Análisis y comparación de los procedimientos para la planificación del

-> 12 (0.3)§(0.4)*++(0.3)§§(0.6)+(2.0)§ intern §bendovertable§§clean cusa § surgeon -->*

Image 1 Image 2 Image 3 Image 4 Image 5 Image 6 Image 7 Image 8 surgeon intern scrub tech 2 scrub tech

In this excerpt, the surgeon tells the intern “you can wash” (l. 02), requesting her to wash the tip of the Cusa. She immediately takes up the request and starts moving, turning towards the Cusa machine (l. 03, Image 1). The surgeon, who is following her with his gaze, reacts to this by pointing at the scrub table, displaying that she should turn there (l. 03, Image 2) and uttering the word “saline” (l. 04), possibly to help her to remember what to do. As a first-year surgeon-in-training, the intern is still learning the procedure and while enthusiastic to accept the surgeon’s request as displayed in her body movement, she does not seem to fully understand the request. The intern looks at the machine, but as she cannot find what she should do, she starts turning back towards the surgeon (l. 05, Image 3). When she is gazing at the surgeon, he repeats his pointing gesture, this time more intensely than earlier (l. 05-06, Images 4-7). The surgeon moves his hand back and forth while pointing at the scrub table, uttering “that way” (l. 06) while he is pointing. The intern follows his hand with her gaze and turns towards the scrub table. In the meantime, the scrub tech, who is also still learning and who is taught by scrub tech 2, also displays that she does not seem to understand her involvement in the activity. She started looking at the surgeon when he was pointing at her scrub table. Her teacher, scrub tech 2, also starts pointing at the scrub table when the surgeon utters “that way” and she continues to point when the surgeon withdraws his hand and turns his gaze back to the patient (l. 06-07, Image 7-8). The intern starts walking to the scrub table, and the scrub tech follows her. While they both gaze at the scrub table, the scrub tech utters “here, I saw it” (l. 08). She starts reaching out towards a bowl on the table. As she is moving her hand forwards, scrub tech 2 starts pointing again, probably towards the correct bowl, and the intern displays that she understood by uttering “oh there” (l. 09) and also moving her right hand towards the scrub table. After a while, the surgeon turns from the patient towards the scrub table. While the scrub tech is passing the bowl with saline towards the intern, the surgeon reinforces and clearly utters his request by saying “clean it in saline” (l. 11). The intern, who now seems to have fully understood the request, leans forward and cleans the tip of the Cusa in the bowl (l. 12).

The excerpt shows how surgeon and intern build common ground on what action should be done next and what the surgeon means by his initial request “you can wash”. The request is formulated as an assertive but also involves the words “you” and “can” as in the indirect requests in earlier examples. In contrast to excerpt 11, the intern does not struggle with recognizing the surgeon’s utterance as a proposal for a joint project. In fact, she immediately displays acceptance by starting to move. However, she has not fully understood the request and first turns towards the Cusa machine instead of the scrub table. The surgeon tries to help her by naming the liquid that she should wash the instrument in (“saline”), thereby hinting that she should turn towards the scrub tech and scrub table, as this is where saline is usually to be found. She does not seem to understand what the surgeon is referring to and turns back to him for help. When she is gazing at the surgeon, he starts pointing back and forth towards the scrub table, underlining his deictic gesture with the words “that way”. The intern gradually turns into the direction indicated by the surgeon. The surgeon is thereby reorienting the intern’s body through his deictic gesture. At this point, the scrub nurses join the project as well: As the intern is turning towards the scrub table, the experienced second scrub tech starts pointing towards the bowl with saline on the scrub table, thereby directing intern and her apprentice scrub tech towards the right location. The scrub techs become involved in the sensemaking process that is needed to reach fulfillment of the request, as the scrub tech should prepare the bowl with saline on the scrub table. She spots the bowl first and displays that she did so by saying “here I saw it”. She moves her hand towards it, and finally the intern also spots the bowl, which she indicates by saying “oh there”. The

surgeon joins the team by the scrub table and similarly as in Excerpt 13, he repeats his request once more before it is finally completed, this time in a slightly modified form, saying “clean it in saline”. As we have seen, participants finely coordinate, using gaze, gesture and their bodies when negotiating fulfillment of a request in open surgery. They incrementally build a shared understanding, displaying their understanding and adding explanations as lack of understanding becomes evident. In experienced teams, this sensemaking process happens in an incremental and largely embodied way, in which verbal utterances are mainly produced to underline the bodily conduct. Team members rely on deictic gestures to highlight particular aspects of the material environment and thereby direct the others’ attention. The struggle does not interrupt the interaction and trouble is not explicitly verbalized. Rather, the team works smoothly, gradually incrementing common ground until the joint understanding is sufficient for fulfillment of the request. As we will see in the following chapter, this is in stark contrast to robotic surgery.

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In the following excerpt, the surgeon is requesting a particular cauterizing instrument that should be attached to the robot arms, a Maryland Bipolar Forceps, which they commonly refer to as “Maryland”. While the scrub tech initially accepts his request, it later turns out that there is no such forceps in this particular operating room and they need to mobilize additional resources in order to get hold of a Maryland.

Excerpt 15. 10-02-17_cam1_surg3R_00008_13:46-15:09.