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May 1, 2013 Volume 77, Number 5
Practical Mindfulness for the O.R.: A Patient Safety Initiative Neil E. Farber, M.D., Ph.D. ASA Wellness Task Force


Mindfulness is being fully aware and attentive on a moment-to-moment basis – non-judgmentally and with openness. “Mindlessness” is common when people are multitasking, distracted, depressed, stressed, overloaded and hurried – the typical day for an anesthesiologist. In the May 2010 ASA NEWSLETTER, Lynda Wells, M.D., described the benefits of mindfulness in terms of awareness, stress management, improved mood, decreased burnout, slowing the aging process and prolonging life. Mindfulness-based interventions have grown exponentially in recent years.1 This article focuses on practical tips, strategies and applications of mindfulness in the operating room (O.R.) for the benefit of the patient and the anesthesia provider.

Why Intraoperative Mindfulness?

  • Safety
    Patient: As anesthesiologists, we pride ourselves on being attentive. Our presence in the O.R. is necessary for optimizing patient safety. Yet physical presence is insufficient, as we need to be fully present mentally as well. Attentional fluctuations have large and complex effects on performance. Attention may greatly improve the detection of subtle changes in a stimulus.2 Atul Gawande, M.D. has written about the importance of performing checklists.3 However, checklists performed mindlessly do not change the incidence of adverse patient events.
    Anesthesiologist: In a medico-legal sense, we are all safer when the patient is safer. Avoiding needle sticks, using infection precautions, and maintaining sterility are all more easily accomplished when you are fully attentive to your tasks and surroundings.

  • Satisfaction
    Patient: When one is fully engaged in communicating with others, relationships will be enhanced. Patient satisfaction with the doctor-patient relationship and confidence in the anesthesiologist help produce a smooth and healthy perioperative course.
    Anesthesiologist: After eight weeks of mindfulness training, brain scans showed increased grey-matter density in the hippocampus, known to be important for learning and memory, and decreased grey-matter density in the amygdala, which plays an important role in anxiety and stress.4 Physicians participating in a mindfulness program displayed more empathy, improved attitudes and decreased symptoms of burnout.5 Decreased mind-wandering turns out to be a better predictor of happiness than the actual activities in which people are engaged.6


  • Incorporating Mindfulness
    1. Performing checklists: Assume there is an error in all checklists and try to be the first to find it. Play detective. Even if you’ve looked at the name and information several times previously, listen to the timeout or go over the blood product labeling as if you’ve never seen it before.
    2. Listening: Each monitor, piece of equipment and alarm has a distinct tone. We become experts at distinguishing between them. Yet we can fail to hear anything at all if we are deeply engrossed in reading a book or mind-wandering. Try to listen to, not just hear, every word spoken, every noise, every sound and the absence of sound in the O.R. The first indication of an arterial laceration and copious blood loss may not be from the surgeon telling you this, but from the abrupt discontinuation of him talking about his weekend. We need to be aware of non-verbal cues and clues. This will not only improve patient safety but will enhance our ability to relate to everyone in the O.R., translating to win-win situations and reduced irreconcilable conflicts.
    3. Scanning: I asked our CA-1 residents how many of them have been bored already in the O.R. during a case. One-hundred percent answered in the affirmative. This was after only a few months of residency! They should be scared, not bored. How can we prevent this from happening? For several years now, I have practiced a Mindful Scanning technique that has prevented boredom and enhanced intraoperative excitement. Every five minutes, start at the far left of the room and try to look at everything in the room. This includes things like the clock, the I.V. pole, any pictures on the walls ... everything. Continue to slowly scan across the room to see not just the patient, but every catheter, tube and monitor attached to the patient. Look at the surgical field and everyone assisting within the field. I once caught a dehydrated surgical tech as she fell toward the floor when I saw her eyes roll back. Look closely at the ventilator, the anesthesia machine and the monitors. Ask yourself, what kind of changes can I make in the ventilator that may even slightly improve ventilation? Continuously doubt that you have established optimum settings and continuously micromanage ventilatory para- meters. Try to calculate fluid shifts and blood volumes for each case. These mental exercises will keep your mind active, involved and focused on your patient. Refill the vaporizer and restock your I.V. supplies. Scan the entire room within five minutes so that you are ready to begin again. After every third scan you may need to take a break from scanning. High-level attentiveness is exciting and energizing but does take some practice to maintain.
    4. Patient-focused Approach: General anesthetic inductions are not always patient-focused. Health care workers – nurses, surgeons, techs and even anesthesia providers – often turn conversations to personal lives, past and future cases, and discussions about employment. You can be the leader in redirecting this focus.

    Tips/Strategies
    1. Mindfulness is a learned habit: The more one does it, the better one gets. Everyone has the ability to do this. It is an acquired skill.
    2. Move beyond breathing practice: The key to enhancing mindfulness is to practice focusing your attention. Many people start with their breathing. Don’t stop there; you can practice mindfulness while you are doing everyday activities7 such as eating, walking, talking or intubating.
    3. Focus on process over outcome:8 The best way to improve out-come is to maintain focus on the entire perioperative course.
    4. Be non-judgmental: Remove emotions such as patient bias. Be open to new information.
    5. Try not to categorize:9 When categories are identified, we simplify and go on autopilot. This leads to incorrect assumptions and inappropriate decisions. Try to continually create new categories – think outside the box, which requires attention.
    6. Reduce automaticity: Seriously consider the direct and indirect consequences of all your actions, especially the ones that we know so well that they become automatic. We would not want someone in the cockpit of the plane flying for extended periods of time on autopilot. As we repeat tasks, they leave from our conscious processes.
    7. Don’t assume that you know: Every time we assume we know the etiology or the outcome, we become mindless and don’t fully process or consider new information.



    Neil E. Farber, M.D., Ph.D. is Associate Professor, Anesthesiology, Pediatrics, and Pharmacology and Toxicology, Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee. Owner, Dynamic Health & Wellness Institute. He is the author of the book Making Lemonade: 101 Recipes to Convert Negatives Into Positives.

    References:
    1. Cullen M. Mindfulness-based inter-ventions: an emerging phenomenon. Mindfulness. 2011;2(3):186-193.
    2. Cohen MR, Maunsell JH. When attention wanders: how uncontrolled fluctuations in attention affect performance. J Neurosci. 2011;31(44):15802-15806.
    3. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books; 2009.
    4. Creswell JD, Way BM, Eisenberger NI, Lieberman MD. Neural correlates of dispositional mindfulness during affect labeling. Psychosom Med. 2007; 69(6):560-565.
    5. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293.
    6. Killingsworth MA, Gilbert DT. A wandering mind is an unhappy mind. Science. 2010;330(6006):932.
    7. Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York: Hyperion Books; 1994.
    8. Langer EJ. Counter Clockwise: Mindful Health and the Power of Possibility. New York, NY: Ballantine Books; 2009.
    9. Langer EJ. Mindfulness. Reading, MA: Perseus Books Group; 1989.