hat is the goal of all of us who work daily in the operating room? I hope W we agree that it is the successful

outcome of the surgical procedure from the patient’s point of view. Let us examine some of the ways in which we are directly or in- directly responsible for the patient’s well- being. What are some of the ways in which technically competent, experienced operating room personnel can improve their relation- ships with the patient?

The patient: first meeting. Suppose you are introduced to someone who impresses you as having charm, intelligence, pleasant good looks, elegant dress, style, carriage- perhaps most of all, quick wit and good humor. Two days later this person enters the hospital with the diagnosis of acute appen-

\\ / I dicitis and is assigned to the operating room where you are circulating nurse. The person now has undergone a remarkable change. Gone are the attractive style and carriage: he arrives in the operating room lying on a

wearing a skimpy hospital gown; the den- tures are out; the hair is covered with a paper bonnet. Narcotic and sedative drugs are listening have wiped out the charm, quick wit, and humor. The dignity is diminished; the unique and awesome situation has induced feelings of dependency and uneasiness.

It is in this second state that many of the operating room personnel first view the pa- tient. They have no way of knowing his true personality or his appearance when well. Be kind and generous, then, in your evaluation of him.

The patient: what he cannot take. The pa- tient is usually premedicated, mainly to allay fear, apprehension, and pain. Seda- tives, tranquilizers, and narcotics depress the cortical centers so that he is usually incapa- ble of joking. His sense of humor is so dulled that he may take offense a t a casual witti- cism. He may have been the life of the party last night, but nothing is funny to him now. He has a tendency to paranoia. If you talk of someone else or discuss the problems of

Shhh! s I ee p i n g

OR patients stretcher. Gone is the elegant dress: he is

Adella DeLappe, MD

1334 AORN Journal. June 1974, Vol 19, N o 6

some other patient, the patient who hears you may misconstrue your re- marks as applying to him and become fearful or hostile.

We must never, in any way, take advantage of this dependent, fearful, depressed, sometimes confused state of the patient’s mind. In no way should we pass judgment on his ac- tions or condition, though he may be hostile, hysterical, belligerent, drunk, abusive, weepy, depressed, groggy, and unable to cooperate. We must al- ways remember that this patient is under stress and the influence of drugs and is therefore not completely responsible for his actions.

Anything that upsets the patient can be detrimental. If he becomes disturbed, we may lose his coopera- tion during the administration of a local or regional block. He may ex- perience a stormy general anesthesia induction period. We must be con- stantly on the lookout for seemingly small things that may be magnified in the patient’s mind.

Modesty is one such concern. To us, one body is much like another. To the patient, his body is unique and precious. Its exposure may lead to feelings of fear, resentment, or shame. We should make every effort to keep the patient covered until gen- eral anesthesia has taken effect; or, if local or regional anesthesia is being used, until the patient’s eyes are shielded from the surgical ex- posure. If the patient is positioned on one side for spinal anesthesia, drape the buttocks and genitalia with a bath blanket or sheet. This will not interfere with the physician’s place- ment of the needle.

There are special concerns when dealing with children. Whenever pos-

sible, wait until the child is asleep before undressing him. Always allow the child to wear panties or pajama trousers to the operating room, and always put the panties or trousers back on before the child wakes. Even though the operation does not involve the genitals, if the child wakes with panties or pajama trousers off he is likely to fear that something was done to him in that region while he was asleep.

When speaking to a child or when speaking within his hearing, do not make any reference to “putting him to sleep.” Many children have had a pet, or have heard of a pet, that was “put to sleep.” When children hear this expression, they fear they will never waken.

Basic approach to the patient. When you receive your patient, greet him pleasantly by name while check- ing chart and arm identification: “Good morning, Mr Thomas Jones? I am your nurse, Miss Smith.” It is best not to ask, “How are you today?” or “How are you feeling?” Most patients respond with the white lie, “Fine.” But usually the patient is not fine; he is apprehensive if not downright fearful, dopey and not quite “with it” if premedicated, awed by the completely new situation, sometimes nauseated or in pain. If the patient is honest enough to answer, “I feel rotten,” or “I am scared,” then what are you going to say? “There’s nothing to be afraid of” is an outright lie, as we all know.

Adella DeLappe, MD, is assistant chief of the Department of Anes- thesiology at the Kaiser Foundation Hospital, Oakland, Calif. She is a graduate of the University of Cali- fornia Medical School, Sun Francisco.

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AORN Journal, June 1974, Vol 19, N o 6 1335

other and comfortable are nebulous B words open to a multitude of interpretations by the patient.

So does the patient. One way out of this situation-if you have stumbled into it-is a simple, “I’m sorry”; but the vibrations are already wrong and difficult to rectify.

This would be a better approach: “Good morning, Mr Thomas Jones? I’m your nurse, Miss Smith. You are looking comfortable this morning.” This is a positive statement. I t re- quires no answer from the patient, no effort by his sedated brain. He’s off the hook and so are you. Even if he is not completely comfortable, the pa- tient may have less pain than he has had in some time because of the pre- medication. Also, “comfortable” is a pleasant but nebulous word, and per- sons vary in their interpretation of it. If you think the patient looks com- fortable, he will try to adjust to this subtle suggestion, for the patient is usually anxious to please and accom- modate those in whose hands his life is literally placed. Most often, he eagerly grasps a positive pleasant suggestion.

In our hospital, the circulating nurse quizzes the patient about aller- gies and asks when food or fluid was last ingested. These questions seem proper and are probably not threaten- ing, although it would be preferable to seek the answers from the chart.

Some questions are disturbing, however. A query such as, “Which

side is your hernia on?” or “Which leg are we working on?” can be up- setting. The patient may think, “I’ve answered that question a hundred times. I’ve seen the doctor write it down. Here I am actually in the op- erating room and they still don’t know which side my hernia is on!” Yet I agree that it is well to find out directly from the patient what and where the operation will be. One way to accomplish this is to say some- thing like, “I know your record says that your hernia is on the right side; but just to double-check for your safety, which side is i t on?” or, “Your record states you’re to have your gallbladder removed today; is this correct?”

Another question that the patient may find threatening is “Have you had any surgical operation or anes- thetic before?” This question causes the patient to regress to an experi- ence that may have been highly un- pleasant, which he then projects into the present situation. The informa- tion can be obtained from the chart. As far as possible, confine your re- marks and queries to those that carry the patient safely through the opera- tion and into a secure future.

Many patients enter the operating room with ankles crossed. It has been suggested that this position repre- sents a feeling of insecurity or

1338 AORN Journal, June 1974, Vol 19, No 6

anxiety. Instead of saying, “Uncross your legs,” it would be preferable to say, “It will be much more comfort- able for you during the operation if you will uncross your legs.”

Two words I would like to delete from the operating room lexicon are “pain” and “hurt.” Remarks such as “Are you in pain?” “Does this hurt?” and “This won’t hurt you” are anathema. Many patients, when ques- tioned about pain or hurt, think that they are expected to have pain or that a procedure should hurt. They will accommodate by answering yes. If you say, “This won’t hurt you,” you could be wrong. It might hurt. That which would not hurt one pa- tient might hurt another.

Instead of “pain” or “hurt,” there is available a marvelous word: “bother.” Like “comfortable,” this is a nebulous word, open to a multitude of interpretations by the patient. “Is what I’m doing (or what he, she, or the surgeon is doing) bothering you?” “This won’t bother you,” or better yet, “You won’t let this bother you” are useful expressions that avoid suggesting pain or hurt.

Don’t block the block. We carry out many blocks a t our hospital. The success of a block can often be as- sured by an understanding, coopera- tive surgeon and circulating nurse. For example, when we establish axil- lary block for an operation on the hand or arm, the preparation of the operative site is frequently started before the block is completely effec- tive. The nurse can be most helpful by saying to the patient, “I’m going to be scrubbing your arm now. You may feel me washing it and that is all right.” Never ask, “Do you feel me washing you?” or “Is your a m

numb yet?” I once heard a nurse who was scrubbing a foot ask the patient, as she squeezed his toe, “Do you feel this?” When the patient replied yes, she remarked over her shoulder to the scrub nurse, “Break out the local set.” It is not the duty of the nurse to ascertain whether or not the block is effective. If the block is not yet set, such a question may make the patient apprehensive and make him wonder whether he will feel the op- eration.

Many a good block is spoiled by the surgeon’s picking up the skin with forceps and asking, “Can you feel this?” Often the patient answers, yes. Then either local anesthetic is in- jected or the patient is subjected to general anesthesia-either quite un- necessary. With a successful block, the patient frequently can feel pres- sure or a position change but does not feel pain. The surgeons in our operating rooms have been instructed to proceed with the operation with- out remark to the patient, as if the block were known to be totally ef- fective. If it is not, the patient will soon let us know.

I dislike testing the blocked area with needle pricks as the block is set- ting because such testing may focus the patient’s attention too keenly on the blocked area. I prefer to watch for other signs of a good block, such as vasodilation or lack of spontaneous muscle movement. In addition, I make the positive suggestion to the patient that his extremity will be- come numb and that it will feel like a piece of wood, as if it did not be- long to him. Such suggestions are eagerly grasped by most patients who are anxious not to have pain.

Since it is difficult to sort out hyp-

1340 AORN Journal, June 1974, Vol 19, N o 6

n occasion, blood pressure falls, 0 pulse rate speeds in response to remarks during general anesthesia.

notic effects from chemical anes- thesia, I also set a time limit on how long the block will last. I have seen evidence that hypnosis definitely en- ters into many blocks: more than one patient has told me that his arm was numb after insertion of the needle, before the anesthetic solution was in- jected.

Cherish the anesthetist-patient bond. Questions, suggestions, and di- rections from several sources tend to bewilder the medicated patient. He wants and needs direction and sug- gestion, but these should come from a single source. Anesthetic procedures require the patient’s understanding and cooperation. To facilitate this, the anesthesiologist establishes a subtle relationship of dominance and submission. That relationship can easily be broken by outside interfer- ence. Most anesthetists use hypnotic techniques, whether the anesthesia is local, regional, or general. These tech- niques frequently go unrecognized by surgical personnel. As the patient is being prepared for anesthesia, he should be concentrating on one voice alone: the voice that is carrying him safely through the induction of anes- thesia. No one else should be explain- ing to him what is happening or what is going to happen to him. As far as possible, only the anesthetist should handle the patient, unless the anes-

thetist requests help in positioning the patient or in restraining him dur- ing second-stage anesthesia. Hearing the one voice and being handled by the one person helps to strengthen the bond between patient and anesthetist.

The patient hears what you say. We all know that conversation dur- ing the surgical procedure should be kept at a minimum. There are vari- ous reasons, including the reduction in the number of bacteria sprayed about the room. One of the most im- portant reasons is the effect that con- versation may have upon the patient. It is self-evident that the patient under local or regional anesthesia, whether medicated or not, hears op- erating room conversation. It is often not appreciated that the patient may hear and later recall conversations that take place while he is under gen- eral anesthesia, in profound shock, or during cardiac arrest, diabetic coma, brain trauma, drug poisoning, or in- sulin shock.

Now that muscle relaxants are used in combination with light gen- eral anesthesia, i t has been shown that sometimes the patient is actually awake but unable to speak or move because of muscle paralysis. When this occurs, he may remember pain as well as conversation. It is at times difficult for even an experienced anesthesiologist to know whether his

1342 AORN Journal, June 1974, Vol 19, No 6

patient is truly unconscious or not. A case in point was reported recently by Dr David Bradley Cheek. As a surgeon was removing an appendix, he complimented the anesthetist with the remark, “That was an excellent anesthetic.” The patient pulled her face from under the mask and said, “It certainly was,” then put her face back under the mask until the opera- tion was completed.’

Absence of pain is not necessarily evidence that chemical anesthesia has taken effect. Dr Cheek notes that Dr Rudolph Selo, an anesthesiologist in Council Bluffs, Iowa, told of a patient who was to undergo cesarean section because of placenta previa.2 Since she had been losing blood, she was receiving oxygen by mask. The anes- thesiologist was busy starting the transfusion, checking the blood pres- sure, keeping his chart, etc, while awaiting completion of preparation of the surgical site. When he finally looked up, he saw to his horror that the surgeon was already holding the baby and his assistant was manipulat- ing the uterus. The anesthesiologist checked his machine to see whether the patient was really receiving only oxygen. She was. He decided to make no change. The operation was com- pleted uneventfully. This was a case of spontaneous hypnoidal state. In such a state, the expectancy of anes- thesia may bring about dissociation from the awareness of pain without affecting the other senses.

It was believed for many years that patients under deep anesthesia did not hear comments made during sur- gical procedures and would not re- call them afterward. B W Levinson of Johannesburg, South Africa, found that after surgical operations, pa-

tients could not recall operating room experiences that had taken place while they were under deep anes- thesia until they were hypnotized. Under hypnosis, they could recall conversations preci~ely.~

As the patient passes through the early stages of anesthesia, the audi- tory sense is the last sense to be lost. But the patient’s hearing becomes distorted, and conversation or noise at this time may result in auditory hallucinations that are disturbing to him. Just when the sense of hearing is completely lost is unknown.

There are many classic cases of conversations that have upset pa- tients. Dr Cheek tells of a relative who underwent radical mastectomy for carcinoma under general anes- thesia. During the operation, the sur- geon made the comment that she would have a good five-year cure. Five years later to the day, she died. No tumor was found at autopsy. She had heard the surgeon’s remark and interpreted it literally, not under- standing that she could live beyond five years.4

We recently had a patient under spinal anesthesia for cesarean sec- tion. The resident inadvertently cut the staff surgeon’s finger, something he had also done two days before. He was greatly chagrined and said, “Oh, no, not again! Now we’ll never get the baby out.” Needless to say, the patient required much reassurance at this point.

A surgeon recently said to the cir- culating nurse, “Don’t bother me now, I’m trying to keep this patient from bleeding to death.” Although a vessel was loose, this was not actually true and he was jesting. But the pa- tient, under general anesthesia, did not know this. It has been noted on

d+ 1344 AORN Journal, June 1974, Vol 19, N o 6

occasion that blood pressure falls and pulse rate speeds in response to life- threatening remarks during general anesthesia.

A colleague of mine responded to a Code Blue for cardiac arrest. During resuscitation, the staff doctor re- marked in jest, “If she doesn’t come out of this, I’ll take her Health Plan card away.” When the patient was questioned later about her memory of resuscitation, she asked, “Are they really going to take my Health Plan card away?”

It is extremely difficult, if not im- possible, to alter the conversation of surgeons, especially in a teaching hospital. One should make some polite and proper attempt to silence upsetting conversations during opera- tions. Such remarks as, “Look, the cancer has spread all over!” “Oh-oh, it’s in the liver!” or “Inoperable!” may cause a precipitous fall in the patient’s blood pressure under gen- eral anesthesia.

Techniques for reassuring the pa- tient during surgical procedures. You may have noticed the anesthetist whispering to the unconscious pa- tient. He may be reassuring the pa- tient that everything is going well, or asking the patient to bring his blood pressure up. He may be giving the patient suggestions that he will do well postoperatively, that he will have little discomfort, will heal rap- idly, will be home again soon. He may be advising the patient of a con- templated position change. Fear of falling is basic, and patients have been known to have cardiac arrest on sudden position change. Patients, awake or asleep, should always be told when you are about to change their position.

Over the years I have discovered a technique that is useful in reducing the patient’s sensory input. Whether the patient is awake, sedated, or asleep during the operation, I say to him in a positive, directive voice, “Now, there may be a lot of conver- sation and peculiar noises going on during your operation. I want you to pay no attention to them. Pay atten- tion only to my voice and only when I am speaking to you. I will let you know when your operation is over.” This is a hypnotic technique called suggestion. Just before a surgical pro- cedure, patients are in a state that leaves them susceptible to suggestion. They want to be directed. For the most part, they want to cooperate.

When I first started using this technique, I omitted the phrase, “. . . and only when I’m speaking to you.” Patients not under general anesthesia would then answer ques- tions that I directed toward operating room personnel and were aware of everything I said during the proced- ure. This obviously was undesirable. I then realized that patients under general anesthesia might also be hearing my remarks. Since I have in- cluded the last phrase, local and re- gional anesthesia have been much smoother, and much less sedation has been required than previously. I feel more relaxed about the patient under general anesthesia,

As an example of the efficacy of this technique, I recently gave a spinal anesthetic to a man for total hip replacement. In addition to pre- medication and spinal anesthetic, he received minimal sedation with a tranquilizer. He was given the sugges- tion about paying no attention to con- versations or noises and the further suggestion that he would have a

1346 AORN J O U T n d , June 1974, Vol 19, N o 6

pleasant sleep. He was told that I would wake him when the operation was over. Part way through the pro- cedure, a metal tray was dropped to the terrazzo floor. Tray and bowl bounced and clattered. Everyone in the operating room was startled ex- cept the patient. My pulse was racing, but as I immediately checked his pulse and blood pressure, I found them stable. He slept on, completely unconcerned. Later, when I told him that the operation was over and he could awake, he immediately opened his eyes and said that he had had a good sleep. He did not mention the loud noise. This was not a unique ex- perience. I have seen its equivalent time and again.

This is a technique, then, by which the patient can be protected from loud noises, life-threatening remarks, disturbing conversation, and divisive- ness in the operating room. Unfortu- nately, it is not a panacea. Some patients are resistant to suggestion, and many anesthetists are not well versed in its application. Since there is no fail-proof technique for cushion- ing the helpless patient against the detrimental effects of such events, we must all be constantly vigilant in our efforts to protect him by avoiding their occurrence.

In summary, a successful operative procedure includes protection of the patient's psyche. Here are some of the ways in which operating room personnel can achieve such protec- tion:

1. Consider the patient as a unique personality-not as a "slir- gical case."

2. Attempt to stabilize and sus- tain the patient's personality and ego.

3. At all times respect the pa- tient's sense of modesty. 4. Avoid discussing events in the

patient's past. 5. Avoid jokes and jests; they

tax the patient's sedated mind. 6. Avoid remarks that may be

life-threatening, whether the pa- tient is awake or asleep.

7. Attempt to temper conversa- tions among the surgeons that may be upsetting to the patient.

8. At all times, avoid loud noises in the operating room.

9. Avoid conversation and un- necessary noise during induction of anesthesia. 10. Do not bring your troubles

and problems verbally into the op- erating room. This is the patient's time, for which he has paid in more ways than one.

11. Team cooperation is essential to the conduct of a successful op- erative procedure. Avoid divisive- ness in the operating room. Alter- cations should be settled in private.

12. Keep in mind that politeness and good manners are essential in- gredients of tranquil surround- ings. 0

Footnotes

I. D B Cheek, "Unconscious perception of meaningful sounds during surgical anesthesia as revealed under hypnosis," American Journal of Clinical Hypnosis, I (January 1959) 101-1 13.

2. Ibid.

3. B W Levinson, "States of awareness during anesthesia," British Journal of Anesthesia, 37 ( 1965) 544-546.

4. D B Cheek, "Applications of Hypnosis Op- erative," Syllabus: The 17th Annual Anesthesiology Course, Park City, Utah, Feb 19-22, 1974, 3-5.

1348 AORN Journal, June 1974, Vol 19, N o 6