Retina Today - Learning in the OR (September 2017)

摘要

Your first experiences in the OR as a vitreoretinal surgery fellow can be overwhelming. There is a steep learning curve, calling on you to grow not only in your technical skills but also in your judgment. As retina fellows across the country transition to a new academic year, we find ourselves trying to navigate the subspecialty and learn as much as we can from our surgical attendings and patients. We asked both recent graduates and seasoned retina attendings for advice based on their experience. What tips can you offer for setting up the patient, the microscope, and yourself at the beginning of a case? Marc Spirn, MD: Spending long hours at the microscope can lead to chronic back and neck strain. Paying attention to your body position and that of the patient is the best way to avoid body fatigue and discomfort. Before the patient enters the room, I typically figure out my chair height and position. The chair height should be set to allow a comfortable knee bend (slightly less than 90°)—like sitting in a chair at the kitchen table. Your spine and head should be in a neutral position. Avoid hyperextending your head by making sure the microscope oculars are properly positioned. Sunir J. Garg, MD: First, I ask the fellows to look at the patient to make sure that the patient’s head is at or over the top of the bed. Sometimes they leave the patient in the middle of the gurney and find themselves wishing for a detachable head halfway through the case. Next, I encourage my fellows to sit on the surgical stool and make sure that their seat height and body position are comfortable. Once they are comfortable, I ask them to bring the microscope into position so that the oculars are at the appropriate height and tilt. Hopefully, by doing this, they do not find themselves leaning forward. Finally, I ask them to wheel the patient toward the microscope and adjust the bed up and down to bring the eye into focus without touching the scope. This usually enables the fellow to be comfortable for the case. Many times, instead, fellows put the bed roughly where they think it should go, and then adjust the microscope, the chair, and their body to the eye—it should be the other way around. Dean Eliott, MD: The surgeon should sit as close to the patient’s head as possible while concentrating on remaining upright with good posture. This is important, as it is easy to slouch into a relaxed position during a long case, which will lead to a position with shoulders forward and neck extended and, ultimately, to neck pain. Each surgeon should ensure that the setup is appropriate for him or her. Do not compromise your position based on the attending’s size and shape. Sometimes we switch seats with the fellow several times during a case, and during each switch is it important to take the time to ensure optimal ergonomics. Bryan Kun Hong, MD: I like to make sure that there is enough space under the patient’s head to fit my legs without bumping the wrist rest, while still allowing me to be able to reach the pedals comfortably. Pearl: Make sure that the wrist rest comes as high as your hip when positioning the patient. What are the most common mistakes retina fellows make when they are learning vitrectomy? Yewlin Chee, MD: It is important to come to the OR prepared. Know all the functions on the pedals for the vitrectomy machine and the microscope; both can and should be practiced before the fellow’s first case until they are second nature. It is difficult to learn how to properly maneuver instruments inside the eye with your hands if you are uncertain about what has to be done with your feet. When I was assisting my attendings as a fellow, I occasionally found it useful to look outside the oculars of the microscope to watch how they were holding their hands and maneuvering the eye. Dr. Eliott: The most common mistakes at the beginning of fellowship are lack of familiarity with the viewing s