The VR surgeon never works alone at the operating table: as a minimum, there is a nurse assisting him. Although the relationship between the two is crucial, it is not discussed in publications.

Pearl

The VR surgeon is only as good as his nurse is. Without a nurse who is a true assistant, the surgeon cannot dedicate his undivided attention to the patient.

Surgeons who do not treasure their nurse do so at their own peril as well as their patient’s.1 Even the slightest problem – an instrument is not immediately available, the vitrectomy machine’s settings are different from what the surgeon expects etc. – will force the surgeon to unnecessarily divert his train of thought from the intraocular task to an “extraocular” problem. When this happens and especially if it does so regularly, it is frustrating – and the frustrated VR surgeon is at an increased risk of committing errors (see the Appendix, Part 2).

A good nurse should pay attention, among others, to the following:

•Always hand the proper instrument to the surgeon (see Sect. 3.7).

–This is not as straightforward as it sounds: many companies do not “colorcode” their forceps or scissors, and it may be too dark in the OR for the nurse to see the tip of the tool. The surgeon does not examine the instrument handed to him before he inserts it into the eye; realizing only then that he was given the wrong forceps, or scissors instead of forceps, is very frustrating.

1 I have been blessed to work throughout my career with absolutely excellent nurses. I cannot overemphasize how grateful and indebted I am to all of them.

F. Kuhn, Vitreoretinal Surgery: Strategies and Tactics,

DOI 10.1007/978-3-319-19479-0_6

•The instrument is placed in the surgeon’s outreached hand correctly (see Fig. 54.7).

–I have seen nurses in various ORs neglect this rule, forcing the surgeon to turn the instrument around before being able to use it. I have also heard frustrated surgeons scream at the nurse when this happens – but this only poisons the well.2

•Learn how to do scleral indentation well (see Chap. 28).

–If the nurse does not look into the microscope3 while indenting the sclera, she may not realize that the height of the indentation changes, greatly increasing the risk of retinal injury.

•Pay close attention to what the surgeon is doing and learn his individual habits.

Q&A

Q Is a good nurse supposed to anticipate the surgeon’s next move?

A Yes. A good nurse does much more than fulfill the surgeon’s verbal requests. She observes the surgeon’s every move, becomes familiar with the particular surgeon’s customs, and tries to prepare for the next surgical maneuver in advance. She also voices her opinion if she thinks something is not right or could be improved (see below).

To closely follow the operation, the nurse must be able to continually see what the surgeon is doing inside the eye. Preferably, she can look into the microscope, or at least view it on a high-resolution, properly placed monitor connected to the video camera (see Sect. 12.4).

•Remain with the surgeon for the duration of the entire operation.

–I have seen ORs where multiple nurses assisted the surgeon during the same, relatively short operation. They did not even announce when one would replace the other. The reason for the changes was not due to some kind of emergency4 – simply a local custom. Nurses have different personalities; their style of assisting is different: it does matter to the surgeon whether he works with the same person throughout. Continually adapting to different nurses’ personality is another potential source of frustration for the surgeon.

2Neither is it a solution if the surgeon totally avoids the conflict and does not address the problem at all. But instead of screaming and shaming her in public, he should privately sit down with the nurse, identify the problem, and find a solution.

3Or at least follow it on the monitor, see below.

4Such as a bathroom break or a crisis phone call.

Pearl

VR surgery is a teamwork. There are many actors on the team, but none is more important than the nurse. It is therefore highly recommended that the surgeon work with the same nurses.

•Help guide the surgeon’s hand if he is presbyopic and has difficulty finding the opening of the cannula to enter the eye.

–It is a suboptimal option to repeatedly turn on the microscope light for cannula entry, nor is it really helpful to leave the room light, even if it is red, on.5 The nurse who gently holds the surgeon’s hand and helps it introduce the instrument through the cannula is doing a great service.

•Prepare for the particulars of the case as much as these can be anticipated, but also be ready to quickly get and supply whatever unexpected tool or material is needed.

–During PPV for RD, the flute needle, endodiathermy, endolaser, and gas are always needed, but silicone oil, PFCL, cryopexy, ICG etc., may also be required. These needs differ from surgeon to surgeon,6 which is one reason why it is so important that the surgeon-nurse team works together long term and during the entire case (see above).

•Keep all the necessary instruments and materials, but only those, on her table (see Sect. 16.11).

–When working in room light, some surgeons prefer grabbing the instrument from the nurse’s table themselves.7

•Pay very close attention not only to the “case” but also to the surgeon. If the nurse has an idea to solve a problem or a suggestion to improve on what the surgeon is doing – she should not be shy (or discouraged) to voice her suggestion (see Fig. 36.2).8

–This, of course, requires that the surgeon be a person who is willing to listen. Often it is not the surgeon who comes up with a unique solution: the “outsider” looks at the issue from a different perspective.9

–I appreciate the nurse as the active, crucial other part of the surgical team, and not as a passive handler of surgical instruments.10

5It is useful for the surgeon to maintain his dark-adapted status.

6Not only case by case.

7Some nurses do not like if the surgeon “touches their table.” The surgeon should respect this.

8I permanently changed certain maneuvers in my own practice based on the advice of the nurse.

9Remember, the idea of the IOL is not Sir Harold Ridley’s; a medical student, Peter Choyce, who was observing Dr. Ridley in surgery, suggested it.

10Much like the role of the-official-with-the-flag in modern football; there is a reason why he is not called as “linesman” anymore but as “the referee’s assistant”.

•Keep a description at hand of the most commonly used medication-dilution rules.

–It is extremely aggravating when a surgeon needs, for instance, antibiotics injected into the infusion bottle, but nobody remembers the correct concentration, and surgery must be stopped to calculate the dosage. Calculating the concentration in such an ad hoc manner, under time pressure, is also a potential source of errors – and the incorrect concentration of an intravitreal medication can have blinding consequences.

•Is very careful in cleaning and handling the delicate intraocular instruments.

–For instance, membrane fragments are caught in-between the forceps jaws, which require instant, in-the-dark cleaning so that the surgeon can carry on with the operation (see Sect. 13.2).

If the surgeon is able to find a nurse who fits what is described above, he has the best possible chance of succeeding in the OR. If, however, the nurse is not a willing partner, whether because of personal or professional reasons, the surgeon should request the OR director to never assign this nurse to his cases.

Q&A

QWhat if the inexperienced fellow is paired with an experienced and dominant nurse?

AOccasionally the nurse’s personality is such that she wants to boss the fellow around. The surgeon must not allow this to happen; he has to hold his line firmly (remaining the “captain in the OR”; see Sect. 16.13). Conversely, he must avoid completely alienating the nurse by becoming too aggressive. A private conversation to identify the problem and find a mutually acceptable compromise is the best way to defuse the situation and prevent future conflicts.