How to Survive Your First Time in the Operating Theatre
From being a fly on the wall, to the primary operator, a PGY3 surgical doctor in training, with a not too distant memory of being the bewildered medical student, offers a thorough guide to your first day in theatre.
In preparation for writing this article, I searched for some of the most commonly googled questions medical students ask about surgery. I found questions like
“Do medical students get to make the opening incision?”
“Common surgeries medical students should know”
well… without any further adieu.
No and none.
Let’s take ten steps back from the anaesthetised patient and go through the basics.
This is a guide written from our experiences being everything from the fly on the wall to the primary operator, but with the fortune of still remembering the terror of walking into an operation as a medical student.
Before you get to the operating room
1. Make sure you are allowed to enter
Make sure you have permission from your clinical school/hospital/supervisors etc. Often the doctors in the operating theatres won’t mind, but you can get in a lot of trouble if you jump in without passing all the necessary checks and balances ie: hand hygiene, no touch technique, orientations, evacuations, you know the drill (pun intended) just tick the boxes before entering.
2. Find the operating theatres in your hospital
You won’t have much time between when you get asked to come and the operation literally starting. To maximise your opportunities to participate you want to try to be there early. The only way to do that is to know the ins and outs of the operating theatres. I would go there on other days, walk around, don’t be scared, work out where all the theatres and offices are, the changing rooms and access points.
3. Ensure you have security access
If you don’t, make sure to follow one of the doctors like a shadow, although that is still very risky... Yes, I have had my bag with my “good clothes” locked in a changing room that I couldn’t access after a long surgery spent retracting bowel where my scrubs were literally soaked in blood and sweat, only to ask a random person, the professor of orthopaedic surgery to let me in. She did. So, remember, get your security clearance to avoid mortal embarrassment.
4. Read about the patients
It isn’t always possible, you might not know which patients are coming in when and for what procedures. A neat trick is to ask the doctor you’re following which patients are coming in and for which operations. It’s a great opportunity to really embed your learning. I once saw a gigantic polycystic kidney teased away from the IVC after reading about the autosomal dominance of PKD 1 & 2, something I’ll now never forget.
5. Watch a video of the operation
YouTube is the bible for surgical trainees. I once heard, “I only know how to do this because I saw it a couple times on YouTube”. Scary, sure, but watching the operation with narration will really help you follow what’s going on. This relies on you knowing the operations that are going to happen, see Step 4.
6. Look up the associated anatomy (optional)
This is highly optional, it’s only if you’re interested. You can expect surgeon’s to operate on a bell curve of teaching skill and social awareness. On the worst side, actively quizzing you on anatomical variants of the posterolateral corner (in the knee, you’re welcome) and telling you to study if you get it wrong; to a surgeon that’s silent throughout in the middle; to the best those that actively teach, assume nothing and ask helpful questions. If you know the anatomy it’ll help you on both ends of the bell curve. Impress the worst and learn more with the best, won’t help with the middle, maybe study meditation instead.
You're in the Operating Theatre, Now What?
7. Find the theatre board
In every set of operating theatres there is a central board, usually near the changing rooms or administrative offices that tell you which teams are operating in which theatres. You may or may not know where to go, if you don’t find the board, find your team and walk to those theatres.
8. Assess the situation
An operating theatre is after all a “theatre” just like a great Shakespearean except you don’t have the benefit of the soliloquy. You need to get good at reading all the non-verbal cues in the room, usually through the window. Some things to consider.
Is there a patient on the bed?
Are the surgeons’ and scrub nurses scrubbed in?
Can you hear music, voices, laughter?
Does it look tense or easy going?
The truth is, if you’ve been told to come to the operating theatre, you should enter, but doing that assessment before entry will set the context.
9. Know the roles of the team and their expectations
In most theatres there will be:
MO: Will scrub, arrives last.
Expectations: Varies by surgeon of course. Once again, sense the room and the moment. Most will expect an introduction even if their back is turned and they’re giving you the RBF with full power, just force yourself to be awkward and introduce yourself. Depending on their position in the teaching bell curve they’ll either be really encouraging to get you involved or actively not let you do anything. In either case attending ward rounds, being present, and engaging adds points here, they’ll try if you do too.
- Surgical assistant (registrar)
MO: Supportive but trying to impress the surgeon, will scrub, often there between cases.
Expectations: Should be your supporting figure. Take their lead on all the social things. Of course it depends on their EQ but generally you can tell by their energy what’s really going on below the surface. Don’t make the mistake of asking them too many questions or “being a friend” after people have left or if they’re the primary operator. They’re probably highly focused on doing a good job so it’s not personal, they just don’t have time to deal with you while they fly the plane for the first time.
- Scrub nurse
MO: Roasting juniors is their delight from medical student to nurses to registrars no one is safe, preparing surgical instruments, they will scrub first.
Expectations: Scrub nurses really run the theatres, they’re audited for infection rate and safety. They’re highly trained and extremely good in their roles. It is literally their job to lay down the law. They don’t like juniors entering their lair introducing uncontrolled risk. Be sure to introduce yourself to them immediately even before the surgeon. Don’t be put off by some condescending and controlling tendencies. I have been told that “you’re endangering the patient (with complete seriousness)” whilst standing more than two metres from anyone or anything. Or the time I was kicked out of theatre for “being too big” while the radiology student and two nursing students stayed in an interesting case with my team. Once you get your letters they’ll start to respect you, because at that point you can be trusted not to de-sterilise yourself.
- Scout nurse
MO: Works with the scrub nurse to get things that aren’t pre-prepared.
Expectations: Scout nurses are like off duty cops. They’re usually scrub nurses but they’re not in the spotlight and are usually more relaxed. They can help you find everything you need to participate, help put your name on the board and introduce you to everyone in the team. Make them your allies.
MO: Sitting to the side with all the monitors, ventilator and drugs.
Expectations: If they’re not adjusting their stock portfolio, they’re probably planning their next weekend bike ride or team coffee order. They expect nothing. Just don’t touch their machines and you’re fine.
- Anaesthetic Nurse (AN)
MO: Direct assistants to anaesthetists will prepare drugs and IVs.
Expectations: Typically they’re the life of the party. They have the easiest job and a friendly boss so they’ll probably make friends with you. If someone says hi to you early on that is hanging around in the anaesthetic area, you’re probably speaking to the AN.
- Theatre Technician
MO: Responsible for the equipment, patient positioning, gelly arm rests and memory foam pillows etc.
Expectations: I can’t tell you how many times I have made friends with someone in the theatre thinking they’re the surgeon and getting excited for the day only to see them adjusting the bed height, grabbing the memory pillow and taking their prescribed break. Never fear, techs usually know everyone in the hospital and their cousin, gregarious and easy going, I highly recommend befriending them.
The scrub nurse, scout nurse and surgical technician will be in the operating room (OR) before everyone else. The nurses setting up the instruments for the surgery and the technician setting up the equipment in the room, patient positioning, lights etc. If you arrive early it is a great opportunity to get those intros done and wait for the surgical team and the patient to arrive a bit later.
10. Introduce yourself at all costs
You MUST introduce yourself to the team. You will usually know someone, the registrar or the surgeon, but they might not be present at the start of the case. You want to make sure the scrub nurse, the real boss, and the other people in the room know who you are. The anaesthetists are often not that interested, they’re focused on their own things, so focus on everyone else.
I used to put my name badge at the top of my scrubs. I found myself wishing I could wear a set of different coloured scrubs, the equivalent of a dunce hat just to make it easier. There are different ways to do the intro effectively depending on the mood of the OR. If you’re early or things are just starting, easy, say hello to everyone, break the ice, tell them your name and role. If you’re entering at a more tense time, you can quietly enter and introduce yourself in whispers to the people working. If you get asked who you are, don’t take it as an offence, surgery is like flying a plane everyone needs to know everyone else, stand straight and say your name, LOUDLY, it's important to be confident, they’ll be waiting to sense weakness.
11. Write your name on the role board
In most ORs there will be a whiteboard or a digital version where you can enter your name and role. This is another great way to introduce yourself without saying anything. In the middle of the operation simply write your name and role on the board and everyone will know who you are, I have done this many times and gone on to watch silently. Fail to write your name up at your own peril.
12. Get in prime position
Now that you’re in the OR, try to get into a good viewing position. Again, there is a complex social nuance here between how well the team can trust you and how far or close you can stand from sterile gowns and drapes without getting told off. A general rule is at least 1m away from anything sterile.
But I want to practice my surgical skills
13. Getting asked to scrub in
Depending on your relationship with the surgeon and their teaching style you could be asked to scrub into the operation. If you’re offered you should always say Yes. It’s okay if you might have to leave during the operation, just tell the surgeon ahead of time.
14. Be honest about scrubbing
Scrubbing for theatre takes a lot of practice there are many steps and you don’t want to compromise patient safety. I’d say in the first 10 to 15 times I scrubbed I just pleaded absolute ignorance to the scout nurse and asked them to help me with everything from my glove size to washing correctly to putting on my gown etc. They’ll be supportive because they were all in the position of not knowing how to do it at one point in their training. If they’re not, that’s their problem.
Once you get a bit better you will walk in before the operation, ask the scout nurse for a gown with your two glove sizes and scrub in without supervision. For now, call for help.
15. Don’t worry if you make a scrubbing mistake
Everyone makes mistakes in their scrubbing, Just own up to it and start again. The gloves and gowns literally grow on trees. Don’t fall into the trap of thinking it doesn’t matter because you won’t be doing much. You’ll be surprised how quickly your additional hands will be put to good use deep in someone’s abdomen, so do it right.
16. Get the right gloves
There are sterile gloves on every ward in the hospital, I encourage you to waste a few. With some friends, get a pair for each of the most common sizes and try them on. When you operate you'll use double gloves to reduce the risk of a glove tearing and needlestick injuries from your instruments. If your perfect fit is a 7.5, get a set of size 8 gloves and size 7.5 gloves. Put on the bigger pair first, then the smaller snug pair over the top. Make sure they’re snug but not too tight, if you feel pressure on your finger tips while putting them on you won’t be able to feel your hands by the end.
17. Donning your sterile gown and gloves
There is no trick here, practice makes perfect. Ask one of the junior doctors in your team to practice with you on the ward. I’ve shown many medical students on the ward how to do it, you will get exponentially better with time and as always, don’t be afraid to ask for help.
You're finally operating with confidence
18. Don’t do too much, just be neutral
This is the easy part, do as you’re told and don’t do too much.
There are three types of surgical assistants.
You want to be neutral, neither good nor bad. It’s actually harder than it seems. You won’t have familiarity with the operation and the anatomy, so it is very hard for you to predict what the surgeon will do next, so don’t try. If you’re retracting, keep retracting until told to do otherwise. If you’re holding the camera in a laparoscopic appendicectomy or a cholecystectomy, aim the camera, ask if they’re happy with the position and hold it steady.
Even junior registrars find it hard to be neutral and only the best are additive. To be additive is to move and assist gracefully in a well choreographed waltz with the primary operator, retracting intuitively, asking for the next instrument without permission, calmly cutting the next stitch without words. It’s a meeting of minds that takes years to achieve.
Last and most importantly, no matter who you’re operating with they ultimately want the same things as you. Admiration, respect and to have a good time. It’s completely fine to laugh, try some jokes and be yourself. The surgeons in the room will thank you for it and will like you more than if you’re silent, paralysed by the fear of retribution. They were once holding the retractor like you.
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