For any specialty, the operating room (OR) is a high-stakes environment where precision and efficiency are paramount. Despite meticulous preparation and planning, things can sometimes go awry. Whether it's an unexpected complication, equipment malfunction or human error, the ability to manage these challenges effectively is crucial for patient safety and recovery. The additional consideration in ophthalmology is that most patients are still awake with mild sedation, which adds another challenge for the surgeon during a stressful situation.

This article provides a structured approach on how to handle issues that may arise in the OR efficiently to ensure the best patient outcomes.

Mitigating the Situation Preoperatively

Informed consent

Take the time in the preoperative evaluation to review all the risks and complications that can occur during surgery. While the informed consent process can be time-consuming, particularly in a busy clinic, reviewing possible risks preoperatively can mitigate patient dissatisfaction postoperatively if a complication does occur.

Have your surgical scheduling team set in place so that this can happen efficiently and effectively. Once the decision is made to proceed with surgery; there are several ways to educate the patient. A surgical scheduler can review the procedure day protocol, find a date and review the consents in order to allow for patients to formulate questions prior to their surgery. There are several informational and consent videos available from the AAO and other resources that review typical surgical procedures and risks which can be utilized during the patient visit as well.

Identifying and Addressing Issues in the OR

Recognizing early signs 

The first step in addressing any issue is to recognize it as soon as possible. Early recognition can prevent further complications. For example, in cataract surgery pay close attention to the patient's anterior chamber fluidics and ask the following questions: how are the pieces following during phacoemulsification? Are there any unanticipated challenges in how the instrumentation is functioning? Being actively involved in every case is paramount.

Pause and assess

Once an issue is identified, pause, perform a quick assessment and stabilize the eye. In the case of a posterior capsule tear, this may mean lowering the bottle height quickly and injecting viscoelastic to inflate the eye. To make this less challenging during a complication, I always encourage younger surgeons to use their non-dominant hand for maneuvers during routine surgery to prepare them for more use of their non-dominant hand during a high-stakes situation. Then, come out of the eye and take a breath. My mentors used to always remind me to “relax” — drop your shoulders and take a deep breath. It is important to take a breath. If a tough case occurs in the middle of your OR schedule, take a minute to pause and recenter so that you can continue on with the rest of your schedule. 

Formulate a plan

Perform a quick assessment to determine the nature and severity of the issue. Talk to your team and find out what the patient’s vitals are — this is critical for cases of intraoperative aqueous misdirection for example to rule out a suprachoroidal hemorrhage. This rapid assessment helps in making informed decisions on how to proceed.

Keep calm and carry on

Remember, our patients are generally awake, so how we communicate with our team impacts the teams’ and patients’ experience during the situation. Be very systematic about what you need. As I am earlier in my career, I have a notebook that I carry with me to every OR. I have complications listed out and what instruments I would need and steps listed out. This helps me to remain calm and to mitigate any further complications in a high-stress situation.

Implement solutions 

Address the issue based on your assessment. This might involve adjusting surgical techniques, replacing faulty equipment or administering medication to stabilize the patient. Ensure that any intervention aligns with established protocols and involves input from relevant specialists if needed.

Call for help

This is not the time to have an ego. If you are in a situation and don’t know how to proceed, if you are lucky to have mentors nearby in the building or even available by phone, take a minute to call. Formulate a plan with your team and remember that the goal is the best patient outcome. 

Interactions With Staff and Patient

Maintaining clear communication

Effective communication among OR staff is essential during a crisis. Use clear, concise language and avoid jargon that might lead to misunderstandings. If anyone needs clarification, encourage that staff feels comfortable to ask.

Managing team dynamics 

Stressful situations can affect team dynamics. Encourage a collaborative atmosphere where every team member feels comfortable voicing concerns and suggestions. Provide support and guidance to staff to help them focus on their roles and responsibilities.

Patient safety and reassurance

While the patient is on the table, focus on their safety and well-being. Continuously monitor their condition and make necessary adjustments to ensure stability. If the situation permits, calmly explain any changes in the procedure to the patient, emphasizing the commitment to their safety and care.

Communicating With the Patient Postoperatively

Honest and compassionate disclosure

Once the patient is in the recovery area, communicate openly about what happened during the surgery. Be honest about any complications or issues that occurred, but deliver the information with empathy and confidence. Spend the time that is needed with the patient and their family to explain what happened, how these issues were managed and the impact they might have on the patient’s recovery. 

Provide clear information

Offer a clear explanation of any changes to the planned post-operative care or recovery process due to the complications. If another surgery is needed or another surgeon is required (eg, a vitreoretinal surgeon), make the call prior to talking to patient and family so they are aware you have a plan for the next steps. Provide information about follow-up appointments and any additional support the patient may need.

Offer support and answer questions

Allow time for the patient and their family to ask questions and express their concerns; do not rush. Provide reassurance and support to help them navigate any anxiety or uncertainty about the recovery process. Ensure they understand the revised care plan and know how to reach out for additional help if needed.

Also, remind the patient and family that you will be with them every step of the way in the post-surgical recovery. Be diligent about follow-up and providing the support the patient needs. Alert your staff so they are aware of the situation during follow-up visits as well. This team approach can greatly impact patient experiences — if the patient feels taken care of, the outcomes are always much better.

Reflecting on Cases and Continuing to Learn

Record every case

If your microscopes have recording capability, record every case. Watch your cases that go well and especially those that do not. Many times, I catch what was the contributing factor to a complication when watching the video post-surgery. Sometimes in a high stress situation it’s difficult to pinpoint when or why a complication occurred as one is trying to stabilize the situation. Playing back my cases allows me to alter my techniques to prevent future issues. 

Keep learning and watching videos

In this day we are lucky to have so many resources available to use. While watching videos of new techniques, also incorporate watching videos of complications and how to recover from them. Life-long learning is a must. 

Talk with your colleagues

We truly are in the best specialty and work with the most supportive people. Every person I have asked for help to review a case has been quick to offer pearls. Take advantage of the wonderful community we have in ophthalmology. 

Conclusion

Handling issues in the OR requires a combination of vigilance, quick thinking and effective communication. By promptly identifying and addressing problems, maintaining clear communication with the surgical team, and providing compassionate and transparent information to the patient postoperatively, surgeons can manage challenging situations effectively and uphold the highest standards of patient care. Remember, the goal is not only to resolve the immediate issue, but also to ensure a positive outcome and recovery experience for the patient. OM 

Sabrina Mukhtar, MD, is an assistant professor of ophthalmology with a specific expertise in cornea and ocular surface disease. Apart from a scholarly and clinical focus on dry eye, she routinely performs cataract, corneal and refractive surgery. Contact her at mukhtars@upmc.edu. Financial disclosure: Dr. Mukhtar is a consultant for STAAR Surgical.