Arquivos de Categoria: Ética Médica

Role of The SURGEON

#TheSurgeon

Attributes of a Good Surgeon


Realising the benefits that good leadership and teamwork can deliver requires commitment from all those involved in patient care. From the surgeon’s viewpoint there are numerous desirable attributes which are developed through medical school education, foundation training, core training and into professional practice. These are outlined below:


1. Clinical Care


An obvious consideration of what makes a “good surgeon” is the care provided to patients throughout the patient journey. This includes technical ability in the operating theatre and non-technical skills.


2. Maintenance and Improvement

Remaining up-to-date with innovations in surgical practice and patient are is an important attribute of a good surgeon. In doing so, one is able to inform patients and explain the reasons for and against procedures, allowing them to make an informed decision. Willingness to learn from  others and improve from others by reviewing personal practice forms part of Continuing Professional Development; this is a requirement in a portfolio to meet revalidation and recertification criteria.

3. Teaching, Training and Supervision

Educating others forms part of professional development and surgeons frequently oversee projects for medical students or trainees. This requires knowledge of the objectives of the tasks undertaken, knowledge of what technical and non-technical skills should be improved and knowledge of how to encourage the development of these skills. The mentormentee relationship should work both ways, such that the mentee is able to approach their supervisor for assistance and is accepting of any  constructive criticism delivered.

4. Relationships with Patients

Relationships with patients are fundamentally based on trust; the patient trusts that the surgeon will do all in their power to help them and their surgical journey. Obtaining informed consent prior to clinical care is based on trust and allows patient autonomy to be upheld. Developing relationships with patients begins from the first consultation and is continued after the day of an operation being undertaken. Acknowledging the needs of the individual and employing effective communication helps in developing an open relationship. In this way patients disclose their medical history and admit underlying fears, allowing better patient care to be delivered.

5. Relationships with Colleagues

Partnership with all members of the multidisciplinary clinical team, management, technicians and support staff fosters healthy working relationships. Consequently, patient care is enhanced through communication, enhanced productivity and an improved team dynamic. Understanding how a colleague works and taking action to facilitate a positive working environment is beneficial to all. Emotional intelligence forms an important component of working relationships, through the ability “to understand and recognize emotional states and to use that understanding to manage one’s self and other individuals or teams”.


6. Health

Maintenance of good personal health and knowing when you must stop working is important in the protection of patient safety. The relevant senior staff must be informed of communicable disease or blood-borne disease transmission. In addition, being vigilant of the health of colleagues forms part of protecting patient safety, for example, failure to report suspicion that the consultant consistently operates after several glasses of wine or that the CT2 has been seen smoking drugs can facilitate the propagation of errors in the workplace. Finally, surgeons are renowned for working at all hours, however acknowledgement that we all need rest is  crucial in good patient care.

Source: Click Here

Not Only SURGEONS

Not Only Surgeons

SURGERY, A NOBLE PROFESSION

Surgery is, indeed, one of the noblest of professions. Here is how Dictionary defines the word noble: 1) possessing outstanding qualities such as eminence, dignity; 2) having power of transmitting by inheritance; 3) indicating superiority or commanding excellence of mind, character, or high ideals or morals. These three attributes befit the profession of surgery. Over centuries, the surgical profession has set the standards of ethical and humane practice. Surgeons have made magnificent contributions in education, clinical care, and science. Their landmark accomplishments in surgical science and innovations in operative technique have revolutionized surgical care, saved countless lives, and significantly improved longevity and the quality of human life. Generations of surgeons have developed their craft and passed it on to succeeding generations, as they have to me and to each one of you, to take into the future.

Beyond its scientific and technical contributions, surgery is uniquely fulfilling as a profession. It has disciplined itself over the centuries and dedicated its practice to the best welfare of all human beings. In return, it has been accorded the respect of society, of other professions, and of policy makers. Its conservative stance has served it well and has been the reason for its constancy and consistency. At the beginning of the 21st century, however, profound changes are taking place at all levels and at a dizzying pace, providing both challenges and opportunities to the surgical profession. These changes are occurring on a global level, on the national level, in science and technology, in healthcare, and in surgical education and practice.

To retain its leadership position in innovation and its attractiveness as a career choice for students, surgery must evolve with the times. It is my belief that surgery needs to introduce changes to create new priorities in clinical practice, education, and research; to increase the morale and prestige of surgeons; and to preserve general surgery as a profession. I am reminded of a Chinese aphorism that says, “You cannot prevent the birds of unhappiness from flying over your head, but you can prevent them from building a nest in your hair.”

ADVANCES IN SCIENCE

The coalescence of major advances in science and technology made the end of the 20th century unique in human history. Notable among the achievements are the development of microchips and miniaturization, which fueled the explosion in information technology. The structure of the human genome is nearly completely elucidated, ushering in the genomic era in which genetic information will be used to predict, on an individual basis, susceptibility to disease and responsiveness to drug therapy. The field of nanotechnology allows scientists to work at a resolution of less than one nanometer, the size of the atom. By comparison, the DNA molecule is 2.5 nanometers.

In the last 50 years, biomedical research became increasingly reductionist, turning physiologists and anatomists into molecular biologists. As a result, two basic science fields—integrative physiology and gross anatomy—now have a lower standing in medical education and surgical science than they once did. Surgery and surgical departments can and possibly should claim these fields, but the window of opportunity is narrow. Research is now moving back from discipline-based reductionist science to multidisciplinary science of complexity, in which biomedical scientists work side by side with engineers, mathematicians, and bioinformatists. The ability of high-speed computers to quickly process tens of millions of pieces of data now allows for data-driven rather than hypothesis-based research. This collaboration among different disciplines has already been successful.

TRANSFORMATION OF HEALTHCARE SYSTEM

During the past 75 years, we have seen the entire healthcare system undergo a profound transformation. In the 1930s and for a considerable period thereafter, medical practice was fee-for-service, the doctor–patient relationship was strong, and the physician perceived himself or herself as being responsible nearly exclusively to his or her individual patients. The texture of medical practice started to change when the federal government became involved in the provision of healthcare in 1965. The committee on “Crossing the Quality Chasm” identified six key attributes of the 21st-century healthcare system. It must be:

  1. Safe, avoiding injuries to patients;
  2. Effective, providing services based on scientific knowledge;
  3. Patient-oriented, respectful of and responsive to individual patients’ needs, values, and preferences;
  4. Timely, reducing waits, eliminating harmful delays for both care receiver and caregiver;
  5. Efficient, avoiding wasted equipment, supplies, ideas, and energy;
  6. Equitable, providing equal care across genders, ethnicities, geographic locations, and socioeconomic strata;

No one knows at present what this 21st-century healthcare system will look like. While care in the old system was reactive, in the new system it will be proactive. The “find it, fix it” approach of the old system will be replaced by a “predict it, prevent it, and if you cannot prevent it, fix it” approach. Sporadic intervention, provided only when patients present with illness, will give way to a system in which physicians and other healthcare providers plan 1-, 5-, and 10-year care programs for each patient. Care will be more interactive, with patients taking a more important role in their own care. The technology-oriented system will become a system that provides graded intervention. Delivery systems will not be fractionated but integrated. Even more importantly, care will not be based simply on experience and clinical impression but on evidence of proven outcome measures. If the old system was cost-insensitive, the new system will be cost-sensitive.

SURGICAL PRACTICE

There are many reasons for the declining interest in general surgery, some of which parallel reasons for the drop in medical school applicants in general. One problem specific to surgery is that medical students are given less and less exposure to surgery, due to the shortening of required surgical rotations. Most important, however, is their perception that the life of the surgical resident is stressful, the work hours too long, and the time for personal and family needs inadequate. The workload of the surgical resident over the years has increased significantly both in amount and intensity, without concomitant increase in the number of residents and at a time when hospitals have significantly reduced the support personnel on the surgical ward and in the operating rooms. Students graduating with debts close to $100,000 simply find the years of training in surgery too long, followed by uncertain practice income after graduation.

From several recent studies, lifestyle is the critical and most pressing issue in surgical residency. Some studies have also shown that the best students tend to select specialties that provide controllable lifestyles, such as radiology, dermatology, and ophthalmology. We have a problem not only in the declining number of students applying for surgical training but also in the declining quality of those who do apply. In a preliminary survey of 153 responding general surgery programs, we found that attrition (i.e., categorical residents leaving the training programs) occurred at a rate of 13% to 19% in the last 5 years. In 2001, 46% of those leaving general surgery training programs cited lifestyle as the major reason.

Unless these trends are reversed, general surgery as a specialty is threatened, and a future shortage of general surgeons is inevitable. I know that the Council of the American Surgical Association is most concerned about the crisis in general surgery. We must do a better job of communicating to students and residents that the practice of surgery is as rewarding as ever and full of opportunities in this new era. Innovations in minimal access and computer-assisted surgery and simulation technology provide exciting new possibilities in surgical training. We must also look very carefully at the demands of surgical residency and improve the life of residents without compromising their surgical experience. Unless we deal with work hours and quality of life issues, we are likely to see continuing decline in the interest of medical students in surgical training.

CONCLUSIONS

In conclusion, the noble profession of surgery must rise to meet numerous challenges as the world in which it operates continues to undergo profound change. These challenges represent opportunities for the profession to develop an international perspective and a global outreach and to address the growing needs of an aging population undergoing major demographic and workforce shifts. The leadership of American surgery has a unique role to play in the formulation of a new healthcare system for the 21st century. This task will require commitment to quality of care and patient safety, and it will depend on harnessing the trust and support of the American public. Advances in science and technology—particularly in minimal access surgery, robotics, and simulation technology—provide unprecedented opportunity for surgeons to continue to make landmark contributions that will improve surgical care and the human condition. I believe it is also crucially important that we train surgeon-scientists who will keep surgery at the cutting edge in the genomic and bioinformatics era. Ours is a noble profession imbued with eminence, dignity, high ideals, and ethical values. It has a rich and proud heritage… and I quote, “The highest intellects, like the tops of mountains, are the first to catch and reflect the dawn.”

Source: Lecture from Haile T. Debas, MD (UCSF School of Medicine, San Francisco, California) Presented at the 122nd Annual Meeting of the American Surgical Association, April 25, 2002, The Homestead, Hot Springs, Virginia.

Complete references here

Adverse events in SURGERY

The surgical domain can be seen as more complex and high risk in its delivery of care than other non-interventional specialities. It is therefore not surprising that in the majority of studies of adverse events in healthcare, at least 50% occurred within the surgical domain and the majority of these in the operating theatre. Furthermore, at least half of these adverse events were also deemed preventable. Just as the multiple studies in the developed world have similar figures for adverse events in hospitalised patients across all specialities, there appears to be a similar rate of harm in surgery. A review of 14 studies, incorporating more than 16000 surgical patients, quoted an adverse event occurring in 14.4% of surgical patients. This was not simply minor harm; a full 3.6% of these adverse events were fatal, 10% severe and 34% moderately harmful. Gawande, a surgeon from Boston, made one of the first attempts to clarify the source of these adverse events.

This paper pioneered the concept that the majority of these adverse events were not due to lack of technical expertise or surgical skill on the part of the surgeon, finding instead that ‘systems factors’ were the main contributing factor in 86% of adverse events. The most common system factors quoted were related to the people involved and how they were functioning in their environment. Communication breakdown was a factor in 43% of incidents, individual cognitive factors (such as decision-making) were cited in 86%, with excessive workload, fatigue and the design or ergonomics of the environment also contributing.

These findings were confirmed in the systematic review of surgical adverse events, where it was found that errors in what were described as ‘nonoperative management’ were implicated in 8.32% of the study population versus only 2.5% contributed to by technical surgical error. In accordance with other high-risk industries, such as commercial aviation, the majority of these adverse events are therefore not caused by failures of technical skill on the part of the individual surgeon, but rather lie within the wider healthcare team, environment and system. Lapses and errors in communication, teamworking, leadership, situational awareness or decision-making all feature highly in post-hoc analysis of surgical adverse events. This knowledge of error causation has been prominent and acknowledged in most other high-risk industries for many years, but it is only recently that healthcare has appreciated this.

Ao Cadáver DESCONHECIDO

Hic locus est ubi mors gaudet succurrere vitae

“É este o lugar onde a morte se alegra de socorrer a vida”

Égide do respeito ao Cadáver no estudo da Anatomia Humana*.

A utilização do cadáver representa uma tríplice lição educativa:

  1. Instrutiva/Informativa: como meio de conhecimento da organização do corpo humano, procedendo ao estudo no vivo;
  2. Normativa/Disciplinadora: através do seu caráter metodológico e de precisão técnica da linguagem;
  3. Estético/Moral: pela natureza do material de estudo, o cadáver, e pelo método primeiro de aprendizado, a dissecção, que é experiência e trabalho repousante na contemplação da beleza e harmonia de construção do organismo humano.

Contudo e essencialmente, porém, lição de ética e de humildade, porque:

  1. Não é o cadáver, doado ou indigente, fato isolado da comunidade, mas seu reflexo, dela provindo. O cadáver que é o meio de aprendizado para adequada assistência do vivo, assim portanto tão importante para a sociedade como o é o paciente;
  2. Esses corpos sem vida são vivificados de forma reiteradas pelo calor da juventude estudiosa através do sentimento de gratidão; O cadáver, antes de tudo “um irmão em Humanidade, se entrega despojadamente ao conhecimento que proporciona aos futuros profissionais, de maneira anônima oriunda do jogo do acaso da vida;
  3. O cadáver anônimo ao receber este título – cadáver desconhecido – e assim ultrapassar o limite estreito de um nome e, despersonalizado, distribui elementos para o bem coletivo, sem ter conhecimento quer antes, durante ou depois de sua imolação, do seu destino a um tempo sublime e sagrado;
  4. O Cadáver desconhecido tudo oferece ao conhecimento sem nada haver recebido daquele que o estuda, que dá sem saber que dá e por isso, sem conhecer recompensa da gratidão e sem sentimento do valor  da sua dádiva generosa, na mais nobre expressão de poderosa caridade universal;
  5. O cadáver que dissecado, desmembrado, simboliza outra forma de crucificação para o bem comum e marca o sentido profundamente humano da Medicina;

Portanto o nosso material de estudo transcende pois ao simples valor de meio e objeto de aprendizado; e nos fala em linguagem universal que nos educa na humildade da limitação humana. Eis porque na austeridade do ambiente do Laboratório de Anatomia a atitude física, mental e verbal do aluno deve ser de sobriedade, respeito, meditação e elevada compostura, manuseando as peças anatômicas com o mais profundo sentimento de respeito e carinho.

Nulla Medicina Sine Anatomia

“Ao curvar-te sobre o cadáver desconhecido…

lembra-te que este corpo nasceu do amor de duas almas; cresceu embalado pela fé e esperança daquela que em seu seio o agasalhou, sorriu e fitou os mesmos sonhos das crianças e dos jovens; por certo amou, foi amado e também acalentou um amanhã feliz. Seu nome só Deus o sabe e agora nesta fria lousa, o destino inexorável deu-lhe o poder e a grandeza de servir a humanidade numa última missão, ENSINAR.

Ó irmão ignoto que tivestes a morada do espirito, o seu corpo, perturbado em seu repouso imutável por nossas mãos ávidas de saber, apresentamos a ti o nosso respeito permanente e infindo AGRADECIMENTO.”

*Adaptação do texto original “Aula Inaugural”

Professor Renato Locchi (1896-1978) / Emérito de Anatomia Humana da Escola Paulista de Medicina.

Aprendendo a Aprender


As oportunidades de aprendizado nos são oferecidas a cada momento, o tempo todo. Aprendemos toda vez que nos damos ao trabalho de pensar sobre o que determinado momento nos trouxe, o que nos ensinou que ainda não sabíamos, o que nos mostrou a respeito dos outros e de nós mesmos, e que antes ignorávamos. E esse processo é tão longo quanto a vida.

O caminho mais curto e certo para a estagnação é perder a disposição de aprender, seja pela arrogância de achar que já sabe tudo, seja pela enganosa convicção de que é cedo demais para adquirir tal conhecimento. A acomodação é outra inimiga do aprendizado, pois paralisa o segundo requisito necessário para que ele ocorra: o esforço. É preciso esforçar-se para manter a mente aberta ao novo, para não se deixar limitar pelos preconceitos e opiniões preconcebidas. E também é preciso esforço para ampliar as oportunidades de aprendizado, reservando tempo para as leituras, para as conversas e atividades instrutivas, para se atualizar e aprofundar seu conhecimento.

Não refiro apenas ao conhecimento necessário à sua profissão, mas a todos os aspectos de sua vida, por exemplo, conhecer mais a fundo sua família – acreditar que já sabemos tudo sobre nossos familiares é um erro fatal em qualquer tipo de relacionamento. Outro equívoco é negligenciar o autoconhecimento: uma série de frustrações, angústias e motivações. Conhecê-las também é um aprendizado constante, talvez o mais árduo de todos.

“Todas me pareceram tão cheias de si”, contou Sócrates, “tão seguras de suas verdades e certezas que, se sou de fato mais sábio do que elas, é pela simples razão de que sei de que não sei aquilo que elas acham que sabem”. Como nos sugere o filósofo com toda a sua perspicácia e sabedoria, a admissão de que ainda temos muito a aprender é o primeiro passo para transformarmos nossa vida em um constante aprendizado. A consciência desse fato enriquece nossas vidas, ampara nossas escolhas e direciona nossas ações. A importância de aprender sempre é tamanha que Stephen R. Covey, autor do best-seller Os 7 Hábitos das Pessoas Altamente Eficazes e 8° Hábito, a coloca entre as quatro necessidades básicas do ser humano – as demais serão afetadas.

O aprendizado, porém, está presente em todas: aprendemos a viver, a amar, a deixar um legado e, até mesmo, aprendemos a aprender.

NOTTS: OR Etiquette

If OR etiquette represents a code of conduct—respect, communication, shared mental model, and teamwork—then manners represent the behaviors that embody this code of behavior. These seem like simple rules that should have been learned at an early age, but a few pointers will go a long way toward integrating junior residents and students into the OR team.


1. Be polite.
2. Be respectful.
3. Be humble.
4. Learn everyone’s name.
5. Offer help without being asked.
6. Ask for help when needed.
7. Thank your colleagues.
8. Keep the patient at the center of all you do.


Rude, disruptive, or disrespectful behavior is not tolerated. Do not yell or make sarcastic comments. Do not make jokes with sexual or racial themes. Do not gossip or denigrate others. Many surgeons enjoy listening to music in the operating room, but in choosing a playlist, be aware that some music may have offensive lyrics that should not be played in the workplace. It is most polite to ask before playing music and to check in with music preferences, as not everyone in the OR may appreciate loud death metal. Music should be turned off during critical times such as the initial time-out. Surgeons use social media like many others, but the OR is not the place to check Facebook or Instagram. When posting to social media, be professional—anything posted to the Internet can be screen captured and spread, no matter what privacy settings you may have turned on. A recent study of publicly accessible Facebook posts showed 14.1% of surgery residents had posted potentially unprofessional content, and 12.2% had clearly unprofessional content, with violations of patient privacy being one of the most common problems, along with description of binge drinking and racially or sexually offensive material. Specific to the OR, be aware that social media postings with potentially identified patient information are absolutely forbidden. This does not need to include a name of a patient to be identifiable information—a few details of a particularly unique case and a timestamped posting can be enough to cause trouble.

Link to References HERE

NOTTS: Giving and Receiving Feedback

Feedback has gained an increasingly important role in surgical education. Feedback may be summative and/or formative. Summative feedback is often given at discrete time points such as the end of a rotation and is a culmination of observations of performance. Formative feedback involves an ongoing assessment of skills or knowledge and may be given throughout an education experience. There is an often misunderstood distinction between teaching and feedback. As an example, teaching is when the attending surgeon corrects the resident’s needle angle during a bowel anastomosis. Feedback is when the attending surgeon and resident meet after the case and discuss performance—either technical or nontechnical. For example, a feedback session might discuss room setup, efficiency, technical maneuvers, and communication. Giving and receiving feedback are distinct skills that require both parties to be attentive and open. To facilitate this process, several methods have been described that turn feedback into an active process for both parties. Ideally, the mentor and the trainee have a briefing prior to the case in order to set learning objectives and then formally debrief after the case to discuss how well the learning objectives were met as well as ways to improve this in the future. In the press of clinical concerns and the drive toward efficiency, the debrief session is often skipped or missed. It is incumbent on the learner, therefore, to specifically seek out and ask the attending surgeon for feedback and if necessary to schedule formal meeting times. It is also important for feedback to flow both ways, and the attending surgeon should ask for feedback from the residents as well. A good methodology for providing feedback is to ask an open-ended question such as “How did you think that operation went?” Which can be followed with “What went well?” and “What could have gone better?” This allows the person providing feedback with a baseline to start from and allow for self-reflection on the part of the learner. This can be followed with specific feedback about one to two actionable items, preferably relating back to the goals stated during the initial briefing.

Link to References HERE

NOTTS: Leadership and Followership

Although the OR may seem like a highly regimented environment, each member of the surgical team will serve as both a “leader” and a “follower” at different points during the operation. This includes everyone from the most senior attending surgeon to the most junior medical student. Within the OR, the surgical attending has ultimate responsibility for the patient. However, surgical residents will often act as leaders to junior residents and medical students. In the setting of “progressive autonomy” for surgical trainees, the attending surgeon may also formally or informally cede control of the case to the resident or fellow and may take a follower role him or herself. In fact, more often than not, the surgical attending will assist a senior resident through a case, rather than perform the operation with the resident’s assistance. In the OR, the team leader is responsible for setting the tone. It is up to the leader to make sure that all team members have a shared understanding of how the day will proceed as well as any potential problems that may arise. In many cases, the surgical attending does not arrive to the OR until the patient has arrived, been intubated, and prepped and draped. In this case, it is up to the senior-most resident to lead the team. A resident who arrives early, completes the surgical timeout in a thorough but efficient manner, and moves the room forward is much more effective than one who arrives late or is not familiar with the patient or the case. While an extensive discussion of successful leadership traits is outside of the realm of this chapter, in general a good leader is one who outlines a clear vision of the work that needs to be accomplished while also empowering those around them to take ownership over their individual work. While leadership is a commonly discussed topic, what is less commonly discussed is the importance of “followership.” While there are several different descriptions of the various types of “followers” on any given team, many focus on a spectrum from passive to active and from dependent, uncritical thinking to independent, critical thinking. Compared to the field of leadership, the study of followership is relatively new, but it is generally agreed that effective followers are those who are paying attention to what is going on around them, taking an active interest in the process, and questioning or challenging leadership or the status quo when necessary. This last point is especially critical. In the OR, being a good follower is a crucial component to maintaining patient safety as it is incumbent upon the followers (including residents, medical students, nursing staff, and all other participants) to speak up if they notice that something is going wrong or that the environment has become unsafe. Especially for more junior members of the team, it can be intimidating to alert the attending that he or she may be making a mistake or misjudging the situation. However, it is important to remember that such actions, when carried out with tact and respect, are in the best interest of the patient and may actually prevent serious harm from occurring.

Link to References HERE

NOTTS: Communication

One of the most important determinants of a successful operation is ongoing effective communication between all members of the surgical team. The goal is for each member of the team to have a common understanding about the patient, the proposed operation, and the expected flow of the case—the “shared mental model.” One of the most common communication tools used in this setting is the surgical pause or “time-out.” While many institutions use a time-out, many of these are unstructured and therefore miss an opportunity to ingrain a culture of communication. In order to combat this, we strongly recommend using a structured and formalized checklist as part of the surgical pause. The prototype for this type of structured process is the World Health Organization Surgical Safety Checklist. The Surgical Safety Checklist, introduced in 2008, is a 19-point checklist to be used at 3 time points—immediately when the patient enters the operating room (prior to induction of anesthesia), just before the skin incision and just before the patient leaves the operating room. The checklist was tested in eight cities throughout the world to test its impact on patient morbidity and mortality. In a before-after study design, the investigators found that implementation of the checklist was associated with a significant reduction in mortality rate (1.5% vs. 0.8%, p < 0.01) and inpatient complications (11.0% vs. 7.0%, p < 0.01). While the checklist has largely been heralded as a success, some critics have asserted that it is not the checklist itself that reduces complications but rather the fact that the checklist provides an opportunity for the team to come together and discuss critical elements that are not to be missed. It is our opinion that it does not matter how the checklist works, only that it does.

Several additional studies have shown other benefits to introduction of a formalized checklist, including reduced mortality, morbidity, and hospital length of stay as demonstrated in a recent randomized controlled study that showed reduction in complications from 19.9% to 11.5% with introduction of the checklist. Despite this, some other studies of surgical checklists have shown no improvement in outcomes. This seems to be due to implementation issues, with wide variations in implementation between institutions and even between different specialties within an institution, with suboptimal implementation being common. Institutions who adopt a checklist in name only, but whose team members ignore or minimize the process, are unlikely to reap the benefits. On the other hand, institutions that develop a strong culture of safety with robust and mandatory implementation will see better results. This speaks to the importance of the etiquette of the OR—the code of conduct that regulates our actions. In order to derive the most benefit from the surgical safety checklist, all team members must be present and actively engaged in the process. Music should be turned off, side conversations stopped, and all attention should be focused on the checklist items and how they relate to the patient. Typically it is the role of the surgical attending, fellow, or resident to lead the checklist. As the designated leader, it is important to review and discuss each individual item on the checklist. This includes ensuring that every team member has introduced themselves and making it clear that all individuals in the OR are empowered to speak up if they become aware of a potentially unsafe situation. The checklist can be modified by individual hospitals or services to include relevant items specific to their patient population. For example, if a specific surgical team has additional items that must not be forgotten (e.g., processes regarding cardiopulmonary bypass in cardiac surgery), this can be included. Many checklists also include a debriefing section for use at the end of the case including items such as specimen processing, communication with the patient’s family, and who will accompany the patient to the postanesthesia or intensive care unit.

Link to References HERE

NOTTS: The Operating Room Team

Introduction

“Analysis of medical errors has shown that more than two-thirds involve issues of team communication, and these are contributed to by issues of institutional and team culture. These errors can include missed communication, inaccurate communication, or inability or unwillingness of team members to speak up—all of which can be related to the culture of a team or institution and which are dramatically affected based on the tone and climate set by surgeon leaders, both in and out of the operating room. Every team and institution have a “safety culture”—the attitudes, behaviors, and expectations that affect patient outcomes for good or for ill. There is increasing evidence that this safety culture directly affects both morbidity and mortality. For example, in a study of 31 hospitals in South Carolina, institutional safety culture was directly related to patient death. For every 1-point change (on a 7-point scale) in the hospital-level scores for respect, clinical leadership, and assertiveness, 30-day mortality after surgery decreased from 29% to 14%. In another example, measures of safety culture across 22 hospitals in Michigan directly predicted patient outcomes after bariatric surgery. In that study, when nurses rated coordination of OR teams as acceptable, rather than excellent, serious complications were 22% more likely.

The Operating Room Team

The act of surgery is inherently team-based. Each operation requires the surgeon to work closely and effectively with their assistants, anesthesia providers, nursing staff, surgical technologists, and ancillary staff members to make the OR function. Team members frequently move in and out of the OR, with change of shift or for breaks, and additional team members may be required for specialty or emergency care. The key is to remember that the patient is at the center of the team, thus the phrase “patient-centered care.” Always keep in mind that patient safety and well-being are at the heart of all our efforts. It is especially important that all members of the team have a “shared mental model”—a common understanding of the issues, both medical and logistical, which might affect the course of an operation. This allows for improved efficiency, better situational awareness, and better ability to recognize and respond to issues. Here we describe the individuals commonly encountered in the operating room.

The Surgeons

Every surgical team will consist of an attending surgeon, usually accompanied by one or more assistants. In the learning environment, it is important for the surgeons to discuss roles and responsibilities as well as educational goals for the case, which may vary depending on the level of training and experience of the team members. An important concept in surgical education is “progressive autonomy,” in which learners are allowed to take on more and more responsibility in an operation based on their level of competency. A preoperative discussion between the surgeon and the resident is critical to clear understanding of which parts of the operation the learner can be expected to perform and when the attending might need to take control of the case. It is the responsibility of every member of the surgeon’s team to review the patient’s case in detail to understand their past medical and surgical history, their current disease and how it has been managed to date, relevant medications, and review of all diagnostic studies to anticipate difficulties that may be encountered during the operation. Secondarily, it is incumbent on each member to discuss the case with other members of the team to ensure that all individuals have a shared mental model of the operative plan, the postoperative plan, and any anticipated difficulties. During the operation, the patient is the focus of the team. Each individual is expected to do their part to advance the operation while helping other team members to do the same. Following the operation, it is important to discuss postoperative care such as pain management, dietary restrictions, venous thromboembolism prophylaxis, and the need for new or existing prescription medications.

Scrub Nurse and Circulator

Working closely with every surgical team is the surgical technologist or scrub nurse, often referred to as the “scrub.” This individual will have various levels of training depending on their background—he or she may be a certified surgical technician or a nurse with extra training. The scrub is an integral part of the team as they are responsible for ensuring that all necessary equipment is open or readily available prior to the case starting, anticipating the needs of the surgeon to maximize efficiency, and troubleshooting when there are equipment problems or failures. Depending on the scope of practice as defined by state law and regulations, the scrub may or may not be authorized to assist with limited surgical tasks. It is the responsibility of the surgeon (or surgical resident in their place) to meet with the scrub ahead of time, confirm that all necessary equipment is available, and confirm this during the surgical pause or “time-out.” Doing so will foster a collegial environment while also helping the case run more smoothly. The circulator is typically a nurse by training who is responsible for maintaining the flow of the OR, while the surgeons are sterilely gowned and gloved. It is important (especially for new residents) to introduce yourself to the circulator to open the flow of communication for the day and to give them a baseline understanding of your skill level so that they can assist you as necessary. For example, the circulator may pay extra close attention to the medical student as they don their sterile gown and glove to ensure that they do not break the sterile field. Throughout the case, the circulator works to maintain the flow of the OR. As such, the circulator is not always available to assist in tasks not related to the direct care of the patient.

The Anesthesia Team

Without the anesthesia team, the surgeon cannot operate. The anesthesia team consists of either an attending anesthesiologist who is present for the duration of the case or an anesthesia resident or certified registered nurse anesthetist (CRNA) who is supervised by an attending anesthesiologist who may be overseeing several operations at once. In some states, depending on state law, a CRNA can also practice independently. The anesthesia provider is often helped by an anesthesia technician, much like the surgeon is helped by a surgical technician. The anesthesia team is responsible for providing pain control and sedation, managing the airway, medical and fluid management throughout the case, and monitoring the patient for any physiologic derangements that may or may not be related to the operation at hand. They should meet the patient ahead of time to evaluate for any risk factors such as underlying cardiovascular or pulmonary disease. Communication with the anesthesia team is critical for maintaining the safety and well-being of the patient. One of the most important tools to promote this communication is the surgical pause or “time-out”. Throughout the case, the surgical team must also alert the anesthesia team if they anticipate significant hemodynamic changes for the patient. This can range from events as common as insufflation of pneumoperitoneum during a laparoscopic operation to more uncommon events such as unexpected, significant hemorrhage. Conversely, it is imperative that the anesthesia team communicates with the surgeon about any significant changes in hemodynamic status or about other issues that may impact patient care. Finally, it is important to debrief with anesthesia at the end of the case, to ensure that all members of the team have the same situational awareness and understanding of the patient’s intraoperative course and postoperative plan. This includes issues such as fluid and electrolyte management, expected or potential postoperative issues, and a plan for pain management.

Link to References HERE

NON-TECHNICAL SKILLS FOR SURGEONS (NOTTS)

“NON-TECHNICAL SKILLS FOR SURGEONS (NOTTS) was developed by a team in Scotland at the University of Aberdeen and funded by the Royal College of Surgeons of Edinburgh and NHS Education for Scotland; lead investigator Steven Yule, PhD, was a part of this team and now brings his experience and expertise to the United States with the Non-Technical Skills Lab at Brigham and Women’s Hospital and Harvard Medical School. NOTSS was developed from the bottom up with a panel of subject matter experts (consultant/attending surgeons/psychologists) in place of adapting an existing framework employed by other industries. The aim of the NOTSS project was to develop and test an educational system for assessment and training based on observable behavioral skills in the intraoperative phase of surgery (Yule et al. Surg Clin N Am 2012;92:37-50).

THE NOTSS SYSTEM

was written in surgical language for trained surgeons to observe, rate, and provide feedback on non-technical skills in a structured manner (Yule et al. Surg Clin N Am 2012;92:37-50). The NOTSS taxonomy is broken down into four distinct categories of non-technical skill: Situation Awareness, Decision Making, Communication and Teamwork, and Leadership (Yule et al. World J Surg 2008;32:548-556), each with associated elements. Good and poor behaviors were carefully written for each element. The Royal College of Surgeons of Edinburgh also provide resources for training non-technical skills. Click Here!

Fundamentals of Acceptable
Behavior in the Operating Room

“As much as the culture and practice of surgery have changed and evolved over the last several hundred years, it remains true that the operating room (OR) can be an intimating place for medical students or junior residents. In the past, surgeons have often had the reputation of being arrogant or demeaning, with frequent stories akin to hazing of junior residents in the OR, or of impulsive, disruptive behavior aimed at team members such as nursing staff, anesthesia team, and support personnel. In fact, this type of “old-school” behavior is no longer acceptable, for many reasons. The OR is a special place, but it is still in the end a workplace, and workplace norms of mutual respect and polite behavior must apply. In the modern era, it is clear that surgeons must work in a respectful and collaborative fashion with all members of the patient care team. It is incumbent on the surgeon to create an atmosphere of mutual respect, trust, and communication. This is often called “OR etiquette,” as etiquette is defined as a code of conduct among a group or professionals that should dictate how we act and work with others. This is related to but distinct from manners—which are behaviors (good or bad) that reflect our attitude toward others. Etiquette, therefore, creates the structure within which manners exist.”

Link to References HERE

Patient SAFETY

Resultado de imagem para The ‘Swiss cheese’ model according

Organ specialization and case load have been a big issue during recent years and for most cancers a direct relation between high volume and a better outcome has been demonstrated by reviewing the recent literature. Concentration in clinics of high-risk procedures with a certain volume (procedures such as esophagectomy, pancreatectomy and hepatic resection) might prevent many postoperative deaths per year. Also, other procedures such as thyroidectomy and colon resections have shown the same tendency to a lesser extent. Reduction of postoperative mortality by 5% is in general as effective as toxic adjuvant treatment and should have high priority in achieving the highest quality in cancer surgery.

Not only can a reduction in morbidity and mortality be achieved but also a better functional and even financial outcome is possible. Sometimes too much attention has been focused on numbers per year, since even smaller hospitals with dedicated teams can achieve good results. It is very likely that not only volume but also training and specialization result in a better outcome. The setting of an absolute number of cases is not very productive and diverts attention from organized multidisciplinary mee-tings, appropriate infrastructure and availability of modern techniques.

The focus of interest should be directed more towards analyzing and optimizing the whole process of diagnosis and treatment, since this whole process can put the patient at severe risk, especially during the in-patient period. Avoidance of mistakes has received a lot of attention during recent years. It has resulted in interest in patient safety as a concept. Since the publication of the report To Err is Human issued by the Institute of Medicine the approach to errors has changed.

Resultado de imagem para report To Err is Human issued by the Institute of Medicine

Individuals can make mistakes but a system approach concentrates on the conditions under which individuals work and tries to build defenses to overt or mitigate the effects of mistakes. This is very well visualized by the Swiss cheese model. Several layers of defense, each with its own holes, are put around a procedure. Both active failures and latent conditions cause holes in each layer. The usual way of thinking is to close the holes in the last layer of defense; however, redesigning the process and the closing of a hole in a much earlier layer will probably be more effective.

Root cause analysis is the way to go back in the process and try to identify weak points in the procedure. A good example is the incorrect position of a colostomy after an abdominoperineal resection. It is easy to blame the resident for not selecting the correct position during surgery or even marking the wrong spot the day before the operation. A better solution would be either proper training of the junior or having the right spot tattooed during the outpatient clinic by a stoma therapist.

Imagem relacionada

Marking of the correct part and site of the body has become a safety measure and the patient should be instructed to ask for this procedure for there own safety. It is important to get rid of the ‘blame and shame’ culture and introduce a more open environment in which it is possible to report on near misses and mistakes. The safety climate in a surgical department can be measured in a validated way and is an essential part of a culture in which patient safety can flourish. Reduction of complications in the direct postoperative period after a surgical procedure has many aspects not related to the cancer surgery itself, but to the invasive nature of the intervention.

Resultado de imagem para surgical specialization and quality of patient safety

Great attention to every detail during the preoperative work-up and clinical period may result in the reduction of adverse events. This is what is termed ‘the first time at risk’ above. There are also examples of actions in optimizing results that are more cancer specific. For instance the use of techniques stimulating wound healing after an abdominoperineal resection such as an omentoplasty or rectal abdominis flap may prevent a delay in adjuvant systemic treatment for rectal cancer.

Careful attention towards wound healing in sarcoma will avoid postponement of the necessary adjuvant radiotherapy. Omitting a computer scan with iodine-containing contrast in the diagnostic work-up for a thyroid cancer makes postoperative radioactive treatment with iodine possible earlier resulting in a possible better outcome. Harvesting a sufficient number of lymph nodes in colon cancer may avoid discussions about the indication for adjuvant chemotherapy.

Most of the examples for patient safety in the clinical period are in relation to optimal use of multimodality treatment or to effects of surgery in general. Sometimes there has to be a balanced risk of the acceptance with a more extensive surgical procedure of a higher morbidity to achieve a better long-term cancer result. The reverse is also possible when a good short-term outcome of a local excision in rectal cancer has to be counterbalanced by a higher local recurrence rate. Quality assurance for all the participating disciplines (both diagnostic and therapeutic) is a key element in the set up of clinical prospective randomized trials.

Resultado de imagem para surgical specialization and quality of patient safety

The GOOD SURGEON


Surgery is an extremely enjoyable, intellectually demanding and satisfying career, and many more people apply to become surgeons each year than there are available places.

Those who are successful have to be ready not just to learn a great deal, but have the right kind of personality for the job.

 Is a surgical career right for you?

Read the link…

THE GOOD SURGEON


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Centro Cirúrgico: O TEMPLO DO CIRURGIÃO.

BLOCO CIRÚRGICO: O TEMPLO DO CIRURGIÃO.

BLOCO CIRÚRGICO: O TEMPLO DO CIRURGIÃO.


Templo (do latim templum, “local sagrado”) é uma estrutura arquitetônica dedicada ao serviço religioso. O termo também pode ser usado em sentido figurado. Neste sentido, é o reflexo do mundo divino, a habitação de Deus sobre a terra, o lugar da Presença Real. É o resumo do macrocosmo e também a imagem do microcosmo: ‘o corpo é o templo do Espírito Santo’ (I, Coríntios, 6, 19).

Dos locais especiais, O corpo humano (morada da alma), a Cavidade Peritoneal e o Bloco Cirúrgico, se bem analisados, são muito semelhantes e merecem atitudes e comportamentos respeitáveis. O Templo, em todos os credos, induz à meditação, absoluto silêncio tentando ouvir o Ser Supremo. A cavidade peritoneal, espaço imaculado da homeostase, quando injuriada, reage gritando em dor, implorando uma precoce e efetiva ação terapêutica.

O Bloco Cirúrgico, abrigo momentâneo do indivíduo solitário, que mudo e quase morto de medo, recorre à prece implorando a troca do acidente, da complicação, da recorrência, da seqüela, da mutilação, da iatrogenia e do risco de óbito pela agressiva intervenção que lhe restaure a saúde, patrimônio magno de todo ser vivo.

O Bloco Cirúrgico clama por respeito ao paciente cirúrgico, antes mesmo de ser tomado por local banal, misturando condutas vulgares, atitudes menores, desvio de comportamento e propósitos secundários. Trabalhar no Bloco Cirúrgico significa buscar a perfeição técnica, revivendo os ensinamentos de William Stewart Halsted , precursor da arte de operar, dissecando para facilitar, pinçando e ligando um vaso sangüíneo, removendo tecido macerado, evitando corpos estranhos e reduzindo espaço vazio, numa síntese feita com a ansiedade e vontade da primeira e a necessidade e experiência da última.

Mas, se a cirurgia e o cirurgião vêm sofrendo grande evolução, técnica a primeira e científica o segundo, desde o início do século, a imagem que todo doente faz persiste numa simbiose entre mitos e verdades. A cirurgia significa enfrentar ambiente desconhecido chamado “sala de cirurgia” onde a fobia ganha espaço rumo ao infinito. O medo prepondera em muitos.

A confiança é um reconhecimento e um troféu que o cirurgião recebe dos pacientes e seus familiares. Tanto a CONFIANÇA quanto a SEGURANÇA  têm que ser preservadas a qualquer custo. Não podem correr o risco de serem corroídas por palavras e atitudes de qualquer membro da equipe cirúrgica. Não foi tarefa fácil transformar, para a população, o ato cirúrgico numa atividade científica, indispensável, útil e por demais segura. Da conquista da cirurgia, como excelente arma terapêutica para a manutenção de um alto padrão de qualidade técnica, resta a responsabilidade dos cirurgiões, os herdeiros do suor e sangue, que se iniciou com o trabalho desenvolvido por Billroth, Lister, Halsted, Moyniham, Kocher e uma legião de figuras humanas dignas do maior respeito, admiração e gratidão universal.

No ato operatório os pacientes SÃO TODOS SEMELHANTES EM SUAS DIFERENÇAS, desde a afecção, ao prognóstico, ao caráter da cirurgia e especialmente sua relação com o ato operatório.  Logo o cirurgião entra no bloco cirúrgico com esperança e não deve sair com dúvida. Nosso trabalho é de equipe,  cada um contribui com uma parcela, maior ou menor, para a concretização do todo, do ato cirúrgico por completo, com muita dedicação e sabedoria.  Toda tarefa, da limpeza do chão ao ato de operar, num crescendo, se faz em função de cada um e em benefício da maioria, o mais perfeito possível e de uma só vez, quase sempre sem oportunidade de repetição e previsão de término.

O trabalho do CIRURGIÃO é feito com carinho, muita dignidade, humildade e executado em função da alegria do resultado obtido aliado a dimensão ética do dever cumprido que transcende a sua existência. A vida do cirurgião se materializa no ato operatório e o bloco cirúrgico, palco do nosso trabalho não tolera e jamais permite atitudes menores, inferiores, ambas prejudiciais a todos os pacientes e a cada cirurgião. Como ambiente de trabalho de uma equipe diversificada, precisa manter, a todo custo, o controle de qualidade, por lidar com o que há de mais precioso na Terra: o ser humano.

GOSSIPIBOMA

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O termo “gossipiboma” refere-se a uma matriz de matéria têxtil envolvida por reacção de corpo estranho. O termo é derivado do latim “Gossypium”, algodão, e o Swahili “boma”, que significa “esconderijo”. Também conhecida como textiloma, originada de “textilis” (tecer em latim) e “oma” (doença, tumor ou inchaço em grego). O primeiro caso foi descrito por Wilson em 1884. Gossipibomas foram relatados após operações em muitos processos, e em diferentes órgãos e localização. Mas, o local mais comum é o abdominal. Gaze e compressas são os materiais mais comumente retidos após laparotomia. A incidência de gossipibomas é variável e subnotificada, principalmente devido às implicações legais de sua detecção, mas também porque muitos pacientes permanecem assintomáticos. A apresentação clínica é também variável. O tratamento recomendado é a excisão que pretende evitar as complicações que conduzem a taxa de mortalidade entre11-35%.

Epidemiologia                             

Ele ocorre entre 1/1000 a 1/1500 nas operações intra-abdominais. A apresentação clínica é variável e depende da localização do corpo estranho e sobre o tipo de reação inflamatória apresentada pela hospedeiro. Podem existir formas agudas e crônicas. A forma aguda tende a apresentar-se com fístulas e abcessos cutâneos, enquanto que a crônica como massa encapsulada (granuloma de corpo estranho) e sintomas inespecíficos. Gossipibomas ocorrem mais comumente após operação abdominal e pélvica. Eles são mais frequentes em pacientes obesos e quando a operação é realizada em emergência. A incidência é maior em nove vezes após operação de emergência, e de quatro em procedimentos não planejados no decorrer de uma intervenção, mudando o que se pretendia realizar. Outros fatores predisponentes incluem operações em campo de batalha, complicações intra-operatórias, tais como perda intensa de sangue, a incapacidade de realizar contagem de materiais cirúrgicos no final do processo, tempo de operação prolongado e as mudanças no pessoal médico e de enfermagem durante o operação.

Evolução clínica

O tempo entre a operação e aparecimento de manifestações clínicas de Gossipiboma é variável, em particular se o material permanecer estéril. Ele depende da localização do material retido e do tipo de reação orgânica, e foi estimado em entre 10 dias a vários anos. Em patologia, duas reações de corpo estranho pode occorer. A primeira resposta é a produção asséptica de fibrina, o que leva à formação de aderências, material de encapsulamento e à formação de granulomas de corpo estranho. Nesta apresentação, o paciente pode permanecer assintomático por meses ou anos. A segunda resposta é exsudativa, com formação de abcessos, fístulas aos órgãos internos como o estômago, intestino, bexiga, cólon ou vagina, ou também fístula externa para a parede abdominal. Os sintomas dependem do órgão afetado principalmente e podem resultar da compressão, obstrução, síndrome de má absorção, ou crescimento bacteriano. Eles incluem dor abdominal, tumor palpável, náuseas, vômitos, sangramento retal, diarréia, disúria, piúria, hematúria e urgência urinária. Os sintomas sistêmicos como febre, anorexia, anemia e perda de peso também podem occurer. No entanto, a resposta inflamatória e aderências podem formar uma cápsula com o bloqueio omental e órgãos adjacentes, podendo o paciente permanecer assintomático. A falta de sintomas pode dificultar ou retardar o diagnóstico, que muitas vezes é realizado incidentalmente.

Possibilidades diagnósticas

O diagnóstico pode ser difícil. Suspeita clínica e o uso de estudos de imagem são importantes, pois é a regra a inexistência ou inespecificidade de sintomas em vários anos após a operação. No pré-operatório pode ser levantada suspeita por meio de estudos radiológicos ou endoscópicos. Muitos casos só são descobertos no intra-operatório. Tomografia computadorizada é o exame complementar de escolha para o diagnóstico e avaliação dessas complicações. Ele fornece informações detalhadas sobre a lesão na maioria dos casos. A aparência pode ser lesão cística espongiforme, cápsula hiperdensa em camadas concêntricas, ou calcificações murais. A presença de gás é indicativa de perfuração do intestino ou à formação de abcessos. Os principais diagnósticos diferenciais são: aderências pós-operatórias, fecalomas, contusões, hematomas, intussuscepção, volvo, tumores e abscessos intracavitários.

Tratamento e Prognóstico

O tratamento de escolha é a remoção cirúrgica que pode ser realizada por laparoscopia ou laparotomia, e visa prevenir complicações. O prognóstico da gossipiboma é variável com taxas de mortalidade de 11 para 35%. Quando a remoção ocorre no período pós-operatório imediato, a morbidade e mortalidade são baixas; no entanto, se o material foi mantido por um longo tempo a remoção pode exigir operação extensa e ter elevado índice de complicações.

Implicações médico-legais

Há muitas implicações médico-legais com gossypiboma. Revisão de negligência médica impetradas entre 1988 e 1994 revelou 40 casos de gossipiboma, que representaram 48% de todos os corpos estranhos. Não foi possível determinar se o material esquecimento representou falta de qualidade do cirurgião ou quadro de enfermagem.

Procedimentos preventivos

A abordagem mais importante é a prevenção. As medidas preventivas necessárias incluem o uso de material têxtil com marcadores radiopacos e contagem minuciosa de materiais cirúrgicos. São recomendadas quatro contagens: na montagem do material, antes da operação, no início do fechamento da cavidade e durante a síntese da pele.  Dhillon e Park reforçam a importância da exploração dos quatro quadrantes abdominais no final da operação em todos os casos, mesmo após a contagem das compressas. No caso de contagem incorreta, a menos que o paciente seja considerado instável, a síntese da cavidade não deve ser realizada até que todas elas estejam localizados.

CONCLUSÃO

Gossipiboma é um problema médico-legal sério e sua incidência está aparentemente aumentando. Por isso, os meios e métodos nos procedimentos cirúrgicos durante o ato operatório e no contexto geral da sala de operações precisam ser revistos para tomarem-se medidas preventivas. Formação continuada de profissionais da área médica e estrita adesão à técnica operatória são primordiais para a prevenção de gossipiboma.

10 Princípios da RELAÇÃO MÉDICO-PACIENTE

A necessidade de tratamento cirúrgico é algo que sempre tem conotação ameaçadora para o paciente e familiares. A possibilidade de dor, mutilação ou complicações constitui uma ameaça real ou fantasiosa, mesmo em situações desejáveis, como a correção de malformações, o aperfeiçoamento estético, os partos e outras eventualidades nas quais não exista doença. A anestesia em suas várias modalidades é outro evento preocupante. A lembrança de maus resultados vem sempre a mente quando uma intervenção cirúrgica é cogitada. Nos últimos anos, o progresso tecnológico que atingiu a medicina tem sido extremamente exaltado pela mídia. Este fato tem levado a população leiga à falsa impressão de que a medicina e os médicos são capazes de resolver todas as situações. Quando ocorre reversão desta expectativa fala-se em “erro médico”. Para que não se cometa injustiça, este tema deve ser discutido pela sociedade como um todo, e não somente por setores que vêem nele a possibilidade de auferir lucros. Infelizmente, em lugar de uma análise consequente, tem sido comum denegrir a imagem do médico, atribuindo-lhe responsabilidade exclusiva por todas as falhas do sistema de saúde. Os maus resultados profissionais, comuns em todas as profissões, são “imperdoáveis” em  medicina, na visão de pessoas que insistem em elevar os médicos à categoria de “infalíveis”,  esquecendo-se de que a medicina e os médicos têm compromisso apenas com os meios adotados para a recuperação dos pacientes, e nunca com os resultados. Com o objetivo de fortalecer o relacionamento médico/paciente em clínica cirúrgica e prevenir insatisfações e petições judiciais, seguem-se algumas sugestões que eventualmente podem ser úteis:

1ª. Jamais ceder às pressões de serviços de saúde que visem impor a mentalidade de “linha de produção”, exigindo o “atendimentos” em série dos pacientes. Nessas circunstâncias não sobra tempo para um relacionamento afetivo e efetivo e este é, sem dúvida, o primeiro passo para acusações injustas ou descabidas diante de adversidades;

2ª. Esclarecer ao paciente e ou aos familiares todos os pormenores do ato cirúrgico. As informações devem ser claras, em linguagem simples e acessível, evitando termos técnicos incompreensíveis. Deve-se entrar em detalhes sobre a operação proposta, suas conseqüências e seus riscos; Conduzir com competência o pré-operatório, lembrando que, na avaliação do paciente, é indispensável o exame clínico completo.Os especialistas que se sentirem inseguros em relação ao mesmo devem solicitar o parecer de um clínico ou internista acostumado a fazê-lo; Lembrar que a avaliação do risco cirúrgico é muito mais abrangente do que o simples exame cardiológico. Existem riscos aumentados também em relação aos outros sistemas e aparelhos. Não negligenciar a avaliação psicológica do paciente; Em relação aos exames subsidiários pré-operatórios, lembrar que existe um consenso na literatura médica que vai desde a sua não realização em casos selecionados, até a sua realização fundamentada no exame clínico e em parâmetros como vulto da intervenção, idade e sexo. Em jovens do sexo masculino, sadios, com exame clínico normal, é perfeitamente justificável não realizar exames complementares em intervenções de pequeno e médio porte;

3ª. Nas intervenções com objetivos estéticos, analisar cuidadosamente as expectativas do paciente em relação aos resultados. Verificar senão são excessivamente  fantasiosas, em busca somente de ganhos afetivos. Nestes casos, é freqüente que a não consumação dos mesmos se reverta em sentimen-tos negativos em relação ao cirurgião, que pode torna-se o único “culpado”; Jamais garantir resultados ou minimizar o risco. Em relação ao risco, é compreensível que o paciente e familiares não queiram falar ou ouvir sobre o mesmo. Ainda assim, o profissional deve ter habilidade suficiente para abordar o assunto sem atemorizar ou gerar pânico, porém sem omitir a verdade;

4ª. Na avaliação do risco cirúrgico é indispensávela participação do anestesiologista. A esse profissional compete a avaliação do risco anestésico. O tipo de anestesia não deve ser imposto pelo cirurgião e sim discutido como anestesiologista, respeitando sempre sua indicação ou contra-indicação. A avaliação anestesio-lógica nas situações eletivas deve ser realizada em consulta especializada antes da internação hospitalar. É desejável que o paciente conheça, com antecedência,seu anestesiologista; Alertar o paciente sobre a possibilidade de ocorrências imprevisíveis durante a intervenção cirúrgica. Esclarecer que as mesmas poderão alterar o planejamento cirúrgico e exigir mudanças técnicas ou táticas que, por sua vez, poderão implicar novos desdobramentos, como aumento da permanência hospitalar, maior risco ou maiores custos;

5ª. Lembrar que, salvo em situações de emergência e urgência declaradas, é facultado ao cirurgião usar os dispositivos do parágrafo primeiro do artigo 61 do Código de Ética Médica, ou seja, deixar de operar o paciente com o qual não foi possível estabelecer um relacionamento de confiança recíproca. Nesta situação é necessário garantir a transferência do paciente para outro profissional, que deverá ser informado

sobre os detalhes do caso;

6ª. Diante da possibilidade de futuras incompreensões, queixas ou petições, não hesitar em solicitar ao paciente ou a seu responsável legal a assinatura de um “Termo de Consentimento Esclarecido”, que deverá também ser assinado por duas testemunhas não envolvidas no caso;

7ª. Não deixar de preencher corretamente o prontuário ou a ficha clínica do paciente, na qual deverão constar os dados referentes ao exame clínico, aos exames subsidiários, especificando os resultados, o local e data em que foram realizados e aos esclarecimentos prestados;

8ª. Descrever com detalhes o ato cirúrgico. Caso haja material a ser encaminhado para exame anatomopatológico, preencher o laudo de encaminhamento e cientificar-se de que o material foi corretamente acondicionado e identificado;

9ª. Conduzir o pós-operatório anotando as datas e os horários das visitas médicas, bem como todas as providências tomadas. No momento da alta, reavaliar o paciente e registrar as recomendações em relação ao acompanhamento ambulatorial. Estas sugestões se prestam a qualquer tipo de tratamento cirúrgico. O tempo gasto ao adotá-las é altamente recompensado e pode evitar futuros dissabores e danos morais e ou financeiros para o cirurgião e equipe.

10ª.Lembrar que pacientes emocionalmente instáveis,neuróticos ou psicóticos são maus candidatos às intervenções cirúrgicas. Nestes casos impõem-se medidas suporte conduzidas por especialista na área. A apreensão diante das intervenções cirúrgicas é absolutamente normal. Ao contrário, o total destemor deve ser motivo de suspeita a cerca da integridade emocional do paciente;

O aspecto ético na relação médico paciente, acima de valores ou conceitos morais, pressupõe respeito mútuo entre ambas as partes, para que o produto final seja o melhor possível, a manutenção da saúde e da vida. O médico, como qualquer outro profissional, deve seguir preceitos éticos e legais. Não deve, sob pena de processos e punição, incorrer em desvios de conduta como imperícia, imprudência e negligência. Para o bom exercício da medicina é fundamental o bom preparo cognitivo, técnico, afetivo e moral. No caso particular do ato cirúrgico, o cirurgião deve ser eclético, dominar as várias técnicas cirúrgicas e conhecer suas vantagens e desvantagens, para empregar a mais adequada para cada situação em particular e assim melhor beneficiar seus pacientes.

The General Surgery Job Market

Surgeon digital paint practise by lupinemoonfeather

There is a current shortage of general surgeons nationwide. A growing elderly population and ongoing trends toward increased health care use have contributed to a higher demand for surgical services, without a corresponding increase in the supply of surgeons. The number of general surgeons per 100,000 people in the United States declined by 26% from the 1980s to 2005. Cumulative growth in demand for general surgery is projected to exceed 25% by 2025. The Association of American Medical Colleges has projected a shortage of 41,000 general surgeons by 2025. General surgeons make up 33% of the total projected physician shortage, the second highest after primary care physicians, who make up 37% of the total shortage. Despite the demand for general surgeons, the percentage of general surgery trainees going directly into practice is decreasing while the percentage of trainees pursuing subspecialty training is increasing. A recent study reported that graduating residents who lacked confidence in their skills to operate independently were more likely to pursue subspecialty training. This suggests that some graduating residents are motivated to obtain subspecialty training to gain more experience rather than narrow their clinical scope of practice. Given the projected shortage of general surgeons, this will be a crucial distinction when reforming surgical education. General surgery trainees interested in career planning would benefit from understanding the demand for general and/or specialty skills in a job market heavily influenced by a constant stream of new graduates. However, little is currently known about the demand for subspecialty vs general surgical skills in the current job market. The goal of this study was to describe the current job market for general surgeons in the United States, using Oregon and Wisconsin as surrogates. Furthermore, we sought to compare the skills required by the job market with those of   graduating trainees with the goal of gaining insight that might assist in workforce planning and surgical education reform.

THE GENERAL SURGERY JOB MARKET_REVIEW ARTICLE

COMO PODEMOS CURAR A MEDICINA ? (Atul Gawande)

“Nos últimos anos percebemos que estávamos na mais profunda crise da existência da medicina, devido a algo sobre o que você normalmente não pensa quando você é um médico preocupado em fazer o bem para as pessoas, que é o custo do tratamento de saúde. Não há um país no mundo que não esteja perguntando agora se podemos custear o que médicos fazem. A luta política que desenvolvemos tornou-se aquela sobre se o governo é o problema ou se as companhias de seguro são o problema. E a resposta é sim e não; é mais profundo que tudo isso. A causa de nossos problemas é, na verdade, a complexidade que a ciência nos deu. E para entender isso, voltarei algumas gerações…”

UM TOQUE DE MÉDICO (Abraham Verghese)


“A medicina moderna está ameaçada a perder uma ferramenta fora de moda, mas poderosa: o toque humano. O médico e escritor Abraham Verghese descreve nosso estranho novo mundo, onde pacientes são meramente pontos de informação e clama pelo retorno do tradicional exame frente a frente.”

LIFE AS A SURGEON


Life as a Surgeon
Surgical careers begin long before one is known as a surgeon. Medicine in general, and surgery in particular, is competitive from the start. As the competition begins, in college or earlier, students are confronted with choices of doing what interests them and what they may truly enjoy vs doing what is required to get to the next step. It is easy to get caught up in the routine of what is required and to lose track of why one wanted to become a doctor, much less a surgeon, in the first place. The professions of medicine and surgery are vocations that require extensive knowledge and skill. They also require a high level of discretion and trustworthiness. The social contract between the medical profession and the public holds professionals to very high standards of competence and moral responsibility. Tom Krizek goes on to explain that a profession is a declaration of a way of life ‘‘in which expert knowledge is used not primarily for personal gain, but for the benefit of those who need that knowledge.’’

For physicians, part of professionalism requires that when confronted with a choice between what is good for the physician and what is good for the patient, they choose the latter. This occurs and is expected sometimes to the detriment of personal good and that of physicians’ families. Tom Krizek even goes so far as to question whether surgery is an ‘‘impairing profession.’’ This forces one to consider the anticipated lifestyle. In sorting this out, it is neither an ethical breach nor a sign of weakness to allocate high priority to families and to personal well-being. When trying to explain why surgery may be an impairing profession, Krizek expands with a cynical description of the selection process. Medical schools seek applicants with high intelligence; responsible behavior; a studious, hard-working nature; a logical and scientific approach to life and academics; and concern for living creatures. He goes further to explain that in addition to these characteristics, medical schools also look for intensity and drive, but are often unable to make distinctions among those who are too intense, have too much drive, or are too ingratiating.

Medical School
There are many ethical challenges confronting medical students. As they start, medical students often have altruistic intentions, and at the same time are concerned with financial security. The cost of medical education is significant. This can encourage graduates to choose specialty training according to what will provide them the most expedient means of repaying their debt. This can have a significant, and deleterious, impact on the health care system in that the majority of medical graduates choose to pursue specialty training, leaving a gap in the availability of primary care providers. As medical students move into their clinical training, they begin interacting with patients. One concern during this time is how medical students should respond and carry on once they believe that a mistake on their part has resulted in the injury or death of another human being. In addition, the demands of studying for tests, giving presentations, writing notes, and seeing patients can be overwhelming. The humanistic and altruistic values that medical students have when they enter medical school can be lost as they take on so much responsibility. They can start to see patient interactions as obstacles that get in the way of their other work requirements. During their clinical years, medical students decide what field they will ultimately pursue. For students to make an informed decision about a career in surgery, they need to know what surgeons do, why they do it, and how surgery differs from other branches of medicine. It is important for them to be aware of what the life of a surgeon entails and whether it is possible for them to balance a surgical career with a rewarding family life.

Surgical Residency
Beginning residents are confronted with a seemingly unbearable workload, and they experience exhaustion to the point where the patient may seem like ‘‘the enemy.’’ At the same time, they must learn how to establish strong trusting relationships with patients. For the first time, they face the challenge of accepting morbidity and death that may have resulted directly from their own actions. It is important that residents learn ways to communicate their experience to friends and family, who may not understand the details of a surgeon’s work but can provide valuable support. The mid-level resident confronts the ethical management of ascending levels of responsibility and risks, along with increasing emphasis on technical knowledge and skills. It is at this level that the surgical education process is challenged to deal with the resident who does not display the ability to gain the skills required to complete training as a surgeon. Residents at this level also must deal with the increasing level of responsibility to the more junior residents and medical students who are dependent on them as teacher, organizer, and role model. All of this increasing responsibility comes at a time when the resident must read extensively, maintain a family life, and begin to put long-range plans into practice in preparation for the last rotation into the chosen final career path. The senior surgical resident should have acquired the basics of surgical technique and patient management, accepting nearly independent responsibility for patient care. The resident at this level must efficiently and fairly coordinate the functioning team, engage in teaching activities, and work closely with all complements of the staff. As far as ethics education is concerned, residents at this stage should be able to teach leadership, teamwork, and decision-making. They should be prepared to take on the value judgments that guide the financial and political aspects of the medical and surgical practice.

The Complete Surgeon
The trained surgeon must be aware of the need to differentiate between the business incentives of medical care and doing what is right for a sick individual. As financial and professional pressures become more intense, the challenge increases to appropriately prioritize and balance the demands of patient care, family, education, teaching, and research. For example, how does the surgeon deal with the choice between attending a child’s graduation or operating on an old patient who requests him rather than an extremely well-trained associate who is on call? How many times do surgeons make poor choices with respect to the balance of family vs work commitments? Someone else can
competently care for patients, but only parents can be uniquely present in the lives of their children. Time flies, and surgeons must often remind themselves that their lives and the lives of their family members are not just a dress rehearsal.

Knowing When to Quit
A 65-year-old surgeon who maintains a full operating and office schedule, is active in community and medical organizations, and has trained most of her surgical colleagues is considering where to go next with her career. Recently, her hospital acquired the equipment to allow robotic dissection in the area where she does her most complicated procedures. She has just signed up to learn this new technology, but is beginning to reflect on the advisability of doing this. How long should she continue at this pace, and how does she know when to slow down and eventually quit operating and taking the responsibility of caring for patients? Murray Brennan summarizes the dilemma of the senior surgeon well. The senior surgeon is old enough and experienced enough to do what he does well. He yearns for the less complicated days where he works and is rewarded for his endeavors. He becomes frustrated by restrictive legislation, the tyranny of compliance, and the loss of autonomy. Now regulated, restricted, and burdened with compliance, with every medical decision questioned by an algorithm or guideline, he watches his autonomy of care be ever eroded. Frustrated at not being able to provide the care, the education, and the role model for his juniors, he abandons the challenge.

Finishing with Grace
Each surgeon should continuously map a career pathway that integrates personal and professional goals with the outcome of maintaining value, balance, and personal satisfaction throughout his or her professional career. He or she should cultivate habits of personal renewal, emotional self-awareness, and connection with colleagues and support systems, and must find genuine meaning in work to combat the many challenges. Surgeons also need to set an example of good health for their patients. Maintaining these values and healthy habits is the work of a lifetime. Rothenberger describes the master surgeon as a person who not only knows when rules apply, recognizes patterns, and has the experience to know what to do, but also knows when rules do not apply, when they must be altered to fit the specifics of an individual case, and when inaction is the best course of action. Every occasion is used to learn more, to gain perspective and nuance. In surgery, this is the rare individual who puts it all together, combining the cognitive abilities, the technical skills, and the individualized decision-making needed to tailor care to a specific patient’s illness, needs, and preferences despite incomplete and conflicting data. The master surgeon has an intuitive grasp of clinical situations and recognizes potential difficulties before they become major problems. He prioritizes and focuses on real problems. He possesses insight and finds creative ways to manage unusual and complex situations. He is realistic, self-critical, and humble. He understands his limitations and is willing to seek help without hesitation. He adjusts his plans to fit the specifics of the situation. He worries about his decisions, but is emotionally stable.

Ethics in Surgery : R.I.S.K.

CIRURGIA SEGURA

Renewed public attention is being paid to ethics today. There are governmental ethics commissions, research ethics boards, and corporate ethics committees. Some of these institutional entities are little more than window dressing, whereas others are investigative bodies called into being, for example, on suspicion that financial records have been altered or data have been presented in a deceptive manner. However, many of these groups do important work, and the fact that they have been established at all suggests that we are not as certain as we once were, or thought we were, about where the moral boundaries are and how we would know if we overstepped them. In search of insight and guidance, we turn to ethics. In the professions, which are largely self-regulating, and especially in the medical profession, whose primary purpose is to be responsive to people in need, ethics is at the heart of the enterprise.

Responsibility to the patient in contemporary clinical ethics entails maximal patient participation, as permitted by the patient’s condition, in decisions regarding the course of care. For the surgeon, this means arriving at an accurate diagnosis of the patient’s complaint, making a treatment recommendation based on the best knowledge available, and then talking with the patient about the merits and drawbacks of the recommended course in light of the patient’s life values. For the patient, maximal participation in decision making means having a conversation with the surgeon about the recommendation, why it seems reasonable and desirable, what the alternatives are, if any, and what the probable risks are of accepting the recommendation or pursuing an alternative course.

This view of ethically sound clinical care has evolved over the latter half of the 20th century from a doctor-knows-best ethic that worked reasonably well for both patients and physicians at a time when medical knowledge was limited and most of what medicine could do for patients could be carried in the doctor’s black bag or handled in a small, uncluttered office or operating room. What practical steps can be taken by clinicians to evaluate patient attitudes and behavior relative to the patient’s cultural context so that the physician and patient together can reach mutually desired goals of care? Marjorie Kagawa-Singer and her colleagues at the University of California, Los Angeles, developed a useful tool for ascertaining patients’ levels of cultural influence. It goes by the acronym RISK:

Resources: On what tangible resources can the patient draw, and how readily available are they?

Individual identity and acculturation: What is the context of the patient’s personal circumstances and her degree of integration within her community?

Skills: What skills are available to the patient that allow him to adapt to the demands of the condition?

Knowledge: What can be discerned from a conversation with the patient about the beliefs and customs prevalent in her community and relevant to illness and health, including attitudes about decision making and other issues that may affect the physician-patient relationship.

Leadership in SURGICAL TEAM


Leadership is a process of social influence in which one person can enlist the aid and support of others in the accomplishment of a common task. Successful leaders can predict the future and set the most suitable goals for organizations. Effective leadership among medical professionals is crucial for the efficient performance of a healthcare system. Recently, as a result of various events and reports such as the ‘Bristol Inquiry’, and ‘To Err is Human’ by the Institute of Medicine, the healthcare organizations across different regions have emphasized the need for effective leadership at all levels within clinical and academic fields. Traditionally, leadership in clinical disciplines needed to display excellence in three areas: patient care, research and education.


Within the field of surgery, the last decade has seen various transformations such as technology innovation, changes to training requirements, redistribution of working roles, multi-disciplinary collaboration and financial challenges. Therefore, the current concept of leadership demands to set up agendas in line with the changing healthcare scenario. This entails identifying the needs and initiating changes to allow substantive development and implementation of up-to-date evidence. This article delineates the definition and concept of leadership in surgery. We identify the leadership attributes of surgeons and consider leadership training and assessment. We also consider future challenges and recommendations for the role of leadership in surgery.

PRINCIPLES OF LEADERSHIP FOR GENERAL SURGEONS

Not only SURGEONS

Imagem


“… We need a system… which will produce not only surgeons but surgeons of the highest type,…men to study surgery and to devote their energy and their lives to raising the standard of surgical science…”

WS Halsted – Bull Johns Hopkins Hosp 15: 267, 1904.


O RELATO CIRÚRGICO


DESCRIÇÃO DO ATO OPERATÓRIO – RELATO CIRÚRGICO


Conterá os dados de identificação do paciente, o nome do procedimento cirúrgico, o diagnóstico, o nome do cirurgião e de seus auxiliares, incluindo-se os da equipe de enfermagem, hora do início e do fim da operação, descrição sumária do estado geral do paciente. É prejudicial descrever “oficiosamente” o ato operatório, isto é, fazer descrição sumariíssima apenas dos tempos cirúrgicos básicos com apresentação do mesmo relatório para todos os procedimentos idênticos. É preciso criticar com veemência relatos cirúrgicos em que constem apenas “cirurgia feita pela técnica habitual”. Valiosos detalhes são omitidos e se perdem para consultas, pesquisas e esclarecimentos. Deve-se evitar “descrição” prévia, injustificável em todos os casos. O ato cirúrgico será registrado como dissertação minuciosa das táticas e técnicas operatórias usadas, dos acidentes cirúrgicos, das dificuldades técnicas, daquilo que foi visto e realizado do início ao fim do procedimento. Pela sua importância, tal relatório poderá ser refeito em ocasião de mais calma e propícia à reflexão, atentando-se ao maior zelo pela legibilidade. É muito importante registrar:

1. as condições do paciente antes e após da operação

2. afecções concomitantes

3. tempo de início e do fim da operação

4.posição do paciente e uso de coxim

5. aspecto da afecção em questão (grau de inflamação, disseminação e gravidade)

6. produto(s) usado(s) na anti-sepsia

7. via de acesso

8. uso de eletrocautério

9. fios utilizados e tipos de sutura

10. descrição minuciosa da técnica cirúrgica realizada

Os exames radiológicos transoperatórios e a falta de material quando houver também deverão ser descritos. A obtenção de peças cirúrgicas para histopatologia, biópsias, secreções colhidas para estudos laboratoriais, lavações, tipo de suturas (pontos contínuos, separados, especiais), inclusive as realizadas no fechamento da ferida cirúrgica e tipo de curativo. Objetos que constituem indício de crime devem ser classificados e rotulados para envio ao instituto médico-legal ou à autoridade policial. É recomendável desenhar,esquematicamente, aspectos importantes da operação.  descrição detalhada das lesões por arma branca e, se possível, do trajeto interno detalhado do projetis de arma de fogo; anotar se o projetil foi extraído ou não, assim como outros corpos estranhos. Anotar a solicitação do exame histopatológico das peças cirúrgicas que demandem estudo para diagnóstico. Preencher o cabeçalho e demais itens da folha de descrição, como data, hora e duração do ato cirúrgico, forma de anestesia, anotar nome dos auxiliares médicos e dos outros profissionais de toda a equipe, assinatura e carimbo. A descrição cirúrgica deve constituir atrativo relato de valor científico, cuja leitura inspire confiança e crédito. A equipe deve conferir todo o material cirúrgico, inclusive gazes e compressas, antes e depois da operação, para evitar permanência de corpo estranho no paciente. É preciso que esses fatos sejam anotados no prontuário, assim como intercorrências dignas de nota durante o ato cirúrgico. Folha de descrição cirúrgica bem preenchida é documento comprovante imprescindível dos procedimentos cirúrgicos e, em geral, é imprescindível para cobrança dos gastos pelo serviço de faturamento e, principalmente, para comprovação do que foi realizado pela equipe cirúrgica em casos de dúvidas, demanda judicial ou processo ético-profissional.

“Ex nihilo nihil fit”

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Safe Surgery Save Lives

Evento Adverso (EA) é definido de acordo com a International Classification for Patient Safety proposta pela World Alliance for Patient Safety da Organização Mundial de Saúde (OMS) como incidente que resulta em dano (harm) ao paciente. Incidente definido como evento ou circunstância que poderia ter causado ou que resultou desnecessariamente em dano ao paciente e evento como algo que acontece com ou envolve o paciente. Os eventos adversos (EAs) têm estimativa de ocorrência em 4 a 16% de todos os pacientes hospitalizados, sendo que mais de metade nos cuidados cirúrgicos, dos quais acima de 50% são evitáveis. A ocorrência de EAs é considerada um problemade importância internacional sendo crescente o envolvimento de pesquisadores,profissionais de saúde e gestores de saúde na avaliação de EAs e inúmeras as instituições,redes de relacionamento e websites referentes ao tema.

Em 2004, expressando a preocupação mundial com a segurança de pacientes, foi  criada pela OMS a World Alliance for Patient Safety tendo como elemento central a formulação do Global Patient Safety Challenge, que engloba temas representativos dos principais aspectos dos riscos relacionados com a assistência à saúde, considerados relevantes para os países membros da OMS. O primeiro tema selecionado foi infecção associada à prestação de serviço em saúde, seguido de segurança dos cuidados cirúrgicos,tendo como objetivo prevenir erros, evitar danos e salvar vidas. O número de cirurgias de maior porte realizadas anualmente no mundo foi estimado pela OMS em 234 milhões, o que corresponde a uma cirurgia para cada 25 pessoas.

Cirurgia de maior porte inclui qualquer procedimento realizado na sala de cirurgia envolvendo incisão, excisão, manipulação, ou sutura de tecido que geralmente requer anestesia geral ou regional, ou sedação profunda para controlar a dor. Em países industrializados complicações ocorrem em 3 – 16% dos procedimentos cirúrgicos realizados em pacientes internados, com taxa de mortalidade de 0,4 – 0,8%. Estudos realizados em países em desenvolvimento estimam uma taxa de mortalidade de 5 a 10% em pacientes submetidos à cirurgia de maior porte. A segurança em cirurgia emerge como importante preocupação para a saúde pública global. Cirurgia é um dos mais complexos e caros serviços prestados pelos sistemas de saúde.

Nos países em desenvolvimento , o mau estado da infraestrutura e dos equipamentos; os problemas quanto ao suprimento e à qualidade de medicamentos e de material médico-cirúrgico; as falhas na gestão da organização e no controle de infecção; o desempenho insatisfatório dos profissionais devido à baixa motivação ou à deficiência na capacitação técnica; as falhas no correto diagnóstico pré-operatório; as deficiências na consulta pré-anestésica, e o subfinanciamento dos custos operacionais dos serviços de saúde, tornam a probabilidade de ocorrência de eventos adversos muito maior do que em países industrializados.

Veja alguns dados:

§4% pacientes sofrem algum tipo de dano no Hospital
§70% dos eventos adversos provocam uma incapacidade temporal
§14% dos incidentes são mortais
§60% são evitáveis

World Alliance for Patient Safety : forward programme. World Health Organization 2004, apud: Harvard Medical Practice Study in 1991

Eventos Adversos na Clínica Cirúrgica


EVENTOS ADVERSOS # COMPLICAÇÕES


O termo Evento Adverso (EA) cirúrgico é relativamente novo, mas o conceito de monitoramento dos resultados cirúrgicos, incluindo complicações pós-operatórias é muito antigo, havendo referência a sistemas de coleta de informações hospitalares existentes em 1732. Estatísticas vitais existem na Grã-Bretanha desde 1838. Em 1850 foi estabelecida a associação entre transmissão de infecção e a higiene da mão e em 1854 destacados os riscos aos pacientes relacionados com a má higiene nos hospitais. Em 1910, Ernest Codman apontou a necessidade de avaliação rotineira dos resultados negativos em cirurgias para a melhoria da qualidade da assistência. Nos anos 90 do século passado, continuou a expansão do interesse no campo de erros e danos relacionados com a assistência à saúde, porém com mudança no foco daspesquisas, que inicialmente buscavam estimar a frequência e natureza dos EAs em instituições e mais recentemente uma ênfase dirigida a como lidar melhor com o problema e uma crescente concordância com uma abordagem sistêmica ou organizacional.


EAs cirúrgicos contribuem significativamente para a morbidade pós-operatória, sendo sua avaliação e monitoramento frequentemente imprecisos e com validade incerta. Dada a tendência de redução do tempo de permanência hospitalar e o aumento no uso de  técnicas cirúrgicas inovadoras, especialmente minimamente invasivas e os procedimentos endoscópicos, a avaliação e o monitoramento eficiente dos eventos adversos cirúrgicos tornam-se cruciais. Alguns atributos comuns foram identificados em recente revisão de eventos adversos : EAs são desfavoráveis, indesejáveis e prejudiciais, têm impacto sobre o paciente e estão associados a um processo da assistência à saúde, mais do que a um processo natural de doenças. Estudos sobre eventos adversos têm demonstrado a complexidade de sua análise devido à variabilidade dos sistemas de registro e a extensa gama de definições na literatura científica para complicações pós-operatórias.

As complicações pós-operatórias resultam da interação de fatores dependentes do paciente, de sua enfermidade e da atenção à saúde recebida. O estudo dos EAs cirúrgicos tem especial relevância por sua frequência, porque em parte são atribuíveis a deficiências na atenção à saúde, pelo impacto considerável sobre a saúde dos pacientes, pela repercussão econômica no gasto social e sanitário e por constituir um instrumento de avaliação da qualidade da assistência. Os eventos adversos de maior interesse à saúde pública são os evitáveis, suscetíveis a intervenções dirigidas à sua prevenção. Os eventos adversos cirúrgicos estão relacionados com acidentes intra-operatórios cirúrgicos ou anestésicos, com complicações pós-operatórias imediatas ou tardias e com o fracasso da intervenção cirúrgica.

Os EAs cirúrgicos foram objeto de estudos realizados nos EUA , Austrália e Espanha . No estudo sobre EAs cirúrgicos em hospitais de Colorado e Utah (EUA) foi calculada a taxa de incidência de 1,9% para o total de pacientes internados. Dentre os pacientes submetidos à cirurgia e nos casos de parto a taxa de incidência de EAs cirúrgicos foi de 3,0%, sendo 54% considerados evitáveis. Foi estimado que 5,6% dos EAs cirúrgicos resultaram em óbito. No estudo para determinar a taxa de EAs em pacientes cirúrgicos na Austrália , a prevalência de internações cirúrgicas associadas com um EA foi calculada em 21,9%. Quanto à prevenção, foram classificados como altamente evitáveis 47,6% dos EAs, pouco evitáveis 31,4% e 20,8% não evitáveis.

Foi realizado um estudo para descrever os eventos adversos em cirurgias de parede abdominal e analisar as associações entre os resultados e determinadas características dospacientes, em um serviço de cirurgia geral em Valencia, Espanha . Complicações foram identificadas em 16,32% dos pacientes. A relevância da questão da segurança em cirurgia no Brasil pode ser evidenciada pelos resultados do estudo de Mendes et al. (2009) , especialmente se considerarmos o volume de internações relacionadas com cirurgia ocorridas no país no ano de 2003, cerca de três milhões, ano de referência do estudo mencionado . Além disso, poucos hospitais brasileiros cumprem a legislação sanitária para o licenciamento de estabelecimentos hospitalares.

Dados oriundos do Conselho Regional de Medicina do Estado de São Paulo, referentes à inspeção de 743 hospitais realizadas no ano de 2003, demonstram que 52,5% apresentaram condições físicas inadequadas, em desacordo com a legislação sanitária. Deve ainda ser destacado que os hospitais de pequeno porte, ou seja, com até cinquenta leitos, representam 62% dos estabelecimentos hospitalares e 18% dos leitos existentes no sistema de saúde brasileiro. Esses hospitais estão distribuídos principalmente em municípios de pequeno porte interioranos, são de baixa complexidade e densidade tecnológica, apresentam taxa de ocupação baixa (32,8%) e 89% possuem sala de cirurgia.

O CIRURGIÃO (POEMA)

O CIRURGIÃO

Um corpo inerte aguarda sobre a mesa
Naquele palco despido de alegria.

O artista das obras efêmeras se apresenta.
A opereta começa, ausente de melodia
E o mascarado mudo trabalha com presteza.

Sempre começa com esperança e só términa com certeza.

Se uma vida prolonga, a outra vai-se escapando.

E nem sempre do mundo o aplauso conquistando
Assim segue o artista da obra traiçoeira e conquistas passageiras.

Há muito não espera do mundo os louros da vitória
Estudar, trabalhar é sua história, e a tua maior glória
Hás de encontrar na paz do dever cumprido.

Quando a vivência teus cabelos prateando
E o teu sábio bisturi, num canto repousando

Uma vez que sua missão vai terminando
Espera do bom Deus  por tudo, a ti, seja piedoso.

SOIS VÓS INSTRUMENTO DA TUA OBRA.

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The Qualities of a GOOD SURGEON


Following is a list of Dr. Ephraim McDowell’s personal qualities described as “C” words along with evidence corroborating each of the characteristics.


Courageous: When he agreed to attempt an operation that his teachers had stated was doomed to result in death, he, as well as his patient, showed great courage.

Compassionate:  He was concerned for his patient and responded to Mrs. Crawford’s pleas for help.

Communicative: He explained to his patient the details of her condition and her chances of survival so that she could make an informed choice.

Committed: He promised his patient that if she traveled to Danville, he would do the operation. He made a commitment to her care.

Confident: He assured the patient that he would do his best, and she expressed confidence in him by traveling 60 miles by horseback to his home.

Competent: Although lacking a formal medical degree, he had served an apprenticeship in medicine for 2 years in Staunton, Virginia, and he had spent 2 years in the study of medicine at the University of Edinburgh, an excellent medical school. In addition, he had taken private lessons from John Bell, one of the best surgeons in Europe. By 1809 he was an experienced surgeon.

Carefull: Despite the fact that 2 physicians had pronounced Mrs. Crawford as pregnant, he did a careful physical examination and diagnosed that she was not pregnant but had an ovarian tumor. He also carefully planned each operative procedure with a review of the pertinent anatomic details. As a devout Presbyterian, he wrote special prayers for especially difficult cases and performed many of these operations on Sundays.

Courteous: He was humble and courteous in his dealings with others. Even when he was publicly and privately criticized after the publication of his case reports, he did not react with vitriol. The qualities of character demonstrated by Dr. Ephraim McDowell 200 years ago are still essential for surgeons today.

Etiqueta Médica : Postura do Cirurgião Geral na U.T.I.

ImagemA etiqueta no ambiente hospitalar vai além das regras de boa convivência. Ela oferece recursos para que os profissionais construam relacionamentos sólidos, além de ensiná-los a lidar com os “sabotadores da carreira”, como indiscrição e a falta de educação. Logo as atitudes no trabalho devem ser pautadas pelo bom senso, pelo bom gosto e pelo equilíbrio. Esses três fatores têm um único objetivo: fazer-nos pessoas melhores na convivência com os demais. Certamente, pensar muito antes de agir nos protege de escolhas equivocadas de comportamentos. As relações de trabalho e os ambientes hospitalares mudaram muito nos últimos anos, assim como as regras de convivência e as competências relacionais. Hoje, muitas empresas adotam estações de trabalho em que todos compartilham o mesmo espaço. Tudo o que se fala pode ser ouvido. A privacidade é muito menor, o que exige discrição. As atribuições das lideranças também evoluíram: em vez de mandar, os líderes devem convencer as suas equipes para serem respeitados. Outro desafio é promover a boa convivência entre gerações diferentes nas empresas. Os avanços tecnológicos exigem muito mais dos relacionamentos com colegas de todos os níveis. Portanto, o uso de emails, redes sociais e mensagens instantâneas, entre outros recursos, deve preservar sempre a cortesia, o respeito e a devida atenção ao outro. Sendo a “regra de platina” das relações humanas: trate os outros melhor do que você gostaria de ser tratado!

Ao encaminhar o paciente no pós-operatório para U.T.I. o Cirurgião legalmente mantém sua responsabilidade sob os cuidados cirúrgicos deste paciente, sendo a partir daí um dos profissionais que participará na orientação das condutas clínicas relacionadas ao procedimento cirúrgico do paciente. Desta forma deve ficar á livre disposição dos INTENSIVISTAS para dirimir qualquer dúvida ou prestar orientações quanto a evolução cirúrgica do paciente em questão.

Alguns cuidados são importantes para serem lembrados nesta relação CIRURGIÃO e o Corpo Clínico das Unidades de TERAPIA INTENSIVA…

  1. Ao executar um procedimento cirúrgico, lembre-se que se algum evento adverso pode ocorrer, este um dia irá acontecer (Lei de Murphy). Prepara-se o pior possível. Se pensas que após uma complicação cirúrgica as coisas não podem piorar, acredite que podem. E serão justamente esta equipe de Especialistas que nos ajudaram a conduzir melhor o caso.
  2. Nada na Medicina permanece constante, em especial no pós-operatório,  e nenhum órgão falha isoladamente.
  3. Cuidado com a Lei da Especialização: se fores um martelo, o resto do mundo é um prego. Aquele que pensa que sabe tudo, não sabe nada.
  4. Um “abdómen agudo cirúrgico” é diagnosticado após o exame físico por parte de um cirurgião EXPERIENTE e COMPROMETIDO, podendo ou não ser ratificado pelos exames complementares. Não existe nenhum teste complementar isolado para isso.
  5. Antes de solicitarmos um exame complementar, precisamos planejar o que faremos se for positivo ou negativo. Se as respostas forem iguais, não o solicitaremos. Corolário: Se o teste não altera a nossa estratégia, não solicitaremos.
  6. Não existe nenhum efeito adverso que não possa ser causado por um determinado fármaco. Se o fármaco não é essencial no tratamento, não usaremos.
  7. Geralmente a qualidade do cuidado prestado ao paciente é inversamente proporcional ao número de especialidades (consultores) envolvidos nesse caso particular. Todo paciente cirúrgico possui um único cirurgião responsável pelo procedimento em questão.
  8. Se as orientações médicas forem passíveis de má interpretação pela equipe multidisciplinar, elas certamente serão mal interpretadas. Portanto precisamos sempre nos perguntar: “Eu fui claro nas minhas orientações?”.
  9. Nunca ignore uma chamada de atenção de um dos membros da equipe Multidisciplinar, em especial do corpo de enfermagem. É função destes colegas nos informar. A nossa função é decidir. Seja cordial e serás retribuído da mesma maneira. Se fores desagradável, terás uma vida miserável. Jamais confunda o carteiro com a mensagem da carta.
  10. Se não sabes o que fazer, não faças nada e pede ajuda. Fazer mal não é melhor que não fazer nada. Pede e insiste na ajuda se tiveres dúvidas ou complicações que você nunca conduziu. Erros de inexperiência em doentes críticos podem ter consequências catastróficas.

Deixe nos comentários a sua contribuição.

BOM PLANTÃO.

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