In the 1930's Chinese leftist cooperative groups were admired for their vigorous resistance to the Japanese. Their motto "gung-ho", literally "work together", was adopted by US marines operating behind enemy lines. Emulating the cooperative meetings of the leftists the marines began to convene "gung-ho" meetings in which problems could be threshed out and orders explained. The term has since come to mean energetic and zealous.(Clairborne 1988)
When considering the cooperative enterprise of the OR we might take this approach as a model. To transform a chaotic, heated improvisational approach requires coordination and it requires a gung-ho spirit which starts from the top. Participation in scheduled problem solving meetings to link the surgeons perspective to that of the circulating nurses and technicians. This is to insert yourself into the chain of command of the hospital structure but is more effective than attempting to affect change by complaining at the medical staff or hospital administrative level. Staff turn over and the inability for many ORs to dedicate staff to specialize in orthopaedics are obstacles. A gung-ho core of orthopedic fanatics within the culture of the OR is the goal.
While initiatives like the push for "sign your site" and intraoperative "time out" are sensible they are as important symbolically beyond their effectiveness in practice, should that be demonstrated. The target of each is hubris,arrogance, or the numbing effect of routine and any other all too human tendency which can result in error which in the case of surgery may be irreversible. Both measures reflect a basic methodology employed in airline and military activities in which zero tolerance for error is combated by systems of cross checks and verification.
Surgery is collective enterprise but the buck stops with the surgeon. Everything should be done to enable the full concentration of the surgeon on the physical tasks and intra-operative decisions that are necessary for an optimal result.
The atmosphere of the OR will vary with the personality of the surgeon. Some surgeons are comfortable with social exchanges and discussion of common interests shared by members of the OR team, humor and gossip. Unfortunately to the extent this is beneficial it must be weighed against the potential impact of verbal exchange on the incidence of intraoperative infection.
Traffic flow in and out of the room once the surgery has commenced is a necessity at times. Unecessary traffic can be avoided by planning ahead so that the equiptment is in the room, and avoiding a casual flux of personel as a matter of OR policy.