Chapter 18: Notes from Your Attending

First time in the OR, huh? Well, don’t touch anything. Just put your hands where I tell you to. You’re probably not going to understand anything we’re doing, so you can ask some questions when it’s a good time. As long as you read for the cases, you’ll be fine. Sit back and watch the master at work.

Don’t mind him. It’s easy to lose sight of how overwhelming this place can be. To make things more difficult, every OR is a little bit different. We’ll try to give you some tips that will apply to most of them and get you off on the right foot for the others. The first tip, as you’ve probably already guessed, is that the operating theatre (to use an old-school and Very British term) is a very structured place, with a long list of rules (both published and unpublished), and it can be tense at times. One of the key roles of the attending surgeon (which some fill better than others) is to make sure the right level of tension is maintained; too much tension makes the team ineffective, while too little could lead to distraction.

All right, so you think you are worthy of attempting to grace the hallowed halls of my operating room? Well, just know that I expect you to know EVERYTHING about the patient we are about to treat. I mean, shoe size, what they had for dinner two weeks ago, great-grandmother’s maiden name. EVERYTHING. However, don’t talk to me beforehand. Don’t make eye contact, as a matter of fact. Speak when spoken to, and softly at that.

Okay, so this is a little extreme, don’t you think? It is true: most of us expect you to know as much about the patient as is feasible and appropriate. It is important for you to know why we are taking this particular patient to the OR, why we felt that an operation is what this person needed. Next, read about the operation itself. How is it performed? A brief review of a surgical atlas will help you understand what we are doing, keep you engaged during the surgery by knowing the anatomy and the steps, and will impress the heck out your attending. Know about the disease process that necessitates operative intervention. Know about alternative treatments and possible complications of the procedure. That said, we understand how incredibly hectic and tiring it can be as a medical student on their first surgery rotation. Two or three years ago, you were an undergraduate trying to schedule all of your classes to start no earlier than noon, and now you’re waking up at 4 a.m. to be the first to round on patients, and then running from time commitment to time commitment. Maybe you were assigned to scrub the case 5 seconds before its scheduled start time. We remember what it was like. Just try your best. Be interested. Care about learning, care about the patient.

Here is a list of people who work in the perioperative area to whom you should feel comfortable introducing yourself: everyone. When it looks like we, the attendings, are free from distractions, introduce yourself to us. Introduce yourself to the patient and the patient’s family if no one from the surgery team has already done so. Explain your role to these people to increase their comfort level. Introduce yourself to the anesthesia team, the peri-operative nursing team, and the OR staff before the case starts. You will be surprised at how quickly you become included as a member of the team by introducing yourself, and by learning other team members’ names.

So, are you just going to stand there? How about a little shave? No, not for me, for the patient—you aren’t going to make a cut in that hairy mess are you? Forget it, the nurse can do that. Just get the lights and slam a catheter in. Page me when you’re prepped.

Now’s a good time to bring up that we have no idea what you know and what you don’t. You may have been an emergency department technician before medical school and placed hundreds of nasogastric tubes and urinary catheters. You may, on the other hand, be wondering which tube goes in which hole. Anywhere on that spectrum is just fine as long as you admit where you are. As you’ve hopefully already discovered, one of the best ways to approach any such task is to admit when you don’t know how to do something and ask to learn. “Learning by doing” is great. Learning by faking it and putting a patient at risk isn’t. We remember that performing invasive procedures on an awake patient can be mighty intimidating, so now is your chance to learn while the patient is asleep. Don’t be afraid to ask if you can learn how to place these tubes and catheters.

Even if you’re new to the OR, you can still help get everything prepared and move the preoperative time along. The nurses and technicians have a great deal of work to finish before the first incision, and with much of it you’re not allowed to help. However, anyone can help position the patient properly, move the overhead lights so that they’re pointing at the area where we’ll be operating, help place sequential compression devices, and, once taught, remove any unwanted hair from that area. If you haven’t already met the members of the OR team, now’s a good time; and if you can’t think of anything to do, one of the nicest ways for you to endear yourself to the OR staff is by asking them what you can do to help.

What exactly are you doing? Did anyone actually teach you how to scrub? Here, just watch me. Wet your hands, rub soap on them with the brush, and then let them dry. Or, I guess, you can use the alcohol thing, but nobody who knows what they’re doing really does. How much more difficult could you possibly make it? No, not like that. Okay, now you’ve got to start over. Do it like I was doing. No, like I was doing. Maybe you should sit this one out and just watch. No, then I’ll just get the same evaluations again…. Nurse? Nurse! Can you get out here to show this one how to scrub?

Scrubbing isn’t hard, but it’s systematic, and there are plenty of little things that mess us up. That’s right, we still mess up with something as simple and routine as scrubbing from time to time as well. Before you go to the scrub area, ensure the scrub tech or nurse has sterile gloves and a gown available for you. If you’re wearing a ring or a watch, take it off and put it somewhere that you won’t lose it or put it into the laundry. Take your pager or phone off and leave them on the counter. Then ensure your mask is just as you like it and your eye protection is in place; once scrubbed, you won’t be able to touch them again until the case is done.

Depending on your hospital, people may preferentially use an alcohol-based surgical hand scrub or a traditional wet hand scrub. Either is acceptable but you can learn how to do both in your OR orientation and then use whichever you prefer (within your hospital’s policies, of course). Surgeons have different preferences in many different areas; one of the ways we find which preference is most comfortable for us is by trying the different options. Whichever method of scrubbing you use, follow the directions precisely. Don’t try to go too fast—like much of surgery, scrubbing will take practice—and don’t follow the bad examples you may see that do a suboptimal scrub. You can do better for your patient.

Ideally, you’ll have an opportunity to speak with the attending surgeon or residents at the scrub sink before entering the case. This is the time to get focused, to get ready for the task at hand. The more senior members of your team may ask you what you’d like to learn during this case or give you an idea of what the general approach to the surgery will be.

When you’re done, enter the operating room by opening the door with your back, and stand in line to get a towel (if you used water) and your gown and gloves from the scrub tech. There’s tradition at work here, too; though most of us don’t even notice, some attending surgeons will expect that they’ll be gowned and gloved before the other members of the team.

Here’s where you stand: out of my way, that’s where. If I hear you breathe, if I see you twitch, you’re out of my OR. Can’t see anything? Well, that’s too bad for you. Suction there. NO, there. NO, THERE!! Can’t you see where the blood is?!? Remember before when I said speak when spoken to? Well, that is especially true right now. No I won’t let you throw a stitch this case, but here is a retractor for you to hold for the next 6 hours. And no, I don’t care how much your arm hurts. That pain is what learning feels like.

By now, you should know that you are a valuable member of the OR team. As such, you are not expected to just cower in the corner now that the drapes are on. This is important to know from the very beginning of the case, known as the “time-out,” when the surgeon or nurse reads through a checklist to ensure that all steps have been completed so the procedure can start safely. During this time, every member of the OR team should feel empowered to speak up if anything seems amiss. This means YOU. As always, this is done to ensure that we are doing the right thing to the correct patient. If you are intimidated, give the resident standing next to you a quick nudge. However, please make sure we are aware of any issues before we start. Will we be a little ashamed that a med student caught something we didn’t? Perhaps. But if it leads to better care of our patient, BELIEVE US, we will be thankful.

Once the operation has begun, this should be the fun part. Yes, it’s true, we might need you to hold a retractor for a bit or suction some blood away from the operative field. We are, in fact, very appreciative for this thankless work. However, you are the one paying good money to be here, and as such you should be getting something out of it, too. If you can’t see what is happening in the case, let us know. We may be able to reposition you elsewhere around the patient. Perhaps the circulating nurse can get you a step stool. Advocate for yourself, and we’ll try to help the best we can.

We appreciate students who are proactive in helping during the case but it can be tricky to find a happy medium. Try to pick up on our cues to the best of your ability and always think of patient and team safety when making your moves. You may have been told to never touch the scrub tech’s instrument stand. This is true. He or she has this set up in a very particular way, with sharp objects that could injure you if you try to grab at things. Always ask permission if you feel like it would help the case for you to take an instrument off the tray—for your safety and the scrub tech’s sanity.

After you’ve toiled away, hopefully seen amazing anatomy that is a true privilege to behold, all the while taking in skillful surgical technique, it’s your time to shine. It’s closing time. This is a part of the case where residents are typically most comfortable and happy to give up the reins. This is where you can get your first experience practicing surgical skills on a real live human being. So, when the skin suture comes onto the field, if it looks like you are getting passed over you should speak up. There might be a rush to finish up the case and you might get accidentally (or purposefully) ignored, so make your goal of participating in the closure known; also, make sure that you’ve been practicing your suturing outside the OR because some attendings will only let you “play” if you have been practicing via simulation. Participating in the wound closure in the OR is how you get to hone the skills that you can’t develop anywhere else. This is why the OR is so great.

We’re done. Get the next one ready; page me when you’re prepped.

If it’s a busy day, we may have already stepped out of the room while you’re closing. Ideally, even if delegating the final dressings to the rest of the team, we’re still available as attendings to ensure the case has gone the way that’s best for the patient, as well as to ensure that the trainees at all levels have had their experience and education furthered by being a part of the team during this case. If we did have to step out, that responsibility’s not passed up; we’ll try to make it up to you. We may do a “debriefing” before we’re even completely done with the case, or, though less than perfect, while we’re getting ready for the next one. As we’ve talked about above, though, please do feel that you can come to us to ask questions about the case or to clarify learning points even if we haven’t taken the initiative to formally debrief.

One of the tasks traditionally delegated to the most junior surgeons in the room, the lowest-ranking resident and medical student, is assisting with transporting the patient out of the operating room. This isn’t meant to be yet another thankless piece of scut, but rather a display of teamwork and a safety mechanism—if something goes amiss during transport to the recovery area or ICU, you may be the person with the most direct line of communication to the attending surgeon. Not all hospitals continue this tradition; at some, the attending always stays with the patient, while at others, the surgeon leaves the patient in the able care of the anesthesiology and nursing teams. If you are accompanying the patient, give them your full attention; now’s not the time to check your social media feeds (and remember that you should never, ever Tweet about what you’ve just been doing).

Once the patient’s safely out of the OR, there’s still work to do. Residents will often be writing operative notes and placing postop orders. You’re encouraged to ask them to teach you how. They’re there to teach, as well, and most are thrilled to do so. Learn what tests and monitoring most postoperative patients need, how to write coherent IV fluid orders, and why some patients get antibiotics after their surgery and others don’t. A huge portion of surgery takes place before and after the operating room. Don’t neglect this important part of your education.

Yes? Do I know you? Oh, sure, you’re the med student. Yeah, good job. Keep reading.

Feedback may be the most difficult part of your surgical rotation, for both you and your attending surgeon. There are many books written on how to give and accept appropriate feedback, and while we try hard, we’re not perfect. We’ll try to give you feedback frequently, after each case and each presentation, but we’ll admit that we get distracted and busy, too. If you’re seeking areas in which you might improve—and you should be—please approach us early and often regarding things you can do better. You can even reach out to our administrative assistants to perhaps schedule one-on-one time in an office setting. An interaction with an attending that doesn’t lead to obtaining meaningful feedback is a wasted learning opportunity. We as attendings can easily lose sight of this, so please seek us out.

On the other hand, don’t take the comments we give as simple generics that don’t really apply to you. As we noted, we’re not all great at the skill, but we really do want to give you feedback that meaningful for you. A short comment may seem like a throwaway, but take it to heart. If you are getting feedback as part of a group of students and residents, always assume the constructive feedback is meant for you individually, and not someone who’s doing “worse” than you are.

And we’ve joked about it plenty, but there are unfortunately people in academic surgery who don’t demonstrate the constructive, team-oriented, Uber-teacher approach that most of us desire, that most of us understand is the best culture to manage the great responsibility of patient care. You’ll work with them, and, despite the difficulties, hopefully you’ll learn from them. If their feedback isn’t always constructive, do what you can to separate the personality from the feedback and find the nugget of useful information within their tirades. They can’t always be avoided—but they can still be educational.

Thanks for joining the team, and good luck.