7 Annoying Distractions in the Operating Room, and How It’s Detrimental to Patient Care

October 6, 2015 by  

People used to joke that in the 1970s and 1980s, only doctors and drug dealers had pagers. Drug dealers have moved on to more sophisticated technology, and doctors are probably the only profession using pagers. In our academic institution, residents still use pagers for consults and emergencies.
I’m reminded of this every time I’m in the operating room (OR), with the resident’s pager going off with the old-style shrieking, high-pitched ringer multiple times throughout the day. People in the OR don’t seem to mind at all, expect for me. Perhaps they’ve all been desensitized to all the technology-related noise and distractions that are so common today.
Besides pager noise pollution, there are a number of other distractions that can potentially lead to less than ideal surgical results. Here are annoying 7 distractions in the OR that can be detrimental to patient care:
1. Pagers
Most of the modern pagers have more pleasing ringtones, and even a vibrate option, but it seems that most doctors continue to use the most annoying ringtone to get their attention. It’s not just the bothersome ringtone—it also causes my assistant to get distracted and ends up having the circulating nurse call back the page and relay messages back to the person who initiated the page. Sometimes, the resident scrubs out to talk on the phone or gets called to the floor or ER to handle any emergency situations. Needless to say, this can be very distracting.
2. Chatter
Contrary to the old days when the OR was thought to be an operating theater, conversations start up between various non-surgical staff. Many are for reasons related to the surgical procedure, but often times, it’s just chi-chat. When I was in medical school, these conversions used to be in hushed tones, but now it’s at regular conversation levels. You can sometimes have two pairs of people having conversations.
3. Music
Every surgeon has preferences for whether or not they want music playing at all, and if they like music, will have very different tastes. My personal preference is to have no music at all. I take surgery seriously, as if I’m taking a test. Having music in the background may be soothing or relaxing to some people, but it can definitely have conscious or subconscious detrimental effects on test-taking or even surgery. Also, not every one will like the kind of music that’s chosen to be played. Studies have shown conflicting results on whether music in the OR can alter outcomes. 
If we’re at the end of a case and closing and if someone requests, music, I insist on classical, jazz, or instrumental music only with no words.
3. Too many screens
This may only apply to some of the newer operating rooms. In my hospital with new operating rooms, there are literally 4 LCD monitors, usually hooked up to the camera that I’m using for the patent. Anesthesia has their own 2 to 3 monitors. The problem is that I can usually see 2 or three others in my direct line of sight or peripheral field of vision. Having the camera attached and not holding it steady will make the image shake or move around, making everyone in the room dizzy. Having two extra large LCD monitors make things much worse. Oftentimes, I go around to turn off one or two monitors, and switch the third monitor to the anesthesia machine, keeping only one for myself.
4. Screen savers
One really annoying thing that my hospital has done in the name of patient safety is to install screen savers that animate different messages, like wash your hands often, check the patient’s ID multiple times, get your flu shot, or don’t recap needles. The problem is that the animation is really distracting, in addition to being reminded of things that we’re already doing anyway. Now imagine seeing 4 monitors transitioning to a different screen every minute, like what you would see at a flat screen TV wall at Best Buy.
What I usually do is to turn off the screen savers at the beginning of each case. I do the same thing when seeing patients in the office, as it detracts from the doctor-patient experience. 
5. Instrument noise
There can be dozens of medical equipment in a modern operating room. Some of these machines can beep, hum, buzz, screech or hiss at extremely loud noise levels. Alarm sounds can be even louder. These distractions can occur repeatedly throughout the case. Many studies have shown that sound levels in the OR can routinely exceed 100 dB, sometimes as high as 131 dB. 100 dB is as loud as a lawnmower or a motorcycle. 
6. Too hot or cold temperature
The OR is intentionally kept somewhat cool, but oftentimes, it’s much too cold. Being dressed in scrubs in low 60 degree temperatures can be quite uncomfortable. Putting on surgical gowns makes things much more tolerable, but the circulating nurse and anesthesia staff are frequently shivering. The patient is always comfortable, with a warming blanket throughout the case. Rarely, it can get uncomfortably hot. In most cases the temperature can be adjusted, but not always.
7. No place to write
With more modern ORs, it’s expected that everything will be documented in the computer. However, the vast majority of paperwork that’s done in the OR is still done on paper. Since the one desk/table is being used by the circulating nurse, the only place for me to write my notes and discharge paperwork is on a trash bin, or small light source box. As you can imagine, these are not the most ideal surfaces to write on.
These 7 annoying distractions may be unique to my particular situation, but I’m sure that most surgeons will experience some, if not most of these same issues. 
Some of these distractions may not be a big deal. But if added together, especially if they occur simultaneously at critical times during surgery, you can imagine it can potentially lead to less than optimal medical or surgical results. Here’s an article summarizing these potential dangers. Bare minimum, it can lead to miscommunication or misunderstandings amongst the staff.
In this age of high-technology and multitasking, we assume that we can handle multiple tasks at the same time. However, it’s been shown that we can focus on only one thing at a time. Various distractions can divert our attention away from our main area of focus. It doesn’t take a brain surgeon to know that these distractions do not provide the ideal situation for good patient care.
If you’ve undergone surgery recently, have you noticed any of the issues that I mentioned in this blog? Please enter your responses in the text box below.

State Of The Art Surgery for Sleep Apnea: Update From My Annual Academy Meeting

October 1, 2015 by  

Smiling team of doctors and nurses at hospital

It seems like surgical options for patients with obstructive sleep apnea who can’t tolerate CPAP oral appliances is growing rapidly. I haven’t attended my annual Otolaryngology – Head & Neck Surgery Academy meeting since 2013. This year at our meeting in Dallas, there were significantly more presentations and surgical options compared to years past. The two most prominent high-tech options were tongue nerve stimulation (pacemaker) and robotic surgery for the tongue. 

Since it was a meeting for surgeons only, there were no CPAP companies, sleep testing or dental device companies on the convention floor. 
Here’s a rundown of the 5 things I learned or was most impressed about:
1. Nasal valve and septal procedures.
There wasn’t a specific new technique to help you breathe better through your nose, but there was a number of courses that reviewed the state of the art in dealing to difficult noses. These courses covered a review of basic techniques to complicated reconstructive techniques. As you may know, I usually recommend proper nasal breathing before moving on to treat snoring, upper airway resistance syndrome or obstructive sleep apnea. This can also allow you to use CPAP or dental appliances much more effectively.
2. Tongue and hyoid suspension.
I first began doing tongue base and hyoid suspension early in my career about 15 years ago, but have shifted to other options like tongue reduction procedures.  Advancements in suture placement techniques and more studies showing good results has made me start thinking about re-staring these options again. 
3. Tongue nerve stimulation (Inspire and ImThera).
Inspire received FDA approval last year for their hypoglossal (tongue) nerve pacemaker technology. There’s been a limited number of implants to date but the preliminary results look promising. ImThera, which already has been approved by regulators in Europe, and is currently undergoing their definitive study for FDA clearance in the US. Note that this option only addresses the tongue. If you have other areas of obstruction (soft palate or nose), results may not be as good.
4. Robotic surgery (DaVinci and Medrobotics).
There are many different ways of seeing what you’re doing with tongue base surgery (direct, angled camera and robot) with proponents for all three options. There are also different ways to make cuts (knife, cautery, laser, radio frequency), with proponents for each option as well. Robotic surgery also addresses only the tongue as well (along with the epiglottis). It’s very new and promising technology, but we’ll have to see what the long-term studies show and if insurance will pay cover it routinely. 
5. Midline partial glossectomy.
This wasn’t actually presented, but I met a lot of surgeons using this basic, low-tech technique who are reporting excellent results, usually similar to what’s published for the more high-tech procedures. 
6. Palatal procedures.
The state of the art for soft palate procedures were described, from expansion sphincter pharyngoplasty (ESP), using barbed-sutures to pull on soft palate tissues to perform the ESP, and trans-palatal advancement.
7. Maxillo-mandibular advancement (MMA).
The MMA procedure, where both the upper and lower jaws are moved forward, was presented as another viable first or second line option for surgery. As expected, the results were much better than soft tissue procedures, but with longer recovery and various potential complications such as numbness. As expected, there were strong opinions about the pros and cons doing this as a first line surgical option. 
My take-away from this conference was that ultimately, you can’t say which procedure is better, since most procedures typically address only one of multiple levels of obstruction. Also, most surgeons get really good at doing one or two procedures for each level of obstruction (nose, soft palate, tongue). Two surgeons may get equally good results using completely different operations. Every patient will have different needs at every level of obstruction, and every surgeon will have different options for treating each level. 
If you’ve undergone any of the above mentioned procedures, what was your experience? Please enter your comments below.

Podcast #11: CPAP vs. Surgery—Which Is Better?

September 14, 2015 by  

In this podcast, I’ll be talking about a very controversial subject: CPAP or Surgery: Which is better? Kathy and I will cover  the following:

  • My honest answer to which is better: CPAP or surgery
  • Controversy about surgical success
  • How the Provider Effect influences specialists’ preferences
  • The problem with using the AHI to define surgical success
  • Why conservative surgery can sometimes be detrimental to patients
  • The problem with meta-analyses
  • research study vs. real-world CPAP compliances rates
  • How to overcome indecision due to too many options
  • How to find the right surgeon.

Download MP3

Show Notes:

VA study comparing survival for CPAP vs. UPPP

Netherlands study about average AHI and CPAP usage

Carl Stepnowski interview (iTunes #19) MP3

American Sleep Apnea Association CPAP Assistance Program


How to find the right surgeon

If you found this podcast helpful, please go to iTunes to rate and review this program. This way, more people can find this information to help themselves and others.


Two Things That Go Flop In the Night, Making You Wake Up

September 9, 2015 by  

Occasionally, I will see a patient that experiences obstructed breathing during sleep, but the way that they describe it is bit odd. In fact, when these patients try to describe what’s happening, most doctors may think that they are crazy. This is what happened to one such patient, who after undergoing major tongue and soft palate surgery for sleep apnea, he began to notice a sudden flapping sensation in the throat as he begins to inhale. After complaining repeatedly to his surgeon, he was told to leave the practice.  Another woman complained of difficulty breathing out through her nose during mid-exhalation, starting with a sudden flapping sensation. Both patients did not have any significant apneas on a sleep study.
However, while undergoing sleep endoscopy (looking with a camera at the upper airway while in deep sleep on the operating room), both patients had obvious problems. The first patient was found to have a floppy epiglottis that flopped back suddenly with each inhalation. The epiglottis is a cartilaginous structure that sits on top of the voice-box and just behind the base of the tongue. Due to either a weakened cartilage or change after surgery, it flops back, causing sudden obstruction at each inhale. This causes repeated obstructions and arousals, without leading to frank apneas or hypopnea. In general, these episodes happen more often while on your back (due to gravity) and when in deeper levels of sleep (such as REM, when your muscles are most relaxed).
The second patient was found to have her soft palate flop back up into the back of her nose during mid-exhalation. I’ve described this phenomenon in a past blog post. In both cases, the sudden blockage during inhalation or exhalation will lead to an arousal from deep sleep, any time your throat muscles are more relaxed. In some cases, the second phenomenon can be misinterpreted as a central apnea. Think about what happens when you strain mildly during a bowel movement. There’s no air moving through your mouth or nose, and there’s no movement of your chest or abdomen. In this particular situation, if it lasts for more than 10 seconds, it will be mis-scored as a central apnea.
Unfortunately, the standard options for sleep apnea (CPAP or dental appliances) won’t work as well, since these sudden blockages will keep waking you up. I’m not at a point where I can recommend surgery for these problems, but I have seen various degrees of success after trimming the epiglottis or stiffening the soft palate.
If either of these situations describe you, please leave a comment below.

Podcast #10: 9 Proven Alternatives to CPAP

August 25, 2015 by  

Frustrated CPAP users are constantly asking me what other options are available. There are literally dozens of over-the-counter, natural, prescription, and surgical options that are available. I’ve chosen 9 options that have proven results, based on published research in peer-reviewed medical journals. There may be other options that may work very well, but as of date, I’m not aware of any prospective studies showing significant improvement based on sleep studies as well as quality of life questionnaires.
Download MP3 File
Show Notes
1. Sleep positions: Slumberbump, Rematee Anti-snore Shirt
2. Past podcasts on the advantages and disadvantages of mandibular advancement devices.
3. Acupuncture interview (#52) with Amy Hausman. Research description.
4. Tongue exercises: Interviews with Joy Moeller (#33), Janet Bennet (#45). Meta-analysis article.
5. Provent article
6. Didgeridoo article
7. Throat and tongue surgery interview (mp3).
8. Jaw surgery interview (mp3)with Dr. Kasey Li
9. Tongue nerve stimulation 


If you found this podcast helpful, please go to iTunes to rate and review this program. This way, more people can find this information to help themselves and others.


Podcast #9: Proven Solutions For Your Top 7 CPAP Problems

August 13, 2015 by  

It’s a given that if you use CPAP, you’ll run into problems. The good news is that the vast majority of these problems can be solved, with some guidance and trouble-shooting. 

In this podcast episode, Kathy and I will reveal the Top 7 CPAP Problems you’ll most likely face, with solutions.

Download MP3 file

Top 7 CPAP Problems with Solutions:

  1. Air in stomach/bloating
  2. Mask leak
  3. Water in tubing
  4. Too strong pressure / I can’t breathe out
  5. Facial marks / skin irritation
  6. Dry mouth
  7. Stuffy Nose

Plus more.

Show notes:

VA Study: CPAP vs. UPPP

CPAP hose holder: Hose Buddy 

Bruce Stein’s book: Sleep Apnea and CPAP: A User’s Manual By A User


Interview with Chip Smith of Restoration Medical Supply on CPAP 

Unstuff Your Stuffy Nose E-book

Interview with Eric Cohen of National Sleep Therapy

Interview with Dr. Carl Stepnowsky

Sleepyhead Software

Interview with Nicole Garrison with Respironics

Please tell me your biggest problem with CPAP and how you solved it in the area below.

If you liked this podcast, please go to iTunes to rate and review this program. This way, more people can find this information to help themselves and others.


Why Robin Wears A Mask (And How It Relates to Sleep Apnea)

July 28, 2015 by  

During downtime while away on vacation, my two younger boys were watching Teen Titans on TV. I joined them to watch one episode, where all the young super-heros revealed their deepest secrets. When it was Robin’s turn, he initially refused, but later revealed that he was hiding a big secret: He had an amazingly beautiful male face that drove women and even other men crazy. 


What was portrayed were big eyes, prominent cheekbones, and wide, masculine jaws. A modern version of this type of face can be seen with Fabio (see photo). If you remember the old movie stars from the mid-1900s, most of the men and women had wide jaws and well developed cheekbones. Now, most celebrities have triangle-shaped faces. 
I’ve describe in great detail why this is happening in past articles and in my book. But here’s a summary: Due to a major change in our diets from organic to processed, softer foods, as well as shifting our infants from breast-feeding to bottle-feeding, our jaws are not growing to their full potential, along with more crooked teeth. It’s almost a given that your child will need braces. It’s not a problem with their teeth—it’s a crowding problems caused by smaller jaws.
Although most doctors believe that being overweight is the main reason for obstructive sleep apnea, more and more people with obstructive sleep apnea are now relatively thin. These people will have narrow jaws and a high arched hard palate. Because the roof of the mouth doesn’t drop during development, the upper molars are more narrow, and the nasal septum buckles to one side, causing a deviated nasal septum. 
As you can see, this is not only a cosmetic problem. Unchecked, it can lead to poor breathing, poor sleep, low energy, and lack of productivity. Later on, as your sleep-breathing problem worsens into sleep apnea, you’ll be at higher risk of developing diabetes, high blood pressure, heart disease, stroke, and even cancer.
Do you have any other examples of public figures or celebrities with an “attractive” face? Please enter your examples below.

Podcast #8: The 8 Reasons Why Dental Appliances May Not Work For Your Sleep Apnea

July 18, 2015 by  

If you tuned in to our last episode,  I talked about the 7 reasons why oral appliances may be a good option for those of you with obstructive sleep apnea, and in today’s episode, we’re going to talk about the 8 reason why you may not want to consider oral appliances for sleep apnea.

  1. It’s challenging to find a qualified dentist for every patient

  2. It can change your bite

  3. It’s much more expensive than CPAP

  4. It can be lost or damaged

  5. If you have severe sleep apnea

  6. If you’re severely overweight

  7. If your nose is stuffy

  8. Sometimes, the tongue may not move forward with jaw movement.

Plus two more bonus reasons.

Download mp3

Links and references mentioned:

American Academy of Dental Sleep Medicine

American Academy of Sleep Medicine

Interview with Dr. David Lawler iTunes link #55.

Unstuffy Your Stuffy Nose e-book

Sleep, Interrupted



How Surgery is Like Fishing

July 7, 2015 by  

The other day, my 12 year-old son and I were invited to go fishing on the Long Island Sound. We drove two hours to get to the Eastern end of Long Island, expecting to catch 3 or 4 fish. The three of us went out on a small boat just after high tide. It started slowly in the beginning, but around 2 hours after high tide, we were catching porgies every few minutes. Between my son and me, we caught well over 100 fish! We ended up keeping just under 50 fish due to size restrictions. This was the most amazing fishing experience I have ever had. My son was ecstatic, as he caught the vast majority of the fish.
There were a number of other boats in our area, but they caught only a handful of fish. Some caught none at all. 
You may be asking, what does this have to do surgery? 
It turns out that the friend that invited me had been fishing here for over 40 years. Despite having a small boat with basic equipment, his experience and fishing skills trumped all the other fishermen with bigger boats and fancier fishing equipment.
In the same way, you may think that surgeons who use the latest gadgets and cutting tools make better surgeons, but this is not always the case. One of the most common questions that I get asked is if I use a laser for surgery. I usually answer this question with my Tiger Woods analogy: If Tiger Woods bought a $60 Wilson golf set at K-Mark, he can still beat your pants off, no matter how expensive your golf clubs are.
It’s not how new or fancy or cutting-edge the tool you use. It’s the user’s skill and experience that makes the biggest difference, no matter how fancy or basic the tool. Similarly, a good surgeon will still be able to get great results, even with older, less fancy equipment. 
The good surgeon also knows when to use the right tool for the job. You can sometimes use the most expensive screwdriver to turn a Phillips screw head, but a basic Phillips screwdriver will work much better. You can use the latest laser to cut tissues for a tonsillectomy, but a simple knife or electrical cautery will get the job done much faster, with much less expense. 
Just last week, I had to perform a complicated sinus surgery. The patient had undergone sinus surgery previously by another surgeon, and the anatomy was difficult to navigate. For complicated or repeat sinus procedures, I usually order a sinus CAT scan with 3D image navigation. During the case, the navigation system had to be re-calibrated over and over again, wasting a lot of time. I had to use the standard CAT scan images to do the operation, which made it go much smoother and faster. Image navigation can be a very useful tool for certain situations, but in many cases, it can actually hinder good surgical outcomes. Especially if the surgeon uses it as a crutch, rather than relying on basic anatomy fundamentals.
Everyone has preconceived ideas about what it takes to be a good surgeon. I have to admit that being into gadgets myself, I’m also guilty being attracted to the latest technology. But my recent fishing experience reminded me again that focusing on the fundamentals of any trade, or skill is what makes you a true professional.

Podcast #7: The 7 Reasons Why I Like Dental Appliances for Sleep Apnea

July 1, 2015 by  

Many people hate the idea of using a CPAP mask attached to a hose every night. Fortunately, a good alternative to this is a mandibular advancement devices (also called oral appliances)  come in various models, but they all have one thing in common: The lower jaw is pushed forward against the upper jaw, moving your tongue forward, opening up your airway.
In this podcast episode, I will go over the 7 reasons why I like using mandibular advancement devices to treat obstructive sleep apnea.  
1. No headgear or straps around your face.
2. It’s silent. CPAP 26 dB. 30 is a quiet whisper
3. It’s small and convenient
4. More dentists are available to make these devices, and are usually covered through most major insurances. 
5. Equal to CPAP for people with mild to moderate obstructive sleep apnea.
6. An oral appliance can used as a CPAP mask holder
7. It can be used effectively for snoring and UARS, even if you don’t have obstructive sleep apnea.
Resources and links mentioned:


7 Reasons Why I Love Dental Appliances for Sleep Apnea

5 Reasons Why I Don’t Like Dental Appliances for Sleep Apnea

5 Things You Must Consider Before Trying An Oral Appliance for Sleep Apnea

Sleep Interrupted: A physician reveals the #1 reason why so many of us are sick and tired 

American Academy of Dental Sleep Medicine

Photo of hybrid oral appliance / CPAP nasal pillow

Unstuffy Your Stuffy Nose E-book

Breathe Better, Sleep Better, Live Better Podcast on iTunes (#54)



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The material on this website is for educational and informational purposes only and is not and should not be relied upon or construed as medical, surgical, psychological, or nutritional advice. Please consult your doctor before making any changes to your medical regimen, exercise or diet program. Some links may go to products on Amazon.com, for which Jodev Press is an associate member.

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