4 Signs of Surgeons' Inattention in the OR

These are the four telltale behaviors of automaticity or drifting:

1. Fine tuning. The surgeon continues to engage in extraneous conversation or pauses momentarily to focus on the operative procedure.

2. Focusing more intently. The surgeon withdraws from extraneous conversation or distraction but proceeds without removing or controlling the environmental distractions.

"The surgical fellow had just divided the bile duct during a standard Whipple procedure and was engaged in an extraneous conversation with U2 playing in the background. The surgeon noticed some bleeding and dropped out of the conversation, focusing intently on what they had just divided." Meanwhile the fellow continued talking and the resident and medical student in the room "were literally nodding their heads to the music."

3. Removing distractions.  The surgeon removes distractions, including visitors. He may turn off music and ask that conversations cease.

"The situation was relaxed and proceeding uneventfully. The resident, holding a retractor, was telling an unrelated story to the surgical team with the surgeon laughing in response to her story and joining in the discussing.  In the operative field, a large hepatic vein was opened suddenly, causing a moderate and steady flow of blood loss. Oblivious to this, the resident continued talking. The surgeon said, "Wait one minute. Let's just see where we are." Without the situation fully under control, the resident resumed talking. The surgeon said with some agitation, "Wait one minute, a bit too much bleeding here."