Marlot Kuiper

180 Connective Routines I am sitting on a stool at the corner of the holding, waiting. I am shadowing anaesthesiologist dr. Herbers, and we have been called in to place a last- minute local anaesthetic so the surgeon can later on operate the ruptured tendon in the patient’s arm. In the end, the surgeon decided a local anaesthetic was the best solution at hand. Dr. Herbers has to work fast, as it takes quite some time for the local anaesthetic to work, and the surgeon underlined that he does not want to get behind schedule. Dr. Herbers pulls his phone out of his jacket. “Dr. Herbers speaking. Someone on their way already? Ok, thanks.” We are waiting for someone to bring the ultrasound device, as ultrasound is needed to set the local anaesthetic. “I also have to bring someone out of anaesthesia in OR3” he sighs mostly to himself. When the ultrasound device finally arrives dr. Herbers is ready to get started. “Sorry sir” he says to the patient. “This is definitely not the most fun thing, I will do my best, but this is a very precise job and it’s very unpredictable. Sometimes I immediately see where we should be, sometimes it takes ages before we get to the right spot. Hopefully this is a good day” he smiles. This observation note shows how the anaesthesiologist has to improvise in balancing interacting tasks. The local anaesthetic was not planned at forehand. As a result, the anaesthesiologist has to align his task with the workflow of the radiology department. In performing a local anaesthetic, he relies on the availability of radiology equipment. Besides, the process of placing such a local anaesthetic is very unpredictable in itself; It can turn out quick and easy, but it can also take a very long time to get to the right nerve. It is therefore highly unpredictable how this activity will affect other routines in the flow of the day. 6.4.2 Delays Delays may occur at various points in the surgical process. Mostly, they come about simply because the intervention takes longer than expected. In drafting the operating program, the planner makes ‘calculated guesses’ based on experience. Previous surgeries mostly give a quite accurate indication of the operation’s duration. Nonetheless, there might be complications or unexpected findings that delay the process. The surgeon for example expects to find a colon tumour, but when he opens the abdomen, there are two. Sometimes, the reasons for delay are even more unexpected: