Chapter 7: Personalities in the Operating Room

Analogies make it easier for all of us normal folks to relate to complex things. For instance, if you are a surgical resident, the operating room (OR) will be like your football stadium. You will experience triumphs and severe defeats but in the end, hopefully you will nail the Super Bowl and end up being the bomb.com when it comes to surgery.

Maybe the closest you have ever come to the operating room is watching Grey’s Anatomy. While that steamy drama offers some nice couch entertainment, the real deal is a little different, and you probably won’t run into Meredith Grey or Dr. McSteamy. If you are about to dive into this operative world, you are going to want to have a few pearls up your scrub sleeves. My chosen analogy for the OR is to think of it as the ocean. Now, the ocean can be a really scary place if we go all Jaws with the comparison, or it can be more pleasant, like Finding Nemo. The point is, much like the ocean, the OR can be a fantastical world full of intrigue and positive messages such as “keep on swimming,” or it can be the place of your blood-in-the-water demise. Yikes! That’s dramatic. Either way, let’s get to know your operating neighbors.

This will be your first stop on your way into the OR. I like to think of the scrub sink as the tiny shrimp on the ocean floor. If you just patiently place your hands on the sandy bottom while diving in the ocean, these little guys and gals will scurry out of their holes and start cleaning your fingernails. A few things to know about the sink: it will likely either be motion- or foot pedal-activated (no knobs to turn) (Figure 7.1). If you have never scrubbed in before, ask someone to walk you through the process. It can seem a little awkward the first few times. The great thing about the sink is that it won’t yell or make fun of you. And if you mess up your first try at scrubbing, you simply start again. Just keep swimming…

The circulator nurse is like a sailfish (extremely fast). This person darts around making sure the room is appropriately stocked with whatever is needed to make the surgical case go swiftly and smoothly. Many of these guys/gals have been around since before you were in diapers, and this means she/he knows more than you. You should know that before walking into the room. Always respect their space and their time because they are very busy and will be darting from the computer to the shelves to the OR table like a sailfish on Adderall. Be sure to introduce yourself to the circulator before scrubbing in and write your name on the whiteboard in the room (Figure 7.2) so that the circulator knows who you are. Always offer to grab your own gown and gloves off the shelf to hand to the scrub tech (see below). But remember that if you’ve not done this before, ask for help so that you can maintain sterility.

The scrub tech is like a clownfish (Nemo) and the “scrub table” is the sea anemone. The tech never gets too far from the anemone. Remember to never touch the table, because just like an anemone, it will sting you, and you will likely upset the clownfish. The scrub tech passes instruments to and from the surgeon. Often this will be a very quick and efficient process with instruments flying off the table and into hands with crazy speed. You, my newbie, will want to stand clear. Remember, nobody likes the middleman, so don’t try to be him. While it can seem helpful to pass the instruments from the scrub tech to the surgeon, this is not necessary or wanted. If you see the scrub tech holding an instrument out, waiting for the surgeon to grab it, just let it be. The surgeon will take it herself when she is ready (Figure 7.3).

The anesthesiologist is like a lobster hanging out in the crevices of a coral reef, sometimes a little hidden, but really important to the life cycle. When you are new to the OR, the anesthesiologist can be a good friend to have, especially before you scrub into the case. Prior to getting sterile, there is a lot that happens in the room, including putting the patient to sleep and placing a breathing tube. Hang out with the lobster and you’re likely to see some cool stuff before the surgery ever begins. And remember, when making requests of the anesthesiologist during the case, such as having him/her move the IV pole so you can squeeze closer to the surgical site, always use your “please” and “thank you” nice words. All lobsters appreciate this.

The patient is the whale shark—that big slumbering creature that will sometimes pass by the reef. He just minds his own business, mouth open, feeding on plankton. Remember that patients are at their most vulnerable state in the OR because they are under general anesthesia. So don’t rest your elbow on the whale shark’s head. The patient should always be your number one priority. If you remember this at all times and make all decisions based on that principle, you will be okay. So when you contaminate yourself by touching something that isn’t draped in blue (blue drapes indicate sterility), always speak up and change out those gloves and/or that gown. You may feel a little ridiculous, but remember that we have all done it, and not saying anything will be putting that whale shark in danger. Keep on swimming, little buddy.

This is the shark. Before you get your undies all bunched up, remember that sharks come in many varieties. Maybe you’ll get lucky for your first OR go-around and end up with a nurse shark. But it’s best to be prepared for the gummy, rows-of-teeth, Carcharodon carcharias (a.k.a. the Great White).

Step one is to know some anatomy. This is a fairly easy exercise. For instance, if you are going to be operating on the abdomen, then take a look at the anatomy of the abdomen the night before the case. Memorize things such as the layers of the abdominal wall and where the intestines live in relation to other abdominal organs. If you are going to be operating on a foot, look up the muscles of the foot and what vessels supply the foot, and where the vessels and nerves exist in relation to the foot. For the most part, if you know some anatomy, most surgeons will be pretty pleased and will involve you in the procedure, which is much more fun that just standing there.

Now, if you’re looking for honors, then it’s important to remember that sharks can be pretty full of themselves. Even the nice, smiling ones have worked really hard to achieve and maintain their oceanic position, so a little recognition never hurts. You can easily Google and/or PubMed search your shark’s name to find any articles he/she has written. If any of the articles pertain to your own interests or to the procedure being performed, read it, and then mention it when it seems relevant. The ensuing conversation might be the ticket to making you feel right at home in the operating room.

“Me?” you might ask. Yes, you. You, too, are now a part of this operating room. You are the remora fish (sometimes called a suckerfish) that latches onto the shark and goes on those shark journeys throughout the hospital. This is such a great position to be in because you get to have fairly little responsibility and you get to glean all you can from your surroundings. Take advantage of the view. If you have a question, ask. If you don’t understand something, ask. Just make sure you are nice about it. You know, use those nice people words like “please” and “thanks.” Also, mind your mouth just a little. Don’t be too chatty and don’t get too casual, even if those around you seem to be letting loose a bit. Similar to observing sharks and other sea creatures from a safe distance, remember to be professional and to keep a safe “distance” in the OR. Overall, a good remora is observant. Look around for ways you might be helpful. You may think you have no skills to offer, but you do have legs and arms. Before the surgery even starts, the patient needs help getting onto the surgical table and the patient’s bed needs to be wheeled out into the hallway. It’s always appreciated when you help with this. Similarly, when the case is over, help get the patient off the table and onto the bed. Watch your resident for other ways you might assist.

Imagine a remora fish that is a little bit bigger than you and wears glasses—that’s the surgical resident. This remora is your partner. You are both latched onto the shark. He or she is a little more experienced and wiser than you, and you should use this to your advantage. Follow your resident’s lead and direct most of your questions to your resident. Importantly, never try to make your resident look bad or act as though you know more than the resident. For instance, if the resident is asked a question and seems to be stumped, don’t jump in because you know the answer. Wait until you are asked to do so. The surgeon will not respect you for one-upping, and your resident remora might swim away, leaving you all alone in the deep blue ocean (Figure 7.4).

Well, it’s time to get excited. Having reviewed the crew that lies within the deep blue waters, you’ve essentially stuck in your big toe to test out the temperature. Now all that’s left is for you to cannonball right on in. Enjoy the swim.