Preparing for the Operating Room BEFORE you get to the Operating Room Rajeev Dhupar, MD January 2009

Surgery Surgery is about Learning Surgery is about Taking Care of Patients Surgery is about being Prepared Surgery is Active Surgery is FUN

What kind of surgeon can you be? GeneralPlasticOncology VascularOrthopaedicBurn TransplantENTColo-rectal CardiacNeurosurgeryPediatrics ThoracicUrologyGynecology TraumaOpthomology EndocrineMinimally Invasive

Student (4 yrs) Resident (5-7) Fellow (1-3) Attending Medical School MedicinePsychOB/GynRadiologySurgeryAnes OrthoENTGen SurgUrologyNSGY Plastics/ Vascular/ CT TransplantVascularPlasticsCTTrauma/CC JOB!!! Endocrine How do you get there?

Shadowing a Surgeon 1. Research – what type, whom 2. Call Kathy Haupt –Surgeon –Day, time –Scrubs 3. Go to the OR!!

Before you go to the OR Read about the operation (anatomy, surgical atlas, Chassin’s, Up to Date) Find out about the attending (What are their interests? Profile online) Find the OR!! Meet the people (Be courteous)

Preparing for the OR on your rotation The day before… The day of… The hour before…

The day before the OR Find the OR schedule (write it down) –OR –secretary (Try to) plan what cases you will be involved in; discuss this with the team (everyone); be flexible Read about the patient (H&P by the attending, indications, radiology)

The day of the OR Find out about timing of the case (ask residents/OR front desk) Make sure the patient is prepared -pre-op: labs, EKG, x-ray, NPO, consent, etc. (index card, check boxes)

The hours before the OR Be early Refresh yourself regarding the patient/case (note card) Check the OR schedule (again) Confirm with the team Meet the patient Use the bathroom, eat/drink

The hours before the OR Meet the anesthesia team Meet the scrub/circulator, ask for help Walk back with the patient Watch how the team gets the patient ready, ask how you can help

Your surgery rotation should be… …a time to participate in patient care …an opportunity to learn about disease processes …a study of anatomy …a time to immerse yourself FUN!

Life in the Operating Room Rebecca Edmonds, MD January 27, 2009

Prior to the start of the case… Come prepared –Patient information –Anatomy & physiology Introduce yourself Pull your gloves

Show up on time

Respect the patient Patients are scared Patient may be awake Ask if you should introduce yourself to patient

The surgical hierarchy

What to say… Best to speak when prompted Don’t ask questions during critical portion of case Limit conversation to case-related talk

…and what not to say!

Excuse yourself if your feel sick

Take a break during long cases

Hands off the Mayo!

What am I going to be asked to do?

Your new best friends!

Knot tying

Practice first!

Suture

Drive the camera

And… Answer questions Pay attention Learn Have fun

Why surgeons have the coolest job in the hospital…

Questions??

Introduction to the OR Jennifer B. Ogilvie, MD, FACS Co-Director, Surgical Clerkship University of Pittsburgh Surgery Interest Group January 2009

The Early OR: No Masks Required

Masks and gowns… for some

Masks, Gowns…and a Nun

The Modern OR: Presbyterian Hospital, OR 12

Minimally Invasive Brain Surgery Presbyterian Hospital

Robotic Prostate Surgery Shadyside Hospital

Laparoscopic Surgery Montefiore Hospital

How to Enter the OR Change into clean scrubs Remove all jewelry, watches and rings Remove your pager and cell phone Put on a surgical cap, mask, shoe covers Hair must be completely covered Mask must be tied before entering the OR

Caps The Bouffant The Cap

Masks and Eye Protection No! Wrong mask, no eye protection No!Ditto

Masks and Eye Protection Better! + Best!

Outside the OR: Key People/Areas “The Front Desk” “Charge Nurse” –In charge of all the OR staffing, equipment, troubleshooting OR Secretary –Calls patients to the OR, coordinates the OR schedule –Just slightly less busy than an air traffic controller Preoperative Holding Area (“Preop Hold”) “Recovery” Recovery Room Nurses

Front Desk: Montefiore OR

The OR Team “Circulator” (AKA The Boss) –A nurse responsible for patient care and safety, medical record documentation, OR equipment –Helps obtain and keep track of instruments and supplies (circulating between sterile and non-sterile fields) “Scrub” –An OR Tech or RN who gowns and gloves the surgeons; also sets up, maintains and passes instruments within the sterile field “Anesthesia” –Attending Anesthesiologist, Resident or CRNA, Medical Students, Anesthesia Tech –Administers preoperative sedation, intraoperative anesthesia, and postoperative analgesia in the Recovery Room

The View From the OR Door Montefiore OR 36

Circulator: Montefiore OR 36

Scrub: Montefiore OR 36

Anesthesia: Montefiore OR 36

Surgery Intern: Montefiore OR 36

The Instrument Table

The Mayo Stand

Once you are scrubbed in, gowned and gloved….. Where is the sterile field?? Or, What am I allowed to touch?? and… and… Where do I put my hands?? Where do I put my hands??

Where is the sterile field? You: –Front of the gown from chest to the waist –Gloved hands and arms to the elbows Patient: –Draped part down to the OR table –Anything that falls below the level of the patient table is considered contaminated Sterile Field: –Covered part of the “Mayo stand” (small table where the most commonly used instruments are kept) –Top of the “Back Table” where additional instruments are kept. The sides of the Back Table are not considered sterile –Disposable light handles

The Sterile Field

Sterile or Unsterile… Jeopardy Look for the

Sterile or Unsterile?

Sterile

Unsterile

Sterile

Unsterile

Sterile

Unsterile

Unsterile

Sterile

Unsterile

Unsterile

Sterile

The Sterile Field

Where do I stand? Just ask! “Dr. X, where would you like me to stand”? Once you are scrubbed, put your hands on the sterile field and try not to move unless asked. Do not drop your hands below your waist or table level. Do not raise your hands above your chest. If you are observing an operation and are not scrubbed in, stay about 2 ft away from all sterile fields to avoid contamination. Keep your hands behind your back, being careful not to back into the instrument table.

Where do I stand? If you need to move: –Clasp hands together right below your chest when moving –When moving around someone else, pass back to back. –When passing by a sterile field, face it. When passing a non- sterile field, pass with your back toward it. Do not grab at anything that falls off the side of the table—it is considered contaminated. If something falls, inform the circulating nurse. Do not reach for anything on the Scrub’s Mayo stand or instrument table; ask for the instrument to be given to you.

You’re Contaminated!! If someone tells you that you have contaminated a glove, light handle, or anything else, do not move and do not complain or disagree. It has happened to all of us. If a glove alone is contaminated, hold the hand out away from the sterile field, and a circulating nurse will pull the glove off. The same is true if a glove tears. If you have to change your gown, step away from the table. The circulator will remove first the gown and then the gloves. This procedure prevents the contaminated inside of the gown from passing over the hands. Regown and reglove without scrubbing again (unless glove or gown is torn).

OR Safety Always be aware of "sharps" (needles, scalpels, sharp retractors) on the field. When passing a sharp instrument, alert the other members of the team (i.e. "needle down," "knife down"). For an event such as a needle stick, remain calm, step away from the sterile field and remove your gown and gloves. Wash immediately with soap and water. The circulator will call the Needlestick Hotline. At the end of the operation (once the dressing is on the wound), remove your gown and gloves. To protect yourself, remove the gown first, and remove your gloves last. This system keeps your hands clean of blood or fluids that got onto your gown during the procedure. In accordance with the OSHA Bloodborne Pathogens Standard, wash your hands with soap and water after the surgical procedure.

From McGraw Hill’s Introduction to the Operating Room Avoid stereotyping the nurses as "cranky," the surgeons as "egotistical," and yourself as "clueless" by learning the OR routine. Be alert, attentive, and, above all, patient. Don't be afraid to admit to the scrub and the circulating nurse that you're new in the OR. They are usually happy to help you.