A 65-year-old man was scheduled for an elective
endovascular repair of an abdominal aortic aneurysm. The patient
had an allergy to "IV contrast dye" that was noted during his
preoperative clinic visit with an anesthesiologist. The surgical
physician assistant (PA) documented in a preoperative note that
hydrocortisone should be used before surgery, but no such order was
written. On the day of surgery, a different anesthesiologist
expressed concern about the reported allergy and planned to discuss
with the surgeon—mostly to understand the nature and severity
of the allergy. Fighting time pressures, driven at least in part by
a new policy that tracks and reports delays into the operating room
(OR), the anesthesiologist and his resident induced general
anesthesia, and the resident remained in the room as the attending
left the OR to address an issue regarding another patient.
In the OR, the patient was surrounded by an
attending surgeon, two surgical residents (but not the PA), two
medical students, nursing staff, and a surgical device sales
representative. A "time out" was conducted, during which a nurse
raised concern about the alleged allergy. Everyone else in the room
looked to the anesthesia resident for input. The resident, probably
intimidated by the situation he found himself in, haltingly began
to discuss the allergy, but the surgeons in attendance quickly came
to a "consensus" to administer hydrocortisone and proceed. The
anesthesiology attending returned to the room, upset not to be
included in the time out. He felt that his resident didn't speak up
to adequately address the allergy concern, in part because of the
atmosphere in the OR. While the patient did well during the
surgery, with no evident allergic reaction, the experience raised
concerns about whether time out procedures were serving their
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