Preparing for the Operating Room Preparing for the Operating Room BEFOREBEFORE you get to the Operating Room you get to the Operating Room

Rajeev Dhupar, MDRajeev Dhupar, MDJanuary 2009January 2009

SurgerySurgery

Surgery is about Learning Surgery is about Learning

Surgery is about Taking Care of Surgery is about Taking Care of Patients Patients

Surgery is about being Prepared Surgery is about being Prepared

Surgery is ActiveSurgery is Active

Surgery is Surgery is FUNFUN

What kind of surgeon can you be?What kind of surgeon can you be?

GeneralGeneral PlasticPlastic OncologyOncology

VascularVascular OrthopaedicOrthopaedic BurnBurn

TransplantTransplant ENTENT Colo-Colo-rectalrectal

CardiacCardiac NeurosurgeryNeurosurgery PediatricsPediatrics

ThoracicThoracic UrologyUrology GynecologyGynecology

TraumaTrauma OpthomologyOpthomology

EndocrineEndocrine Minimally InvasiveMinimally Invasive

Student (4 yrs)

Resident (5-7)

Fellow (1-3)

Attending

Medical School

Medicine Psych OB/GynRadiologySurgery Anes

Ortho ENT Gen Surg Urology NSGY Plastics/Vascular/

CT

Transplant Vascular Plastics CT Trauma/CC

JOB!!!

Endocrine

How do you get there?How do you get there?

Shadowing a SurgeonShadowing a Surgeon

1.1. Research – what type, whomResearch – what type, whom

2.2. Call Kathy Haupt Call Kathy Haupt hauptkg@upmc.edu; 647-5314hauptkg@upmc.edu; 647-5314

– SurgeonSurgeon– Day, timeDay, time– ScrubsScrubs

3.3. Go to the OR!!Go to the OR!!

Before you go to the ORBefore you go to the ORRead about the operation Read about the operation (anatomy, surgical atlas, (anatomy, surgical atlas, Chassin’s, Up to Date)Chassin’s, Up to Date)

Find out about the attending Find out about the attending (What are their interests? Profile (What are their interests? Profile online)online)

Find the OR!! Meet the people Find the OR!! Meet the people (Be courteous)(Be courteous)

Preparing for the OR on your rotationPreparing for the OR on your rotation

The day before…The day before…

The day of…The day of…

The hour before…The hour before…

The day before the ORThe day before the ORFind the OR schedule (write it down)Find the OR schedule (write it down)–OROR–secretarysecretary

(Try to) plan what cases you will be (Try to) plan what cases you will be involved in; discuss this with the team involved in; discuss this with the team (everyone); be flexible(everyone); be flexible

Read about the patient (H&P by the Read about the patient (H&P by the attending, attending, indicationsindications, radiology), radiology)

The day of the ORThe day of the OR

Find out about timing of the case Find out about timing of the case (ask residents/OR front desk)(ask residents/OR front desk)

Make sure the patient is prepared Make sure the patient is prepared -pre-op: labs,-pre-op: labs, EKG, x-ray, EKG, x-ray,

NPO, consent, etc.NPO, consent, etc.(index card, check (index card, check boxes)boxes)

The hours before the ORThe hours before the OR

Be earlyBe early

Refresh yourself regarding the Refresh yourself regarding the patient/case (note card)patient/case (note card)

Check the OR schedule (again)Check the OR schedule (again)

Confirm with the teamConfirm with the team

Meet the patientMeet the patient

Use the bathroom, eat/drinkUse the bathroom, eat/drink

The hours before the ORThe hours before the OR

Meet the anesthesia teamMeet the anesthesia team

Meet the scrub/circulator, Meet the scrub/circulator, ask for ask for helphelp

Walk back with the patientWalk back with the patient

Watch how the team gets the Watch how the team gets the patient ready, ask how you can patient ready, ask how you can helphelp

Your surgery rotation should be…Your surgery rotation should be…

……a time to participate in patient a time to participate in patient carecare

……an opportunity to learn about an opportunity to learn about disease processesdisease processes

……a study of anatomya study of anatomy

……a time to a time to immerse immerse yourselfyourself

FUN!FUN!

Life in the Operating RoomLife in the Operating Room

Rebecca Edmonds, MDRebecca Edmonds, MD

January 27, 2009January 27, 2009

Prior to the start of the case…Prior to the start of the case…

Come preparedCome prepared– Patient informationPatient information– Anatomy & physiologyAnatomy & physiology

Introduce yourselfIntroduce yourself

Pull your glovesPull your gloves

Show up on timeShow up on time

Respect the patientRespect the patient

Patients are scaredPatients are scared

Patient may be awakePatient may be awake

Ask if you should Ask if you should introduce yourself to introduce yourself to patientpatient

The surgical hierarchyThe surgical hierarchy

What to say…What to say…

Best to speak when promptedBest to speak when prompted

Don’t ask questions during critical portion Don’t ask questions during critical portion of caseof case

Limit conversation to case-related talkLimit conversation to case-related talk

……and what not to say!and what not to say!

……and what not to say!and what not to say!

Excuse yourself if your feel sickExcuse yourself if your feel sick

Take a break during long casesTake a break during long cases

Hands off the Mayo!Hands off the Mayo!

What am I going to be What am I going to be asked to do?asked to do?

Your new best friends!Your new best friends!

Knot tyingKnot tying

Practice first!Practice first!

SutureSuture

Drive the cameraDrive the camera

And…And…

Answer questionsAnswer questions

Pay attentionPay attention

Learn Learn

Have funHave fun

Why surgeons have the coolest Why surgeons have the coolest job in the hospital…job in the hospital…

Questions??Questions??

edmondsrd@upmc.eduedmondsrd@upmc.edu

Introduction to the ORIntroduction to the OR

Jennifer B. Ogilvie, MD, FACSJennifer B. Ogilvie, MD, FACSCo-Director, Surgical ClerkshipCo-Director, Surgical Clerkship

University of PittsburghUniversity of Pittsburgh

Surgery Interest GroupSurgery Interest GroupJanuary 2009January 2009

The Early OR: The Early OR: No Masks RequiredNo Masks Required

Masks and gowns… for someMasks and gowns… for some

Masks, Gowns…and a NunMasks, Gowns…and a Nun

The Modern OR:The Modern OR: Presbyterian Hospital, OR 12Presbyterian Hospital, OR 12

Minimally Invasive Brain SurgeryMinimally Invasive Brain SurgeryPresbyterian HospitalPresbyterian Hospital

Robotic Prostate SurgeryRobotic Prostate SurgeryShadyside HospitalShadyside Hospital

Laparoscopic Surgery Laparoscopic Surgery Montefiore HospitalMontefiore Hospital

How to Enter the ORHow to Enter the OR

Change into clean scrubsChange into clean scrubs

Remove all jewelry, watches and ringsRemove all jewelry, watches and rings

Remove your pager and cell phoneRemove your pager and cell phone

Put on a surgical cap, mask, shoe coversPut on a surgical cap, mask, shoe covers

Hair must be completely coveredHair must be completely covered

Mask must be tied before entering the ORMask must be tied before entering the OR

CapsCaps

The BouffantThe Bouffant

The CapThe Cap

Masks and Eye ProtectionMasks and Eye Protection

No!No!

Wrong mask, no Wrong mask, no eye protectioneye protection

No!No!

DittoDitto

Masks and Eye ProtectionMasks and Eye Protection

Better!Better!+

Best!Best!

Outside the OR: Outside the OR: Key People/AreasKey People/Areas

““The Front Desk”The Front Desk”““Charge Nurse”Charge Nurse”

– In charge of all the OR staffing, equipment, In charge of all the OR staffing, equipment, troubleshootingtroubleshooting

OR SecretaryOR Secretary– Calls patients to the OR, coordinates the OR scheduleCalls patients to the OR, coordinates the OR schedule– Just slightly less busy than an air traffic controllerJust slightly less busy than an air traffic controller

Preoperative Holding Area (“Preop Hold”)Preoperative Holding Area (“Preop Hold”)

““Recovery”Recovery”Recovery Room NursesRecovery Room Nurses

Front Desk:Front Desk:Montefiore ORMontefiore OR

Front Desk:Front Desk:Montefiore ORMontefiore OR

Front Desk:Front Desk:Montefiore ORMontefiore OR

The OR Team The OR Team

““Circulator” (AKA The Boss)Circulator” (AKA The Boss)– A nurse responsible for patient care and safety, medical record A nurse responsible for patient care and safety, medical record

documentation, OR equipmentdocumentation, OR equipment– Helps obtain and keep track of instruments and supplies Helps obtain and keep track of instruments and supplies

(circulating between sterile and non-sterile fields)(circulating between sterile and non-sterile fields)

““Scrub”Scrub”– An OR Tech or RN who gowns and gloves the surgeons; also An OR Tech or RN who gowns and gloves the surgeons; also

sets up, maintains and passes instruments within the sterile fieldsets up, maintains and passes instruments within the sterile field

““Anesthesia”Anesthesia”– Attending Anesthesiologist, Resident or CRNA, Medical Attending Anesthesiologist, Resident or CRNA, Medical

Students, Anesthesia TechStudents, Anesthesia Tech– Administers preoperative sedation, intraoperative anesthesia, Administers preoperative sedation, intraoperative anesthesia,

and postoperative analgesia in the Recovery Roomand postoperative analgesia in the Recovery Room

The View From the OR DoorThe View From the OR DoorMontefiore OR 36Montefiore OR 36

Circulator: Circulator: Montefiore OR 36Montefiore OR 36

Scrub:Scrub:Montefiore OR 36Montefiore OR 36

Anesthesia: Anesthesia: Montefiore OR 36Montefiore OR 36

Surgery Intern:Surgery Intern:Montefiore OR 36Montefiore OR 36

The Instrument TableThe Instrument Table

The Mayo StandThe Mayo Stand

Once you are scrubbed in, gowned Once you are scrubbed in, gowned and gloved…..and gloved…..

Where is the sterile field??Where is the sterile field??

Or, What am I allowed to touch??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?Where is the sterile field?

You:You: – Front of the gown from chest to the waistFront of the gown from chest to the waist– Gloved hands and arms to the elbowsGloved hands and arms to the elbows

Patient:Patient:– Draped part down to the OR tableDraped part down to the OR table– Anything that falls Anything that falls belowbelow the level of the patient table is the level of the patient table is

considered contaminatedconsidered contaminated

Sterile Field:Sterile Field:– Covered part of the “Mayo stand” (small table where the most Covered part of the “Mayo stand” (small table where the most

commonly used instruments are kept)commonly used instruments are kept)– Top of the “Back Table” where additional instruments are kept. Top of the “Back Table” where additional instruments are kept.

The sides of the Back Table are The sides of the Back Table are notnot considered sterile considered sterile– Disposable light handlesDisposable light handles

The Sterile FieldThe Sterile Field

Sterile or Unsterile… Sterile or Unsterile… JeopardyJeopardy

Look for the

Sterile or Unsterile?Sterile or Unsterile?

SterileSterile

Sterile or Unsterile?Sterile or Unsterile?

UnsterileUnsterile

Sterile or Unsterile?Sterile or Unsterile?

SterileSterile

Sterile or Unsterile?Sterile or Unsterile?

UnsterileUnsterile

Sterile or Unsterile?Sterile or Unsterile?

SterileSterile

Sterile or Unsterile?Sterile or Unsterile?

UnsterileUnsterile

Sterile or Unsterile?Sterile or Unsterile?

UnsterileUnsterile

Sterile or Unsterile?Sterile or Unsterile?

SterileSterile

Sterile or Unsterile?Sterile or Unsterile?

UnsterileUnsterile

Sterile or Unsterile?Sterile or Unsterile?

UnsterileUnsterile

Sterile or Unsterile?Sterile or Unsterile?

SterileSterile

The Sterile FieldThe Sterile Field

Where do I stand?Where do I stand?

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

Where do I stand?Where do I stand?

If you need to move:If you need to move:– Clasp hands together right below your chest when movingClasp hands together right below your chest when moving– When moving around someone else, pass back to back. When moving around someone else, pass back to back. – When passing by a sterile field, face it. When passing a non-When passing by a sterile field, face it. When passing a non-

sterile field, pass with your back toward it. sterile field, pass with your back toward it.

Do not grab at anything that falls off the side of the tableDo not grab at anything that falls off the side of the table—it is considered contaminated. If something falls, —it is considered contaminated. If something falls, inform the circulating nurse. inform the circulating nurse. Do not reach for anything on the Scrub’s Mayo stand Do not reach for anything on the Scrub’s Mayo stand or instrument tableor instrument table; ask for the instrument to be given ; ask for the instrument to be given to you.to you.

You’re Contaminated!!You’re Contaminated!!

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

OR SafetyOR Safety

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

From McGraw Hill’sFrom McGraw Hill’s Introduction to the Operating RoomIntroduction to the Operating Room

Avoid stereotyping the nurses as "cranky," Avoid stereotyping the nurses as "cranky," the surgeons as "egotistical," and yourself the surgeons as "egotistical," and yourself as "clueless" by learning the OR routine.as "clueless" by learning the OR routine.

Be alert, attentive, and, above all, patient.Be alert, attentive, and, above all, patient.

Don't be afraid to admit to the scrub and Don't be afraid to admit to the scrub and the circulating nurse that you're new in the the circulating nurse that you're new in the OR. They are usually happy to help you. OR. They are usually happy to help you.