A Task Completed : Techniques in Hand & Upper Extremity Surgery

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A Task Completed

Pulos, Nicholas MD; Shin, Alexander Y. MD

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Techniques in Hand & Upper Extremity Surgery: December 2022 - Volume 26 - Issue 4 - p 213
doi: 10.1097/BTH.0000000000000414
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The rate of staff turnover in the hospital setting is at a record high.1 Some of this is related to the COVID pandemic, some to burnout resulting in the early retirement of nurses and allied health staff, and some to the allure of the financial benefits of travel nursing. Regardless of the cause, the result has taken its toll on our daily clinical practice, especially in the operating room. Working with new nurses and scrub techs each day brings to light how much we have benefited from the consistency and precision of a well-trained and dedicated team. The recent disruption of the team brings to light the need to recreate the consistency and precision of a well-oiled team.

It has been said that >90% of the success of any complex task occurs before the commencement of the task. Steven Covey, in the Seven Habits of Highly Effective People, lists Habits #1 and 2 as “be proactive” and “start with the end in mind.”2 As a surgeon, being proactive starts with proper patient selection and surgical indications. “Starting with the end in mind” means taking the time for preoperative planning, mentally visualizing the surgery steps and anticipating potential complications and stumbling blocks. While this preparation is great for the surgeon, it does is no good if they are not shared with your team, and the operating room staff.

The question arises on how to re-engage and rebuild a precision team when the team members keep changing. We can take insight from Navy SEAL Admiral William McRaven, author of “Make your Bed.”3 Admiral McRaven clearly recognizes that “life is hard and sometimes there is little you can do to affect the outcome of your day.” However, if you make your bed every morning, you will have accomplished your first task of the day and start your day with a task complete. This simple completed task can give you the encouragement to complete many more additional tasks.

Translating this to the operating room is no different. Start the surgery with a new team with a completed task. We start with meeting the team, providing a detailed briefing, mentally visualizing the outcome (start with the end in mind) and do the surgical pause acknowledging all the team members and their roles. We then “make our bed” we, start every case with a crisp blue towel as a down sheet and a neatly rolled towel bump available should we need it. The first task of the case has now been expertly completed, and we are ready to successfully complete the remaining tasks at hand.

Athletes do this too of course. In golf, it is referred to as the pre-shot routine. A ritual the player does every time before she swings to prepare her body to execute a shot she’s practiced thousands of times. In baseball, batters pick song clips to hear as they walk up to take their at bat. In hockey, goalies prepare the ice in front of their net at the beginning of every period. Whether you’re a Navy Seal, professional athlete, or hand surgeon there’s a benefit to getting some control over a situation you don’t have complete control over—start with making your bed and keep the end in mind.

The operating room is our battlefield and arena. While we do not own it any more than ADM McRaven owned the barracks for his SEAL Team trainees, we are responsible for performing at the possible highest level for our patients. Whether it’s a trigger finger release or multi-digit replant, starting the surgery by controlling what you can control is a powerful beginning. There are many parts of the operation we can’t control, but nearly everything that happens before the incision is in our control.


1. Varner C. Hospitals grappling with nurse exodus. CMAJ. 2021;193:E569–E570.
2. Covey SR. The 7 Habits of Highly Effective People: Restoring the Character Ethic, Rev. ed. DC Books: Free Press; 2004.
3. McRaven WH. Make Your Bed. Grand Central Publishing: Michael Joseph; 2017.
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