Historically, the role of the anesthesiologist was limited to the physician who administers anesthesia to suppress pain and consciousness in a patient undergoing surgery. Today, The American Society of Anesthesiologists defines an anesthesiologist as a perioperative physician, the “all-around” physician responsible for providing medical care through all junctures of a patient’s surgical course. In the current health care system, in addition to providing pain control and life support functions during and after surgery, anesthesiologists play important roles in preoperative surgical planning and preparation as well as many other aspects of patient care.
At many teaching institutions around the country you may encounter anesthesia residents in training. Anesthesiology residency is a four-year program after medical school requiring one year of internship and three years of anesthesia-specific training. Quick tip for medical students: if you do not enjoy physiology and pharmacology, anesthesiology may not be the right specialty for you. A resident performs the roles and responsibilities of an anesthesiologist under supervision of a staff (fully trained) anesthesiologist. During the operation many of the OR staff may come and go but an anesthesiologist will be present during induction, emergence, and all critical portions of the operation. Anesthesia residents often spend rotations in specialized areas of anesthesia as part of their training including cardiac, transplant, pediatric, regional, ambulatory, and neuroanesthesia, as well as critical care, acute pain, and chronic pain. Following residency, some anesthesiologists will pursue fellowship training in these specialties.
THE ANESTHESIOLOGIST’S JOB
The anesthesiologist’s job starts prior to surgery with assessment of the patient’s medical and surgical history. This may start weeks before a planned operation to allow time for appropriate testing and medical treatment if a patient has complex medical problems. The aim of this preoperative evaluation is to discover risk factors that must be assessed and managed, including acute and chronic diseases of the heart, lungs, kidneys, and liver, allergies, medications, and difficult access to the circulation or airway. Failure to carefully evaluate and manage the patient preoperatively may result in delay of the operation or increased complications during or after the surgery. The preoperative evaluation and plan may be performed by another anesthesia provider weeks before but will be reviewed by the anesthesiologist on the day of the operation. Intraoperatively the objectives of the anesthesiologist for the patient include loss of awareness, pain control, vital sign monitoring and intervention, airway management and breathing, and appropriate hydration with intravascular fluid administration. The anesthesiologist assumes control of the patient’s general physiology throughout their operative case.
If a general anesthesia is planned, on arrival into the operating room the patient will first be placed on appropriate monitors for the procedure. For every anesthetic, the patient’s oxygenation, breathing, and circulation are continually monitored as well as temperature if changes are anticipated, intended, or suspected. Monitoring is usually accomplished through use of a pulse oximeter, ECG monitor, blood pressure cuff, and temperature probe. In addition to these standard monitors, some procedures might also require more advanced monitoring and interventions such as a depth of anesthesia monitor, intravascular monitors, and real-time imaging of organs such as the heart with the use of ultrasound. These monitors may be placed before or after initiation of anesthesia (Figure 4.1).
Monitoring equipment for anesthesia. (Photo used with permission from Deanna Attai, UCLA.)
Once the appropriate monitoring is in place, the patient is prepared for the start of anesthesia, which is referred to as “induction.” The patient will be asked to breathe 100% oxygen via a plastic mask that is sealed around the mouth and nose. This step is to give the patient an oxygen reserve from the time the patient stops breathing after induction to when the anesthesiologist can safely assist their breathing. Once the patient is pre-oxygenated, anesthesia is initiated, most often with a memory loss medication (induction agent), a fast-acting pain reliever, and a muscle relaxant given through a vein. The patient will lose consciousness and stop breathing very quickly, almost always in less than a minute. At this point, the anesthesiologist may help the patient breathe with the mask used for pre-oxygenation or proceed directly to placing a hollow plastic tube, called an endotracheal tube, into the trachea, the structure connecting the patient’s mouth to the lungs. To place the endotracheal tube, a laryngoscope is used. A laryngoscope is a blunt metal blade with a bright light on the end, used to push the tongue out of the way and light up the opening of the trachea. When endotracheal tube placement is confirmed, the tube is secured in place and breathing is assisted or taken over for the patient. If the anesthesiologist anticipates a difficult airway, the endotracheal tube might be placed with the patient under light sedation with local anesthetic while the patient remains breathing on their own.
During the operation, the anesthesiologist maintains anesthesia and preserves stable heart and lung function. Most commonly, anesthesia is maintained with a vapor inhaled through the lungs, which travels through the bloodstream and acts on the central nervous system. Maintenance of anesthesia may involve the use of a number of different drugs and fluids, especially when the operation is associated with major interruption of blood flow or major blood loss.
After the operation is complete, if it’s possible for the patient to breathe without assistance the anesthesiologist will reverse the effects of muscle relaxants and anesthetics and remove the endotracheal tube. Awakening from anesthesia is referred to as emergence. If the patient requires continued breathing support, the anesthesiologist may decide to leave the endotracheal tube in. In either event, depending upon the intensity of postoperative care required, the anesthesiologist transports the patient to either the postoperative care unit or an intensive care unit. During this recovery period, the post-anesthesia care unit or critical care nurses may administer drugs to relieve pain, control blood pressure, and stabilize organ function.
Depending on the type and duration of procedure being performed, the anesthesiologist may choose a technique other than general anesthesia. Other types of anesthetics include monitored anesthesia care, regional anesthesia, neuraxial anesthesia, or a combination of these techniques. Oxygenation, ventilation, and perfusion must still be monitored with alternative anesthetic techniques and there is always a possibility of transitioning to general anesthesia during the procedure.
Monitored Anesthesia Care
Monitored anesthesia care (often referred to as MAC) differs from general anesthesia by allowing the patient to continue breathing under their own power and keeping the patient able to respond to touch or verbal stimuli. This is usually accomplished with IV sedative medications or slow, less aggressive infusions of the same medications used to induce general anesthesia. Vapor inhaled anesthetics are rarely used, as they are pungent and unpleasant to breathe spontaneously.
Regional anesthesia involves injection of a local anesthetic around major nerves to block pain from a large region of the body. The nerves are found using anatomic landmark, nerve stimulator, or ultrasound-guided techniques. For example, a supraclavicular block to the brachial plexus will provide anesthesia to the majority of the arm. Nerve blocks are most commonly used for procedures on the hands, arms, legs, or face. The choice to perform regional anesthesia depends on the patient’s ability to tolerate the block, to tolerate the operating room environment, and the length and location of the procedure. Regional anesthesia can also be performed after an operation to provide postoperative pain relief.
Neuraxial anesthesia includes injection or continuous infusions of local anesthetics in close proximity to the spinal cord. A spinal anesthetic is often used for lower abdominal, pelvic, rectal, or lower extremity surgery. This type of anesthetic involves injecting a single dose of local anesthetic agent directly into the spinal cord fluid in the lower back, causing numbness in the lower body.
Epidural or Caudal Anesthetic
An epidural or caudal anesthetic is similar to a spinal anesthetic, and is also commonly used for surgery of the lower limbs and during labor and childbirth. This type of anesthesia involves continual infusion of drugs through a thin catheter that has been placed into the space that surrounds the spinal cord in the lower back, causing numbness in the abdomen and lower body. The advantage of an epidural or caudal anesthetic over spinal is that it allows adjustable anesthetic doses for a long duration. However, epidural and caudal anesthetics can be unreliable in their spread and strength of blocking the nerves due to the complexity of the spaces into which the infusions are entering.
The anesthesiologist is a great resource for learning about airway management, pharmacology, and complex physiology while patients are in the operating room. Their role is central to the safety of the surgical patient before, during, and after their operation.
I remember getting a call at 2:00 in the morning from the obstetrician saying that we had to rush to the OR with an emergency postpartum hemorrhage. Just hours before that, I placed a labor epidural in this same patient to help relieve her pain during labor, in anticipation for her first child. I remember the proud look on the new father’s face as they transferred the family to the postpartum unit. Upon hearing the news that we must rush to surgery, I saw the same father anxiously waiting outside the OR, his face much different this time! I assured him that his wife was in good hands. The OR staff were all busily preparing for emergency surgery. I noticed the patient was afraid and in a state of shock. I grabbed her hand and explained that I would have to place her under general anesthesia so the surgeons could control the bleeding, and I would be by her side and help her get through this unexpected event. I continued to reassure her until she was comfortably asleep under anesthesia. This story exemplifies how I unite my experience as a bedside nurse with my expertise in anesthesia—a unique skill set possessed by Certified Registered Nurse Anesthetists (CRNAs).
CRNAs are highly trained providers of anesthesia. We are first and foremost nurses. Our training begins with a bachelor’s degree in nursing, and all CRNAs must have critical care experience prior to their anesthesia training. This bedside care experience helps CRNAs to connect with their patients on a personal level. It has been invaluable to me as I try to ease the (appropriate) anxiety most patients experience before going to surgery. In addition to our critical care experience, all CRNA programs are between 28 and 36 months, leading to a masters or doctoral degree. Following completion of degree requirements, a rigorous board examination must be passed to ensure competence, and for the safety of the public. These are the entry-level requirements to begin the practice of anesthesia as a nurse.
Anesthesia was first practiced by nurses on the battlefields of the Civil War in 1860 and became the first nursing specialty in the United States. Currently, 38 million anesthetics are provided by CRNAs in the United States each year. At many hospitals where CRNAs practice in a team with anesthesiologists (Figure 4.2). This partnership adds a unique quality to the patients we serve, while keeping safety our top priority.
CRNA working alongside the anesthesiologist. (Photo used with permission from Ruth Braga, University of Utah.)
Anesthesia is 50 times safer today than it was in the 1980s. Practicing anesthesia in teams has the added benefit of making anesthesia even safer for our patients. CRNAs communicate closely with our anesthesiologist colleagues, freeing them to identify risks, mitigate those risks, and provide for a smooth recovery from anesthesia in the recovery room. You will always see an anesthesiologist present during the key moments of anesthesia, including induction, emergence, and placement of invasive lines.
In my anesthesia training I was taught to plan for a smooth anesthetic but always be prepared for the worst. In the example of the postpartum hemorrhage, I had previously prepared myself for any emergency. As the OR staff were busy with the tasks of preparing for surgery, I was free to attend to the patient’s fears. My years of bedside nursing experience made me remember that my duty was not only to administer anesthesia, but also to care holistically for patients and their families.
FROM MEDICAL STUDENT TO SURGEON
A surgical team at an academic medical center is composed of individuals at multiple levels in their training and careers. There is a specific surgical hierarchy in the operating room and it is important for everyone to understand this, especially during cases involving critically ill patients (Figure 4.3).
The attending operates and teaches multiple individuals simultaneously. (Photo used with permission from Ruth Braga, University of Utah.)
The clinical training to become a general surgeon is five years long, following medical school. Other surgical specialties such as obstetrics and gynecology, neurosurgery, or otolaryngology have training that ranges from four to six years. Choosing what type of physician to become is a lengthy process that usually starts during undergraduate training, where premedical students will follow (or “shadow”) senior physicians to better understand what different specialists do. Premedical students have no formal training in OR etiquette or procedure and will usually need specific instructions from the OR nursing and scrub staff on where to stand and how to avoid contaminating the sterile field. If you are a premedical student, I can’t emphasize enough to you—please ask questions when you are observing in the OR so that you don’t breach etiquette or have a negative impact on the safety of the patient.
In medical school, students typically begin to scrub for cases during their third year. Medical students receive varying amounts of training on how to properly scrub and maintain sterility, so assuming they know proper sterile technique can be dangerous. Medical students rotate through various specialties during their clinical years, so they will have limited time and experience in the operating room. They will usually help the surgical team with retraction during cases and generally focus on learning the operative indications and anatomy. Medical students are commonly tasked with closing the incision at the end of the case. Expect medical students to struggle initially with wound closure, and keep in mind how you appreciated the patience of your senior colleagues early in your training.
When a medical student graduates, they are officially referred to as “doctor,” and enter a residency training program. Residency is when physicians become specialists in different areas of medicine such as a family practice, pediatrics, surgery, or radiology. The clinical training to become a surgeon, as noted above, generally lasts five years. First-year residents, referred to as interns, typically spend most of their time outside the OR learning how to manage patients before and after surgery. When interns do come to the operating room they are closely supervised by more-senior doctors and are focused on learning basic surgical techniques. The nursing and scrub staff in the OR can play a tremendous role in shaping these future surgeons by helping them learn the names of instruments and also the safe handling and passing of instruments. It is critically important for residents to learn early how to guard needles and safely pass sharps so that it becomes habit even (and especially) during stressful OR cases.
After completing their internship, residents in their second and third years of residency are referred to as junior residents. Junior residents will scrub most of the bread-and-butter cases for their specialty and help supervise medical students and interns. Residents in their fourth year of training are typically referred to as senior residents, and residents in their final year of surgical training are called chief residents. Senior and chief residents will typically scrub for the more complex cases in the operating room and are also tasked with overseeing the rest of the resident team. Senior and chief residents are sometimes entrusted to take a junior resident through a case as a teacher, but today, with the emphasis on patient safety, the attending is expected to be present. It is not uncommon for senior and chief residents to have to field multiple pages and phone calls while scrubbed in for surgery. It is helpful to remember that residents are functionally expected to be in multiple places at once—operating, managing floor and ICU patients, as well as seeing and staffing consults. It can be frustrating to the OR staff to help with returning pages, but this generally speeds cases along and allows the team to function more efficiently.
After completing a surgical residency many surgeons choose to subspecialize into a more focused practice. These subspecialty programs are called fellowships. Fellows are focused on learning the complex nuances of their subspecialty and generally practice relatively independently under the direction of a mentoring attending surgeon. Fellows will often complete cases as the attending of record and are responsible for teaching and directly supervising residents in the operating room.
Finally, the most senior member of a surgical team is the surgical attending or consultant. The surgical attending is the individual ultimately responsible for the care of the patient in the operating room and makes the final decisions on all care provided to the patient. Depending on the type of case in the OR, there may be multiple attending surgeons present for a given operation, and ideally the interaction is collegial and allows for a safe and efficient operation for the patient. Cases with multiple attending surgeons present a particular challenge for OR staff in terms of setup and expectations, so extra preparation, extra communication, and extra patience is fundamental during these events.
Surgical training is lengthy and rigorous because of the amount of medical knowledge and technical skill that surgeons must have to care for patients. Surgeons have to be able to operate under both ideal and difficult conditions, and they also must know when offering an operation is unlikely to help a patient (and therefore not offer that operation).
Surgery is both an incredibly challenging and an incredibly rewarding career because of the complexity of what surgeons do, and because we are entrusted by patients and families to “fix” something about their health. Most importantly, surgeons cannot function alone; effective teamwork with the rest of the surgical team is mandatory for successful outcomes for our patients.
THE ROLE OF THE RESIDENT IN THE OPERATING ROOM
In the OR, the main goal of the resident is to learn how to perform the operation while providing the best possible care for the patient. The resident is always under the supervision of the attending surgeon, but as the resident’s skill and knowledge improves he or she is given more independence. Before we take the patient into the OR, the resident will ensure that the correct surgery is going to be performed on the correct patient. Under the direction or with the assistance of the attending surgeon, residents identify if and when a patient needs surgery. It is important to discuss the risks, benefits, and alternatives of the surgery with the patient. This is referred to as the informed consent process. Prior to the OR, the resident also ensures that all required paperwork is completed and any necessary labs or imaging are done. Often this requires writing or updating a history and physical.
Prior to the patient arriving to the OR, the resident will review relevant labs and imaging. One of the resident’s jobs is to have the x-rays or scans pulled up on a computer monitor in the OR. If the surgical plan is unclear to the resident, they will ask the attending for clarification as a learning exercise and to optimize the patient’s care and safety. A resident will often speak with the attending to learn how to do the operation as well as how to troubleshoot if there is an event in the operating room. It is important that the resident comes to the operating room completely prepared, with an understanding of the attending’s surgical plan. As the resident becomes more advanced, the attending may challenge them to create their own surgical plan, and will review it with them prior to surgery. The resident also is responsible for verifying that all supplies that may be needed in the surgery are available.
Once the patient arrives in the OR, the resident helps the nurse place the patient on the operating room table. A time-out is conducted to verify the patient’s planned surgery, the indications for it, any drug allergies that the patient has, and the antibiotic plan. The time-out must include the attending surgeon, the anesthesiologist, and the circulating nurse. Once the anesthesiologist puts the patient to sleep, the resident will help get the patient positioned correctly, place the Foley catheter if one is needed, and gather appropriate supplies. If the case is laparoscopic, the resident will help to get the screens into an appropriate position, or may tuck the arms if this helps to position the patient appropriately. Once the patient is safely positioned, the resident will prepare the surgical site, though some attending surgeons prefer to do this, and sometimes circulating nurses may offer to help.
After the surgical scrub, the operative team gowns, gloves, and then drapes the patient (Figure 4.4). The way the patient is draped depends on the surgery to be performed and may be strongly influenced by attending preference. The resident should be familiar with the surgical plan to ensure appropriate draping.
Resident carefully draping the patient. (Photo used with permission from Ruth Braga, University of Utah.)
After all of these preparatory steps, the operation can finally start; as a new observer in the OR you may sometimes wonder if the team spends more time preparing for the case than performing the actual surgery. The resident will either assist the attending or the attending will assist the resident, depending on resident skill and seniority. If the resident is very capable, they may be assisted by a second resident to complete the surgery or may be given responsibility for teaching a junior resident how to perform an operation (Figure 4.5). Throughout the surgery, the resident should ask questions to ensure that they are progressing appropriately through the steps of the operation and that they are effectively using their technical skills. Residents expect the attending to teach during the surgery, and a resident will simultaneously also teach the medical student or junior resident about the anatomy and physiology of the patient, as well as about the surgery being performed (Figure 4.6).
Many hands at work. (Photo used with permission from Sarah Bryczkowski, Rutgers New Jersey Medical School.)
Transplant teaching. (Photo used with permission from University of Utah Health Sciences Center Transplant Team.)
When the operation is complete, the resident will close the patient’s skin and place dressings as appropriate. The resident helps to move the patient back onto their bed and ensure they are taken from the operating room in a safe manner. The resident often has the responsibility for completion of the brief operative note and dictation of the operative report. The resident also write orders for the patient’s care. Finally, the resident makes sure the patient is following an expected postoperative course by checking on the patient after surgery as appropriate to ensure that an urgent or emergent return to the OR is not necessary and that the patient’s postoperative course is as expected.
The resident has a unique dual role in the operating room. While the resident is a doctor who has graduated from medical school, they are also still a learner who is in training. The broad responsibilities of the resident highlight these two sets of responsibilities—the resident is accountable for the safety of the patient as a physician, and also needs to learn to be a safe surgeon.
HOW TO BE A SUPERSTAR MEDICAL STUDENT IN THE OPERATING ROOM
Medical students are an essential part of the surgery team; they serve as the eyes and ears of the team. They are also excellent patient advocates in and out of the operating room. As a medical student, the demands on your time are very different from the demands on residents and faculty, and this fosters a very different patient relationship. Medical students vary by their level of experience and how far along they are in their training. Most commonly, third and fourth year medical students are found in the wards and the OR, as opposed to the first and second year medical students who are cooped up in the classroom.
Depending on your comfort level and prior experience in the OR, your role may vary from helping to set up and retract to first-assisting a case if no other qualified first assistant is available. However, the first and most important role of the medical student is to learn. Learning goes beyond the anatomy, physiology, and technical skills one can learn in the OR. Learning starts with meeting the patient in the pre-op holding area, introducing yourself, then helping to take the patient back to the OR. The OR can be an intimidating place for patients—just like it is for medical students—and having a familiar face present helps ease anxiety. The following is by no means a complete list of the things medical students can help with in the operating room, but is meant to serve as a general guide for medical students and everyone who works with them in the OR. They are things you can help with at the different stages.
BEFORE THE PATIENT ENTERS THE OPERATING ROOM
Make sure you write your name on the board upon entering the OR.
Introduce yourself to the nurse circulator and the surgical technician; ask if you should get your gloves for the case and make sure they have enough gowns for you to have one too.
Pull up any pertinent imaging on the computer screen for the attending surgeon and residents to review before and during the surgery.
ONCE THE PATIENT IS IN THE OPERATING ROOM, BUT STILL LYING ON THE STRETCHER
Hold the door open to help get the patient stretcher into the OR.
If you feel comfortable with it, help transfer the patient to the OR table. If you are not comfortable, you can always help hold the feet while you learn how to help move patients (Figure 4.7).
During the transfer, if you notice that something is caught or the bed is not locked, speak up. Patient safety comes first, and the patient and team will thank you.
If you aren’t sure how you can help, just ask.
Two medical students prepare to assist the patient to move over to the OR table. (Photo used with permission from Ruth Braga, University of Utah.)
ONCE THE PATIENT IS ON THE OR TABLE
Make sure there is someone standing at the bedside to ensure safety of the patient. We can’t have patients falling off of the OR bed.
Take the stretcher out of the OR and “park” it in a nearby spot.
Help place the SCDs (sequential compression devices) on the patient’s legs after you explain to him/her what you are doing. Be sure to plug the devices in and turn them on.
Help keep the patient covered with warm blankets.
Help position the patient; ask the circulating nurse and/or resident what you can help with because you don’t want to be “that” medical student who makes assumptions about positioning the patient.
If hair needs to be shaved from your patient, ask for the clippers and shave at the site where incision will be. If you’ve never shaved a patient before, ask for guidance.
If someone else is shaving the patient, put gloves on and get tape to collect the remaining hair.
Will the patient need a urinary catheter placed? If you have been trained, ask to place it.
If you are comfortable and the team and your facility approve it, you may prep the patient.
Participate in the time-out. If something is said that doesn’t seem right, speak up. Patient safety is first, and this is one place you can be the MVP.
If you find yourself with nothing to do while the patient is being placed to sleep, hold their hand and help to make them comfortable. They’ll really appreciate your kindness.
WHEN THE PATIENT IS PREPPED AND DRAPED
Scrub in. If you haven’t done this before, get someone knowledgeable to coach you through the process (Figure 4.8).
Medical students scrubbing in (but forgot to put goggles down-just ask the nurse to assist you if this happens). (Photo used with permission from Ruth Braga, University of Utah.)
YOU’RE SCRUBBED IN, NOW WHAT?
Don’t break the sterile field.
Pay attention. Be mindful and engaged. Ask questions during the noncritical portions of the case.
You may be asked to retract, cut sutures, tie knots, and maybe even to help close the incision.
Once you are more comfortable, you’ll be able to assist more easily. When you are new to the OR it can be really hard to anticipate what steps are next. The more time you spend scrubbed in, the easier this becomes.
SURGERY IS OVER, NOW WHAT?
Grab warm blankets and a clean gown and help cover the patient and keep them warm.
Help take extra leads, the bovie pad, and other attachments off the patient. If you aren’t sure, ask the circulator or anesthesia. If you remove the bovie grounding pad, make sure to announce that the site looks okay (or if it doesn’t, announce that too, so the team knows and can document appropriately).
Help transfer the patient back to the stretcher or to their inpatient bed.
Write the brief operative note; ask the anesthesia resident/attending how much fluid the patient received, the estimated blood loss, if any urine was measured. All of these things help make your resident’s life easier.
Accompany the patient to PACU or to the ICU and make sure they are safe.
Do post-op checks at approximately two hours and eight hours after the surgery is over. Is the patient’s pain controlled? Are they making urine? Are they having terrible nausea and vomiting? Are their vitals okay? Reporting back on these things to your resident shows them that you really care about your patient (because you do).
Remember, the role of the medical student goes beyond learning the basic anatomy, physiology, and surgical skills needed. The role of the medical student in the operating room is to be a patient advocate, a team player, and most importantly an open-minded learner willing to learn from every member of the highly trained team that participates in the care of the patient in this very special place called the OR. We are fortunate to be part of this process.
THE OPERATING ROOM: VIEW FROM A PHYSICIAN ASSISTANT
The operating room is one of my favorite places to be. I enjoy the music and the silence, the ability to work with my hands while not touching a keyboard, and the conversation and educational experience that time in the OR allows that day-to-day tasks do not.
I also enjoy the raw sense of humor that seems to be characteristic of most operating rooms. The unfiltered conversation that flows so freely is a breath of fresh air from the rehearsed, stale, professional discussions in other clinical settings. This is a place where you truly get to know your peers and begin to connect on a deeper level that develops your overall relationships (and sometimes gives you leverage).
First, I find it helpful to know which areas are considered pre-op, recovery, and post-op. Some hospitals house this area all together, some separate, and some far apart. If you do not know, ask someone to point you in the right direction. The OR nurse manager, the charge nurse, or the OR front desk staff are typically happy to help, as they do not want you messing anything up. While you’re at it, make sure you ask where the locker room is and how to get scrubs.
Upon entering the operating room area, there is usually a red line on the ground and a large sign stating that only OR attire is allowed past this point. Pay attention, but don’t be discouraged if you get yelled at because you forgot to put on your hat. It is not the first time this has happened and it likely won’t be the last. Most hats, masks, and booties (shoe covers) are at every entry point into the OR area. Prior to entering, make a checklist in your head of what you may need. If it is your responsibility, did you bring, sign, and update the H&P? When was the last time you drank water? When was the last time you emptied your bladder? Will x-rays be taken during surgery? If yes, then you need to have lead. What is lead? Those ridiculously heavy, typically sparkly, armor-like aprons that you will see some of the staff wearing in order to shield themselves from x-rays during certain surgery.
If you plan on scrubbing in, the first thing to do is to meet the scrub tech and the circulating nurse in your assigned operating room. If you are really savvy, you will write your full name and credentials on the white board. Always ask if you can get your own gown and gloves for the case. If you don’t know where they are located, ask.
Become familiar with the surgical instruments your surgeon uses. Know what they like—curved versus straight scissors, tapered versus cutting needles. Often there will be different equipment brands, so make sure to familiarize yourself with each so as to not confuse them. If a sales rep is available for a particular product or equipment, do your best to learn everything you can from them in a brief amount of time.
Learn how the surgeon prefers to prep and drape the patient. While you are standing around waiting for anesthesia to intubate the patient, make sure the scrub tech has the appropriate drapes. Many times the circulating nurse will prepare the surgical site, but may appreciate if you offer your assistance (ask before you assume). Once gowned and gloved you should help the surgical tech drape the patient appropriately if needed.
There will likely be several different types of soaps and sanitizing gels available for scrubbing (Figure 4.9). It truly is personal preference, but trust me: anything with iodine is hard on your skin. You always need to scrub (yes, the full five minutes or the brush stroke method) initially. For all subsequent scrubs, you are allowed to use the sanitizing gel unless you have just eaten, gone out for a smoke, or used the restroom, in which case you must scrub again using water.
The variety of soaps/scrub brushes you may see. (Photo used with permission from Ruth Braga, University of Utah.)
After you have scrubbed, it is time to gown and glove. Typically the surgical tech will assist you with both, but if he or she is busy you should know how to do it yourself. For me, this was one of the biggest technical obstacles I faced. I have had a scrub tech watch me fail four times (after the surgeon had already started) before I was able to gown and glove myself, so practice when you can.
During the surgery, always try to think two steps ahead of the surgeon you are working with. Constantly have a lap or Raytech (sterile absorbent cloths) (Figure 4.10) in hand to wipe or dab if needed. Always make sure suction is available to assist in visualizing the site by suctioning the smoke from burning flesh, or suctioning blood (unless you are in a burn OR—then your effort is usually futile). Continuously check to make sure that there is enough light on the area of focus. Sometimes moving the lights is like a game of Tetris and may cause frustration for you and your surgeon. Sometimes the frustration can result in some salty language, either from them or from.
A close-up sponge comparison. (Photo used with permission from Ruth Braga, University of Utah.)
To become a PA, the application process for school is rigorous and admissions are highly competitive. A minimum of two years of college coursework is required, often including prerequisites in chemistry, physiology, anatomy, microbiology, and anatomy. Many programs also expect prior hands-on patient care experience from applicants; the “average” PA student has a bachelor’s degree and three years of healthcare experience before they start PA school. PA school is usually three academic years and results in award of a master’s degree. The education process is a combination of classroom instruction and more than 2000 hours of clinical rotations. After graduation, you must pass a certification exam to become eligible for licensing, after which you may indicate that you are a PA-C (Physician Assistant-Certified). Unlike MDs, who are required to do residencies to become certified in a specific field, postgraduate training for PAs is entirely voluntary and has both advantages and disadvantages. These residency programs include special training in surgery, although this is not a requirement to work as surgical PA.
As a PA working in the OR, you will have many different duties. You have a unique job of assuring that most aspects of surgery, including paperwork, are complete, but at the same time you must be able to do specialty procedures such as suturing, cutting, drilling, and harvesting (veins or skin) that a scrub tech cannot. Patience and practice are the key to excelling in these areas. The final duties of a PA during a case include assuring the right dressing is placed correctly and helping anesthesia and nursing transfer the patient back to the gurney. Once the patient is taken to Post-Anesthesia Care Unit, a brief operative report needs to be completed.
There are those to whom the OR does not “speak.” There is usually a love or hate relationship. But for those of us who do enjoy extremes of temperature, awkward instrument holding, and the challenge of constant variations in patients (not one single patient has read the anatomy book from cover to cover), it gives you a purpose. You will never experience something so raw and delicate as that patient on the table, trusting you with not just their scars, but their life and future.
The circulating nurse, surgical tech, and health care assistant are the primary, consistent roles that you will see in the operating room setting. Some facilities may have specialty teams such as a heart team, transplant team, etc. as surgeries become more complicated and equipment and instruments become more specialized, but the core individuals are stable even among these specialized teams.
The circulator is a registered nurse who is dedicated to caring for one surgical patient at a time. To become a registered nurse, education programs range from 18 months to 4+ years to earn an associate’s or bachelor’s degree in nursing. There is a national trend for the circulator to be Bachelor’s degree prepared.
The circulator has two key roles: to ensure safe delivery of surgical care, and to be a patient advocate. They coordinate patient care with other members of the surgical team from the pre-op area throughout the operative phase and until delivery to the recovery area or the ICU. The circulator ensures that the OR suite is prepared prior to the patient arriving. The appropriate bed, positioning devices, equipment, and medications need to be organized and in place for the surgery. Next, the circulator has a pre-op visit with the patient. They assess the patient and ensure that all paperwork is in order and that any operative questions are addressed. Once the OR suite is ready and the patient is in the room, the circulator often assists with anesthesia induction (Figure 4.11). The circulator also has the responsibility of guiding the “time-out” and making sure that no new information is discovered during the time-out process that changes equipment or care needs for the patient.
The nurse remains nearby during intubation. (Photo used with permission from Ruth Braga, University of Utah.)
Throughout the case, the circulator functions outside of the sterile area in the operating room. Because they are not up at the sterile field and can see the full picture, the circulator assists with monitoring to make sure sterility is never compromised. The circulator also completes all of the OR documentation (this is the very not-glamorous part of the job) (Figure 4.12) and coordinates care of the patient if there is any radiography needed or specimens to be sent. Upon successful completion of surgical counts and wound closure, the circulator will assist anesthesia with extubation and delivery of the patient to the recovery area (Figure 4.13).
Once things have settled, the RN documents activity in the OR, maintains the count, and monitors for breaks in sterility. (Photo used with permission from the University of Utah Health Sciences Center Transplant Team.)
Nurse moves the patient with the other members of the team. (Photo used with permission from Ruth Braga, University of Utah.)
Because the circulator is outside of the sterile field, they often assume responsibility for relaying telephone messages and answering pages for team members who are scrubbed in. This enables the surgical team members to continue caring for other patients while in the OR without compromising the safety or the needs of the patient currently in the OR. For example, if the OR phone rings during induction, the circulator definitely isn’t going to step away to answer it at this critical point. In addition, some surgeons will help the circulator and other team members by declaring certain high-risk portions of procedures as “no outside communication” times. This allows all team members to focus explicitly on the patient in the operating room for that time.
The “scrub,” who may be an RN or a surgical technologist, assists the surgeon throughout the surgery. Surgical tech programs vary in duration from nine months to a two-year associate’s degree. Scrub techs have specialized knowledge in sterile technique, surgical equipment, and surgical procedures.
The scrub technician is responsible for gathering instruments and supplies used during the case and ensuring that the sterility of the procedure is maintained (Figure 4.14). The scrub should have knowledge of the case that is to be performed and communicate with the surgical team to ensure that all needed supplies and instruments are available. Unlike the circulator, the scrub is in the sterile area and is scrubbed in to the case. The scrub handles all sterile supplies and instruments. They set up the sterile field for the surgical team (Figure 4.15), including medications, and organize all of the surgical instruments. Scrubs may also be assigned to specific teams. Specialized scrubs readily anticipate surgeon needs and are able to teach case specifics to new staff (Figure 4.16). The scrub performs the surgical counts and participates in the time-out to verify that all required equipment is present in the operating room. The scrub will assist with every step from draping the patient to preparing dressings for closure; once the patient leaves the room, they prepare the instruments to be cleaned and processed.
With all items opened on the back table, the scrub technician scrubs, gowns, and gloves themselves to set up for the surgery. (Photo used with permission from Ruth Braga, University of Utah.)
Completed setup, ready to begin. (Photo used with permission from Deanna Attai, David Geffen School of Medicine at UCLA.)
The scrub technician is always in tune, listening, anticipating, and watching for what is needed next. (Photo used with permission from the University of Utah Health Sciences Center Transplant Team.)
The healthcare assistant (HCA) is a vastly different role in the OR than on the floors. The HCA role varies by institution, but these individuals work under the direction of the circulating RN. They may have previous experience as a Certified Nursing Assistant (CNA), and many are enrolled in a nursing or other healthcare education program.
The HCA may be responsible for tasks such as preparing the OR suite for surgery, cleaning the OR, stocking supplies, and gathering the required equipment for each case. They may be responsible for transporting patients, delivering specimens to pathology, and picking up blood products at the blood bank. If they have been trained, an HCA may assist with prepping the patient skin, or scrubbing in and assisting with retraction. Their role is vital to the OR. Because the variety of supplies and items in the operating room is so vast, they are an excellent resource for questions. Their specialized knowledge of equipment and beds is invaluable (Figure 4.17).
The HCA helps around the room, gathering supplies, assisting the nurse and team as needed. (Photo used with permission from Ruth Braga, University of Utah.)
Together, the circulator, the scrub technician, and the HCA work closely as the “in the OR” team, communicate what they need, ask questions if they need clarification, and help one another to assist the surgeon and anesthesia with caring for the patient.
A perfusionist will usually be found in an OR where a cardiac procedure is being performed. The perfusionist is an individual trained to operate equipment that reroutes the flow of human blood from the veins to outside the body, and back into the arteries. A perfusionist spends the majority of their day in the operating room but their responsibilities may take them to the ICU, cardiac catheter lab, emergency room, and even on local and long-range transportation of critically ill patients.
There are currently approximately 3500 perfusionists working in the United States. A perfusionist must obtain a bachelor’s degree that includes specific science and math requirements before applying to one of approximately 18 postgraduate programs across the country. Most programs include 12 months of didactic learning followed by 12 months of clinical training. Some programs grant a certificate and others award a master’s degree. After successful completion of an accredited program, a graduate must perform a prescribed number of independent procedures before applying to take scientific and clinical exams. Upon passing both exams, the distinction of Certified Clinical Perfusionist (CCP) is awarded.
The perfusionist’s primary role is the setup and operation of the cardiopulmonary bypass (CPB) system, also known as extracorporeal circulation (ECC) (Figure 4.18). The purpose of CPB is to divert the flow of blood away from the heart and lungs so that the cardiac surgeon can work on a still or non-beating heart. Some of the procedures that require the use of CPB are coronary artery bypass grafts, heart valve repair or replacement, repair of aortic dissection or aneurysm, repair of congenital heart defects, trauma, and heart or lung transplantation. Other OR activities for a perfusionist may include assisting with blood salvage techniques, platelet gel processing for wound healing, anticoagulation monitoring, bypass for liver transplantation, and the administration of hyperthermic chemotherapy to specific areas of the body.
The bypass machine is one of the most fascinating machines in the operating room to see at work, but is also a dangerous trip hazard. Be mindful of it as you back away from the table or move about the OR. (Photo used with permission from Jennie O’Shea, University of Utah.)
Additional cardiopulmonary therapies that a perfusionist can be involved with—often outside of the OR—include intraaortic balloon initiation and monitoring, extracorporeal membrane oxygenation setup and monitoring, and ventricular assist device support.
When a patient is on CPB, the perfusionist is expected to meet the patient’s metabolic needs and preserve organ function. In order to do this, the perfusionist needs to pay particular attention to the patient’s mean arterial pressure and blood flow (based on body surface area), urine output, and cerebral oximetry. Adequate blood electrolyte and red cell concentration, and appropriate anticoagulation status must also be monitored.
In order to provide optimal patient care, the perfusionist works closely with the surgeon, anesthesiologist, and nursing team (Figure 4.19). The language used can be very specific to a cardiac operating room and allows the team to work safely and efficiently together. With time and experience, a new practitioner will understand the meaning and importance of these phrases and cue words.
The perfusionist (seated) is in constant communication with the surgeon. (Photo used with permission from Jennie O’Shea, University of Utah.)
Perfusionists, like other members of the OR team, are one specialized part of that team, and we are here to provide optimal patient care and assist new and seasoned practitioners with the knowledge they need to progress and provide the best patient care possible. We often do that quietly, almost inconspicuously, but with great vigilance; many patients and practitioners are completely unaware of our presence.