, EDs and ORs have an equivalent risk of developing PTSD or related disorders secondary to doing the work we do. You have to have things that bring fulfillment outside of work. For some people it's family, others its friends, sometimes it's a hobby or craft, some people like to train/go to the gym... It's cliche but look at Bryan Sexton's research and "Three Good Things" - I find tools like that valuable as I am forced to reflect, just a little, on the positive things I do have instead of only what isn't right or what I don't have.

[ctsurgeryscrubrn]

@FurBabyMom - I so much appreciate your advice and your willingness to share your personal experiences. I think it’s important to remember that as far as medicine has come, surgery (at its core) continues to be extremely brutal for both patients and their providers. The growth of ‘minimally-invasive’ and ‘robotic’ techniques (which I think are wonderful when used appropriately) does not mean that often times, the best and safest way to the root of the problem remains a massive open procedure requiring saws, chisels, and large retractors.

It’s not easy to explain to patients or their families. And when things go wrong in hearts (as I would imagine in neuro), they go wrong fast. Everybody on the team gives so much to try to restore life against many factors, time being the most critical.

I never want to grow ‘numb’ to a death-on-the-table, but when you scrub on the high-risk aortic team, I am constantly reminded how we are often faced with uphill battles (the 2AM aortic dissection; the Open TAAA repair in a morbidly obese smoker; the Marfan’s patient who is for a re-do of a re-do of a re-do, etc.). But, they need us and in-turn...we need each other.

[FurBabyMom, MSN, RN]

@ctsurgeryscrubrn - yes. Surgery is brutal for patients and providers/staff. I'm currently in school for my Master's...and while I love my classmates, only one understands OR nursing because she did it at one time. The others' experiences are floor, ICU and ED. While other specialties see "bad things", even routinely...the OR is different. Even without traumas and other bad cases - the environment is so high risk...

SO MANY things could go wrong independently or at the same time/in combination. Unidentified patient comes to the OR, gets succinylcholine and/or sevoflurane - most of the time is perfectly benign, but not knowing anything about them - could precipitate an MH reaction. Our jobs require extensive knowledge of management of potential emergency situations - even comparably rare situations like MH.

In surgery we have so many contingencies - if this, then do that, if that happens then the plan is (this). There are so many details to be mindful of, in all cases. But then you have to understand the rationale behind the policy or practice to recognize if it can be omitted if the situation is truly life threatening. Needing to know nuances of consent - who and when can consent for what patients...needing to know about kiddos in state custody in situations that aren't life threateningly emergent... Needing to know all the rules about counting... Needing to know what meds have derivatives of human blood products for when your patient refuses blood products... Needing to understand not just the meds I open while circulating or pass while scrubbing...but what anesthesia is giving and not just the emergency/code/ACLS drugs. Needing to understand how the equipment you are using works and why with some devices certain things can't be used-so understanding implants (neurostimulators, AICDs, etc) AND devices used in the OR.

In general, I try to remember what a privilege it is to care for people at their most vulnerable times. All OR patients are vulnerable, emergencies, traumas, etc., are more so. I think it's an honor for patients and their families to trust me to help keep them or their loved one as safe as I can. I think it's also an honor to be trusted to handle the situations that sometimes occur in the OR (being requested for difficult cases, being requested for coworkers/employees family, friends, etc.'s procedure). The teamwork is amazing, my anesthesia and surgery coworkers are overall amazing, my fellow staff members are overall awesome too...

Not to mention - not that many people, comparatively get to see, do and/or touch the things we get to do. Sure, a lot of other people who work in neuro ORs have probably seen what a brain stem looks like...but that population is so small compared to the population of the country or world. Similarly, not that many people get to see a beating heart before going on bypass or after coming off bypass. Sometimes, I just choose to be in awe of the things I get to do and see and the trust placed in me by so many.

Luckily, in our facility, our providers (surgery and/or anesthesia) disclose OR deaths to family members. Communicating with family members can be rough sometimes though. I had a bunch of family members get angry with me when I'd call and give them vague updates...so I eventually started telling them before we went back, when I interviewed the patient/family, that while I will call and provide updates, they are vague, and that if I take longer than expected to get an update to them it doesn't mean anything bad happened, that no news is good news, and they will get a complete update at the end of the case when their attending surgeon comes out to talk to them.