Vomiting as a Presenting Symptom of Infantile Vitamin B12 Deficiency.

An 8-month-old, exclusively breastfed girl presented with a five-month history of vomiting with subsequent failure to thrive and lethargy. Family history was notable for the maternal history of gastroschisis. Mother had no dietary restrictions and had successfully breastfed multiple children for >12 months without issue. Initial evaluation was notable for macrocytic anemia. Subsequent serum B12 levels were undetectable. Upon further questioning, the mother had significant bowel resection as an infant due to complications of gastroschisis. Maternal serum B12 levels were also undetectable. The infant's symptoms resolved with supplementation.

The Loud Surgeon Behind the Console: Understanding Team Activities During Robot-Assisted Surgery.

OBJECTIVES: To design a data collection methodology to capture team activities during robot-assisted surgery (RAS) (team communications, surgical flow, and procedural interruptions), and use relevant disciplines of Industrial Engineering and Human Factors Engineering to uncover key issues impeding surgical flow and guide evidence-based strategic changes to enhance surgical performance and improve outcomes. DESIGN: Field study, to determine the feasibility of the proposed methodology. SETTING: Recording the operating room (OR) environment during robot-assisted surgeries (RAS). The data collection system included recordings from the console and 3 aerial cameras, in addition to 8 lapel microphones (1 for each OR team member). Questionnaires on team familiarity and cognitive load were collected. PARTICIPANTS: In all, 37 patients and 89 OR staff members have consented to participate in the study. RESULTS: Overall, 37 RAS procedures were recorded (130 console hours). A pilot procedure was evaluated in detail. We were able to characterize team communications in terms of flow, mode, topic, and form. Surgical flow was evaluated in terms of duration, location, personnel involved, purpose, and if movements were avoidable or not. Procedural interruptions were characterized according to their duration, cause, mode of communication, and personnel involved. CONCLUSION: This methodology allowed for the capture of a wide variety of team activities during RAS that would serve as a solid platform to improve nontechnical aspects of RAS.

Evaluation and Impact of Workflow Interruptions During Robot-assisted Surgery.

OBJECTIVE: To analyze and categorize causes for interruptions during robot-assisted surgery. METHODS: We analyzed 10 robot-assisted prostatectomies that were performed by 3 surgeons from October 2014 to June 2015. Interruptions to surgery were defined in terms of duration, stage of surgery, personnel involved, reasons, and impact of the interruption on the surgical workflow. RESULTS: The main reasons for interruptions included the following: console surgeons switching (29%); preparation of the surgical equipment, such as cleaning or changing the camera (29%) or an instrument (27%); or when a suture, stapler, or clip was needed (12%). The most common interruption duration was 10-29 seconds (47.6%), and the least common interruption duration was greater than 90 seconds (3.6%). Additionally, about 14% of the interruptions were considered avoidable, whereas the remaining 86% of interruptions were necessary for surgery. CONCLUSION: By identifying and analyzing interruptions, we can develop evidence-based strategies to improve operating room efficiency, lower costs, and advance patient safety.

Ambulatory movements, team dynamics and interactions during robot-assisted surgery.

OBJECTIVE: To analyse ambulatory movements and team dynamics during robot-assisted surgery (RAS), and to investigate whether congestion of the physical space associated with robotic technology led to workflow challenges or predisposed to errors and adverse events. METHODS: With institutional review board approval, we retrospectively reviewed 10 recorded robot-assisted radical prostatectomies in a single operating room (OR). The OR was divided into eight zones, and all movements were tracked and described in terms of start and end zones, duration, personnel and purpose. Movements were further classified into avoidable (can be eliminated/improved) and unavoidable (necessary for completion of the procedure). RESULTS: The mean operating time was 166 min, of which ambulation constituted 27 min (16%). A total of 2 896 ambulatory movements were identified (mean: 290 ambulatory movements/procedure). Most of the movements were procedure-related (31%), and were performed by the circulating nurse. We identified 11 main pathways in the OR; the heaviest traffic was between the circulating nurse zone, transit zone and supply-1 zone. A total of 50% of ambulatory movements were found to be avoidable. CONCLUSION: More than half of the movements during RAS can be eliminated with an improved OR setting. More studies are needed to design an evidence-based OR layout that enhances access, workflow and patient safety.