Planning to avoid trouble in the operating room: experts' formulation of the preoperative plan.

OBJECTIVE: The purpose of this study was to capture the preoperative plans of expert hepato-pancreato-biliary (HPB) surgeons with the goal of finding consistent aspects of the preoperative planning process. DESIGN: HPB surgeons were asked to think aloud when reviewing 4 preoperative computed tomography scans of patients with distal pancreatic tumors. The imaging features they identified and the planned actions they proposed were tabulated. Surgeons viewed the tabulated list of imaging features for each case and rated the relevance of each feature for their subsequent preoperative plan. Average rater intraclass correlation coefficients were calculated for each type of data collected (imaging features detected, planned actions reported, and relevance of each feature) to establish whether the surgeons were consistent with one another in their responses. Average rater intraclass correlation coefficient values greater than 0.7 were considered indicative of consistency. SETTING: Division of General Surgery, University of Toronto. PARTICIPANTS: HPB surgeons affiliated with the University of Toronto. RESULTS: A total of 11 HPB surgeons thought aloud when reviewing 4 computed tomography scans. Surgeons were consistent in the imaging features they detected but inconsistent in the planned actions they reported. Of the HPB surgeons, 8 completed the assessment of feature relevance. For 3 of the 4 cases, the surgeons were consistent in rating the relevance of specific imaging features on their preoperative plans. CONCLUSION: These results suggest that HPB surgeons are consistent in some aspects of the preoperative planning process but not others. The findings further our understanding of the preoperative planning process and will guide future research on the best ways to incorporate the teaching and evaluation of preoperative planning into surgical training.

Waking up the next morning: surgeons' emotional reactions to adverse events.

CONTEXT: The adverse patient event is an inherent component of surgical practice, but many surgeons are unprepared for the profound emotional responses these events can evoke. This study explored surgeons' reactions to adverse events and their impact on subsequent judgement and decision making. METHODS: Using a constructivist grounded theory approach, we conducted 20 semi-structured, 60-minute interviews with surgeons across subspecialties, experience levels, and sexes to explore surgeons' recollections of reactions to adverse events. Further interviews were conducted with six general surgeons to explore more immediate reactions after 28 adverse events. Data coding was both inductive, developing a new framework based on emergent themes, and deductive, using an existing framework for care providers' reactions to adverse events. RESULTS: Surgeons expressed feeling unique and alone in the depths of their reactions to adverse events and consistently described four phases of response, each containing cognitive and emotive components, following such events. The initial phase (the kick) involved feelings of failure ('Am I good enough?') experienced with a significant physiological response. This was shortly followed by a second phase (the fall), during which the surgeon experienced a sense of chaos and assessed the extent of his or her contribution to the event ('Was it my fault?'). During the third phase (the recovery), the surgeon reflected on the adverse event ('What can I learn?') and experienced a sense of 'moving on'. In the fourth phase (the long-term impact), the surgeon experienced the prolonged and cumulative effects of these reactions on his or her own personal and professional identities. Surgeons also described an effect on their clinical judgement, both for the case in question (minimisation) and future cases (overcompensation). CONCLUSIONS: Surgeons progress through a series of four phases following adverse events that are potentially caused by or directly linked to surgeon error. The framework provided by this study has implications for teaching, surgeon wellness and surgeon error.

Teaching the slowing-down moments of operative judgment.

Surgical judgment has been an elusive construct to define, let alone teach or assess. A recent study has characterized a phenomenon called slowing down when you should, and suggests it is a hallmark for operative judgment. This research highlights areas where surgical judgment can be identified and therefore taught more explicitly in the operating room. Through the identification of these slowing-down moments and an understanding of how control is negotiated between surgeon and trainee during these moments, this article uses several theoretic frameworks to understand how teaching judgment in the operating room can be optimized.

Re-examining the role of hydrogen peroxide in bacteriostatic and bactericidal activities of honey.

The aim of this study was to critically analyze the effects of hydrogen peroxide on growth and survival of bacterial cells in order to prove or disprove its purported role as a main component responsible for the antibacterial activity of honey. Using the sensitive peroxide/peroxidase assay, broth microdilution assay and DNA degradation assays, the quantitative relationships between the content of H(2)O(2) and honey's antibacterial activity was established(.) The results showed that: (A) the average H(2)O(2) content in honey was over 900-fold lower than that observed in disinfectants that kills bacteria on contact. (B) A supplementation of bacterial cultures with H(2)O(2) inhibited E. coli and B. subtilis growth in a concentration-dependent manner, with minimal inhibitory concentrations (MIC(90)) values of 1.25 mM/10(7) cfu/ml and 2.5 mM/10(7) cfu/ml for E. coli and B. subtilis, respectively. In contrast, the MIC(90) of honey against E. coli correlated with honey H(2)O(2) content of 2.5 mM, and growth inhibition of B. subtilis by honey did not correlate with honey H(2)O(2) levels at all. (C) A supplementation of bacterial cultures with H(2)O(2) caused a concentration-dependent degradation of bacterial DNA, with the minimum DNA degrading concentration occurring at 2.5 mM H(2)O(2). DNA degradation by honey occurred at lower than ≤2.5 mM concentration of honey H(2)O(2) suggested an enhancing effect of other honey components. (D) Honeys with low H(2)O(2) content were unable to cleave DNA but the addition of H(2)O(2) restored this activity. The DNase-like activity was heat-resistant but catalase-sensitive indicating that H(2)O(2) participated in the oxidative DNA damage. We concluded that the honey H(2)O(2) was involved in oxidative damage causing bacterial growth inhibition and DNA degradation, but these effects were modulated by other honey components.