Surgery Rotations, It’s not like Grey’s Anatomy

21 May

Intro to 3rd and 4th Year Medical Student Surgery Clerkship

Most of my introduction to the operating room has been via hands-on learning.  The OR staff gave me a tour and a short briefing/reminder of how to scrub, gown and glove, but I still didn’t quite catch the whole process.  I was told that on my first day I would change into the OR scrubs with a jacket and wear the hair and shoe covers before crossing the red line. I would then want to grab my size of gloves and gown and set them up on a mayo stand in the OR room and then scrub…

If you’re anything like I was, green in the OR, you may be thinking to yourself, “When, where, and how am I going to do this without looking like a complete idiot?”  This intro left me with a bunch of new questions which I mostly blame on TV shows for misleading me about what surgery is actually like.

On TV, the surgeon scrubs and walks into the OR where everything is perfectly set up, gets gowned and gloved, and immediately starts cutting.  Once the patient is sewn back up, the surgeon is on to the next case; rinse and repeat.  This, I learned, is far from the truth, or at least in the community hospital that I rotated in.  Perhaps my brief walk through might spare you some of these doe-eyed questions when it’s your turn to check out the OR.

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Dress: Change into clean scrubs from the OR, with a cap and shoe covers, which should all be in the locker room.  Remove all jewelry and watches. Don’t wear nail polish.

Pre-Op: go meet your patient. It is proper etiquette to introduce yourself, know the basics of the surgical procedure you are going to and the patient’s history prior to scrubbing the case.

The Red Line: You can cross the red line when you  are wearing your OR scrubs, cap and shoe covers. This line will be emblazoned on the floor somewhere between the locker room and the OR suites (know where this is!).

The OR:

  • Usually there is a monitor or board (this is like on gray’s anatomy) telling you which OR room your case is in along with what time/physician and procedure.
  • Once you find the room, ALWAYS wear a facemask (find these by the scrub sink) when you enter.  I also make sure to find either a mask with an eye shield or the glasses that work as an eye shield. When not knowing the surgery or the surgeon that well it’s really unpredictable how messy each case can get and is better to be over prepared than under, and some OR’s require eyewear. Often, it is proper etiquette to go in the side or sterile core door instead of the main patient doors to decrease air flow in and out of the OR.
  • The OR is typically staffed by anesthesia (either anesthesiologist or a certified nurse anesthetist), a scrub tech (who will be gloving/gowning you and helping with all of the sterile part of the case, e.g. handing instruments, set-up, etc) and a circulator nurse (who helps with the non-sterile parts of the case, paperwork, getting extra equipment, etc).  Sometimes there are various assistants or medical device representatives your physician may ask to help out also. Make sure to introduce yourself to this team. There is often a white dry erase board in the room, make sure to write your name and credentials on this board to identify yourself.
  • Make sure once you’re in the room not to touch anything that is blue or covered in plastic as this is often sterile and you may contaminate it.
  • Next, find your gown and gloves, (ask on your first day where to find all of this).  Using sterile technique, give your gown/gloves to the scrub tech or circulator nurse to add to the sterile table. Sometimes, they may say they would prefer you to set up on a mayo stand (yes, you should try to know the names of some of the equipment, but this will come with time).   If you are putting anything on the sterile table yourself or gowning/gloving yourself, you better know how to do it correctly and tell the scrub tech/nurse if you don’t!  The last thing you want to do is contaminate their whole table of sterile equipment or worse – the surgical field!  There are lots of youtube videos on this if you need to review!
  • The next part I’ve seen done differently depending on the surgeon and/or hospital.  In some places the patient will be brought into the OR room from pre-op and be prepped for surgery.  This includes patient positioning, a time out confirming the name and birth date of the patient, and anesthesia followed by surgical site prep and urinary catheter placement if needed.  Make sure to be quiet for all of this, usually until the patient is fully under anesthesia.  Some surgeons help with prep and some are scrubbing during this time, so follow the example of your preceptor and feel free to ask the nurse if they would like help.  Things you can help with are getting the lights positioned for the surgery (the elbows of the lights should always be toward the outside of the room and no light arms should be crossing since it’s difficult to pass them around the room once the field is sterile), help move the patient onto the OR table, put the leg cuffs on the patient and make sure the machine is on for the sequential compression device, you may ask the RN if you can insert or help insert the foley, get a warm blanket for the patient, help secure their arms to the arm boards and reassure the patient.
  • Once you exit the OR room to scrub, make sure you have your scrubs, cap, face mask, and eye shield exactly how you like it and secured well because once you scrub there’s no changing it unless you ask for the circulator nurse to adjust it for you. There’s nothing more annoying than having fogged up glasses/eye shield for an hour during a surgery because you didn’t bend the nose piece to your mask just right beforehand. Scrub at the sink, and as etiquette suggests, do not finish before your surgeon and do not enter the OR to gown and glove before your surgeon unless instructed otherwise.
  • Once you are gowned and gloved (either by the scrub tech or by yourself), enter the sterile field, avoiding all that isn’t draped in blue or covered with clear plastic – do not touch anything that does not have a sterile drape on it once you are scrubbed! Rest your hands on the patient, in the sterile field with your belly up to the table; “be one with the sterile field.” If you make it through all of those steps without getting kicked out to re-scrub, (never question the person kicking you out, just go re-scrub), you will advance to either become a really eager retractor holder or hopefully get to do a lot more with your front row seat to the surgery!
  • Other things you may do while in the surgery is sponge blood (dab, don’t rub) and suction blood, fluid and bovie electrocautery smoke (don’t suck bowel and try to avoid actually suctioning tissue, try to hover above it while trying not to put instruments in the surgeon’s field of view also). You may also ask for the suture scissors from the scrub tech when you see the surgeon is tying a knot – this shows you are paying attention and is usually the first step in gaining experience in the OR to be able to do other stuff (suturing).  If you haven’t cut suture for that surgeon previously, always ask where they want the suture cut (on the knot, 1cm from the knot, etc).
  • The surgeon usually dictates the post-op note once the procedure is over, sometimes in the room and sometimes not. If they stick around, you can help clean the surgical site, bandage the wound, undrape the patient, detach the leg compression devices, bovie pad, etc.  You can also help transfer the patient to their bed once anesthesia has given the okay. Make yourself useful and remember; if you’re unsure about something, ask first!
  • One way to always look good is to remember things called out in surgery such as estimated blood loss, specimens taken to pathology, urine output, volume of fluids given.  These are things the surgeon will be noting after the case and if they forget then you look like a rockstar if you remember.  If you are hoping to go into a surgery field start noticing what types of suture that is being used for certain tissue and parts of the surgery and make sure you learn how to tie knots so that when asked if you know how they will let you tie.

Prepping for a Surgery Clerkship:

I’ve found this reference most helpful for surgery, University of Washington’s Turkey Book Surgery Page.  I also really liked the handbook Surgical Recall to review before going into a surgery.  Another way to learn how the surgery will go (reviewing the steps) to be able to follow along easier is to find an example operative note online (you can just google operative note for cholecystectomy and they will pop up) and read through it before going into the case.  I found this helpful with hysterectomy’s in general to really get the order down for what ligaments will be taken down.  It really helped me be able to identify many of my landmarks when I knew when we would be looking for them. 

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