The Patient-Provider Barrier in High-Risk Surgery

Setting the Stage - The Riskiest Cases

As a perioperative nurse who serves in a First Assist role on our high-risk cardiovascular surgery team at a top-tier institution, we often get patients who have been refused surgical intervention at other facilities due to lack of experience with the procedure, operative risk (co-morbidities), or overall complexity. These cases usually involve patients with underlying connective tissue disorders (Marfan Syndrome, Ehlers-Danlos, etc.) or fragile patients who require re-do open cardiovascular procedures. Many of these cases involve the aorta (ascending, descending, thoracoabdominal, arch, and root) and necessitate a highly-skilled team capable of navigating patients through marathon operative times, often with the use of Deep Hypothermic Circulatory Arrest (DHCA) to preserve neurological function during cross-clamp. Patients are of all ages, from 18 to 90, and look to us as their last hope - they are fighters who seek to defy operative mortality statistics to extend and/or improve their quality of life. While we have some of the top surgeons in high-risk cardiovascular surgery, we deal with operative mortality more than most surgical teams.

The Surgical Process - More than the Operating Room

High-risk cardiovascular surgery has a more lengthy pre-operative process that patients and their families go through, and it is taxing. This includes several consultations with the surgical team with one full consultation dedicated to our 'High-Risk Informed Consent' process, which is far more extensive than what one goes through for a procedure that does not carry certain criteria, including significantly high operative mortality. Our surgeons, while technically gifted, are 'old school' and believe in a very standardized, "this is what you're facing" icy message. They often explain things in surgical jargon, respond to clarifying questions in surgical jargon, and look to our Operative Advanced Practice Providers ("Surgical APP"), such as me, to help speak in terms that these desperate families can understand. As a Surgical APP, I do my absolute best to be clear, concise, and cohesive in my messaging. However, we are told that maintaining a barrier is key to our surgical objectivity and operative performance and are not encouraged to give out our email addresses or office numbers, so all inquiries will be centralized through the attendings. This used to be what I thought was 'standard protocol,' but I now realize that regardless of credentials, I am not fulfilling my ultimate mandate as a perioperative nurse, which includes:

• Patient Advocacy: Bringing comfort to the patient and family by letting them know I am in the room to ensure their safety and guide them through the operative process from pre-op to intra-op to post-op.
• Perception and Effectuation of Checks and Balances: Perioperative nurses have a responsibility to ensure safety protocols both for the patient and the team are met in form and substance. This includes the Time-Out process, operative sterility, appropriate equipment, counts, etc. Even if we may not be individually leading each of these, we must show the patient and family that it is a huge part of our job and oversight.

Recently, a young pre-op patient was very intimidated to even speak to me as I stayed back after our final prep rounding. It was at that moment that I felt like everything a perioperative nurse should be, I was not. I had not created an environment of trust and advocacy; I was compounding one of technician. I sat down on the bed and, for the first time in many years, held his hand and talked to him as a 'caregiver' can.  I listened to the fears; I reinforced my admiration of his courage; I emphasized that what was likely the most consequential day of his life would not be just another day in mine.

The attendings were not pleased with this type of connection shared, but I reminded myself that I did not do it for them; I did it for him - that should be the basis of all of our actions - for the benefit of our patients.

Objectivity and Compassion are Mutually Exclusive in the Most Risky Cases

These courageous patients are subject to massive incisions to create large operative fields and exposure, but they are not just 'a field' or 'a case.' These are people with friends, families, hopes, fears, dreams, and dire circumstances. I now know that suturing, retracting, dissecting, clamping, and all the other maneuvers are not the same as actual caretaking. Caretaking is a continuum that extends far before and far beyond those Operating Room doors. Being an objective Surgical First-Assist is important, but it is not 'the objective' of what I stand for. Our new generation of surgeons is embracing a more holistic view towards patient care that goes beyond scalpels and retractors, and I am right there standing with them at that table - one where compassion and empathy coexist with coagulopathy and coronaries.

FACT: I am not a better perioperative nurse because of this realization; I am back to being a perioperative nurse.