Episode 13 Preparing for Operating Theatre

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“Hi, and welcome back to another University of Melbourne MOGCAST. I'm Dr. Hannah Skrzypek, and today I'm going to be talking to you about how to get the most out of your operating theatre attendance. So how to prepare for that first time you go into theatre.

So I'm going to start by taking you on a bit of a virtual tour of the operating theatre complex, because there's not just operating theatres behind those doors. So we've got the change rooms. The preadmission area, this is where patients are checked in, change, meet their anaesthetic and surgical teams preoperatively and await their surgery. There's the in-charge office, where the nurse in charge of the theatre complex can often be found. There's the anaesthetic office and this is a place where the anaesthetists have their desks and they often take breaks in this office between cases and the anaesthetist in charge for the day can be found if any of the anaesthetic teams need some assistance. Then there's a CSSD and this stands for the Central Sterile Supply Department and this department washes, decontaminates and sterilizes all the non disposable equipment.

Next door to that is usually the store room and this is a space that houses all the disposable equipment. Then there's the tea room, the write up room, a place where surgeons can write up their operation notes post operatively. The recovery area, which is where patients go immediately following their surgery for a period of time of close observation before they return to the wards. And then there's the theatres themselves, and the theatres themselves have an anaesthetic bay, a scrub area with a set up room. And then inside the theatre, obviously, there's the theatre bed, the anaesthetic machine and other equipment needed for that particular surgery.

So, two other important things in the operating theatre complex is the theatre board, and this is a large whiteboard that is rewritten every day, and it summarises who's in which theatre doing what for the day, and so it'll have the surgeon listed, the anaesthetist listed, what type of surgery is happening in that theatre. And that's a good place to sort of check in with, to see, okay, I'm with this surgeon in this theatre, and then you'll know where you need to be going. The second thing that's an important thing in the theatre is the line. And this is a line that's usually on the floor, beyond which point you should be in your theatre scrubs with your cap on, your shoe covers on.

So, in the recovery area, in the preadmission area, these are areas where you can enter into the theatre complex without being in your theatre scrubs. But beyond the line, which is where all the operating theatres, the CSSD and the storeroom are, you need to be in your theatre scrubs and your theatre attire before going past this line.

Okay, so that's a little rundown of all the things that you'll encounter behind those closed doors of the operating theatre complex. But next, I want to talk you through who you'll encounter when you're actually in one of the operating theatres, because there's lots and lots of people there, but everyone has a specific role to play.

So, we'll start with the anaesthetic team, and this is usually a consultant anaesthetist. They may have a registrar or fellow working with them. And they've always got an anaesthetic nurse who sets up all the airway trolley, assists the anaesthetist with their drug administration, with their lines, etc. and the set up.

Next is the surgical team, and in public hospitals this may be quite a large team consisting of consultant surgeons, fellows, registrars, residents and interns. But in the private hospital this may just be one surgeon with their assistant.

Next is the nursing team, the surgical nurse team, and this team is divided into the scrub and the scout nurse. So the scrub nurse is the nurse who's going to actually scrub up for the case and looks after all the equipment that the surgeon needs during the case, handing the equipment off to the surgeon as he or she requires it and ensuring the surgical count is correct, everything's maintained in a sterile environment and will be scrubbed for the entirety of the case. The scout is a nurse who is able to stay in the theatre but move in and out as required to get extra equipment that the scrub might need to assist with the surgery.

Another vital team in the theatre is the theatre technician team. So, each theatre usually has one or two techs. And these are people responsible for patient positioning and care. So, moving patients in and out of the theatre, positioning them in a safe way on the operating table, ensuring there's no pressure points or nerve injuries due to positioning. And they're also responsible for all the equipment that gets moved in and out of the operating theatre, depending on what surgery is being performed.

So that's the anaesthetist, the anaesthetic team, the surgical team, the scrub team, the theatre techs, and often there can be other people depending on the type of surgery. So, for example, in obstetrics, there's usually a midwife, and there may even be a paediatrician or a neonatologist present as well. So that's a rundown of who you'll encounter in the operating theatre. I'm going to talk you through now how you should prepare for an elective theatre attendance so that you can get the most out of it and learn the most from that attendance.

So always before the surgery, before the day of surgery, it's important to find out what is on the theatre list that you're going to be attending. And you can do this easily by just knocking on the door of the theatre booking office and they'll have a list that they can share with you that lists the patient and what surgery they're having. Usually in hospitals with electronic medical systems, there'll be a theatre schedule that you can access on the electronic system. Or if you leave it to the night before, you can head into the theatre complex itself and ask the nurse in charge, who will typically have a printed list ready for the next day. So, once you've got that list, then it's important to look up the patients on your electronic medical record system, or if you're still in a hospital that works with paper these histories will be in their preadmission area of the complex the day before the surgery.

It's important to have a look through the patient records and find out what history, what exam, what investigations have led to the patient being scheduled for their particular surgery. That way you'll know already the patient stories before you meet them on the day.

So, as well as getting to know the patients, it's important to get to know the planned surgery. And you can do this in a number of different ways. There are lots of surgical textbooks that go through the steps of various surgeries. There are also some great videos on YouTube that can talk you through a surgery.

And importantly, it's good to revise the anatomy of the region that the surgery is going to be performed on before you see that surgery. So, you can reinforce that anatomy as well.

So, you've got to know the patient's story. You've refreshed your anatomy. You've read up on the surgery. Now it's important also just to refresh yourself on how to perform a surgical scrub.

And this is a skill you'll normally learn in the first one or two years of your medical school program, but there's a great video available online through acorn.org.au. There's a username and password that you should all have a username, University of Melbourne with capital U and capital M and password ACORNDVD, all in capitals. If you then click on the education tab in the menu and then select the surgical hand antisepsis gowning and gloving video. This is a video that will walk you through how to scrub, how to gown, how to glove in a safe way.

And finally, just some logistic things. It's good to just know where you're going so that on the morning of your theatre list, you're not lost around the hospital. So, find out where the theatres are, know how to get there, know where you're going to park, make sure your security pass is working, it will actually let you get into the theatre. Because the worst thing is if you get there and you can't actually get in through the door, usually someone will eventually walk past. But you want to just make sure that's working and make it a bit easier for you.

So, we've gone through a bit of a virtual tour of the operating theatre complex. We've gotten to know who's going to be in the theatre. You've done some preparation before the theatre attendance and now we get to the day of surgery.

So, it's really important that you arrive early, about 30 minutes before the list start time. All the other team members will be there at this time, getting ready, getting things set up, meeting the patients, etc. So, you should be there too, you're part of the team.

So, this includes getting into fresh theatre scrubs, popping on shoe covers, popping on your hair cover, your hat, and these days donning a mask and eyewear.

Once you've changed, head in and check in with the nurse in charge so that they know you are in the complex. Remember they're sitting either in their in-charge office, or they can easily be contacted on the in-charge phone which they'll be carrying at all times and the number you can get either from switchboard or from one of the other team members in the theatre complex.

You then need to introduce yourself to the theatre team and that includes all members of the team; nursing, technicians, anaesthetists and surgical teams and then it's best after that to find the registrar or consultant who is doing the list that day because they will be meeting the patients in the pre admission area and it's during this time that they will be introducing themselves to the patients, confirming the need for surgery, ensuring there are no contra indications that have arisen since they were seen in clinic and re checking the consent.

So, it's ideal if you can meet the patients with the registrar or the surgeon preoperatively, be introduced as part of the team and gain consent at this time to observe their surgery. So then, once you head back into the operating theatre, it's good to put your name on the roll board. So, this is a little whiteboard in each of the theatres that just lists the surgeon doing the case today, the anaesthetist, the scrub and scout team,

the technician, and you, the medical student. So just write up your name on the board.

Now, if you're just observing and you're not able to scrub up, perhaps there are too many people scrubbed in already, for example, then it's good to get in a position where you can see but keeping about a metre away from the sterile field.

You can also have a chat with the anaesthetist during the surgery, who can teach you a little bit about the anaesthetic machine and the anaesthetic. It's good to chat to the scout nurse, who can talk you through some of the equipment that the surgeon is using. And the technicians, too, can teach you about some of the equipment and the important aspects of positioning the patient appropriately.

But if it is possible to scrub up, this is going to allow you to be close to the surgeon, close to the surgery, and then you'll be able to often be talked through what exactly he or she is doing. The anatomy can be pointed out. And you can really have a bit more of a chat about the surgery. So, take the opportunity to scrub up as often as you can. So, lots of people are nervous about scrubbing. The best way to scrub is with someone else. So, you can mimic the steps that they take in washing, gowning and gloving.

If you do contaminate something accidentally, don't worry. Just let the scout nurse know that you need to re scrub and he or she will grab you another set up. Even surgeons who scrub every day need to re scrub every now and again, so it's no big deal and patient safety is the priority. It's always important to also double glove, so you wear half a size bigger as the underglove and then your size of gloves on top as a snug fit because this reduces the chance of a needle stick injury.

If you do scrub up and you're actually asked to assist, then don't worry, you'll be guided exactly on what to do by the surgeon. They'll tell you what to hold, where to retract, what to cut, when to use the suction, how much pressure to place here or there, how you follow a suture, how to hold the camera if you're operating laparoscopically, etc.

Learning to assist well takes a lot of time. You need to learn the steps of the surgery, the instruments, how they're used, deviations in the routine surgery, if there are adhesions or anatomical differences. And you also need to get to know how the surgeon operates. So don't worry if it doesn't feel smooth the first time you do it.

Alright. just a final comment to finish up this MOGCAST. Obviously, sometimes in theatre, things can go not according to plan. There can be complications, there can be large blood loss. And usually when this happens, you'll see the mood of the theatre change. Everyone will get busy doing what they need to do to look after the patient. They'll be communicating with each other. There'll be extra things being brought into the theatre, equipment, assistance, blood products. There might be a code called if there's a massive obstetric haemorrhage.

So, if you see this going on, this is just a time when you just need to step back a little bit Keep quiet. Don't ask any questions at this point in time. Just observe what's going on. See how the team works to look after the patient and just wait until the team has everything under control again. And then once the mood starts to lighten up again, once things are controlled, the emergency is over, the patient is safe, you can see the team

relax, there might start to be some lighter communication among the team members, then this is the time where you might be able to say, “look, can you just talk me through what went on there?” And find out from the team what the issue had been.

And I guess on that note, if you do see something that has worried you or troubled you when you've been in theatre, don't be scared just to reach out either to the surgeon or the anaesthetist to have a bit of a debrief after the case.

And if you just need something more than that, reach out to any of the University of Melbourne staff. We can organise a bit of a sit-down just to talk through what you saw and provide you with a little bit of support.

So that brings me to the end of the MOGCAST. I hope this is a good way that you can get through a little bit of preparation before you go into theatre yourselves.

Some of you will love theatre, some of you won't love theatre, but you'll know that straight away when you get there. And all the best in your studies ongoing.”