how to survive in the operating room

Since this is my first ever post in the medicine category of my blog, I should probably start this with an introduction. Hello! My name is Simi, and I am a third year medical student. As of writing time, I am just about finished with my very first rotation, which was in obstetrics and gynecology (pregnancy/labor and women’s health, respectively) . OBGYN is a fast-paced specialty with a lot of variety. You get to see patients in clinic, and yes, you get to see babies born (a whole ‘nother post in itself), but one thing you might not know is that obgyn doctors are also trained in surgery, mostly for female pelvic problems. That meant for my hapless, bright-eyed self, I spent every third day in the hallowed and dreaded operating room (OR).

Surgery is probably one of the most prestigious divisions of medicine, as well as one of the scariest. Because by nature it involves messing with another person’s body, it’s a highly delicate art and one that requires a lot of rules and regulations in order to have everything run smoothly. The result is that the operating room is by nature a stressful place. For someone coming in to observe a surgery, it can feel like being a small child in a group of adults: “Stand still! Don’t touch that! Be quiet!” But once you learn the rules of the road, the OR is actually an amazing experience. Consider this your guide to being a good student in the OR.

Before the operation

The morning of the surgery, the patient usually comes in at around 5:30 (same time you’ll get in) for their pre-op check. The surgeons (along with you, the medical student) will introduce themselves to the patient and ask them several questions: how they’re feeling, if they’re having any symptoms, if they’ve eaten or taken their medications since last night (they shouldn’t have). The nurses will check their vital signs (blood pressure, heart rate, respiratory rate, etc.) to ensure that the patient is doing okay and is not in any crisis before going into the big operation. All of this will be written down in the patient’s pre-operation note, usually documented with the rest of the patient’s medical records in the electronic medical record (EMR).

The anesthesiologist will then come and have the patient consent to being under anesthesia. Ideally the anesthesiologist will give the patient a sense of what they’re going to do before having them sign the consent form. After that, the circulating nurse will have everyone gather around the patient and confirm the patient’s name, date of birth, and the surgery to be done. Then, it’s time to go to the OR!

Getting into the OR

You and your team will roll the patient over to the operating room. On the way there (or beforehand), you should grab a bouffant cap to cover all your hair, a face-mask to cover your nose and mouth and shoe covers. You are generally not allowed in an operating room without those three things, especially the hairnet and face mask. Once inside the operating room, the nurses and med students (AKA you) help set the room up for optimal surgical success. There are various little things you can do to help get everything going. For my obgyn rotation specifically, our tasks consisted of covering the windows on the OR door (since the surgery was on private parts), helping transfer the patient over to the operating bed, putting compression devices on the patient’s legs to improve circulation and prevent blood clots, and positioning the patient for surgery, among other things. You may have similar small tasks before your surgery. They may seem menial, but they’re necessary.

After everything is set up and the patient is under anesthesia, it’s time for the surgeons to “scrub in”. Scrubbing in is a meticulous process where the surgeons essentially sterilize themselves in order to make sure that no unnecessary germs get on the patient. If you’re a third or fourth year medical student, you will likely end up scrubbing into some surgeries, as it is a skill one needs to learn before graduating and going into residency. It can be hard to get everything correct at first, so don’t feel bad if you don’t scrub in perfectly on the first try (or the second or the third or the fourth try; honestly, it’s awkward and you don’t have much time to learn it beforehand).

You start the scrubbing in process by using a sponge to wash your hands. You start with your fingers, then your palms, and then your forearms and go all the way down to your elbows, and you should spend a decent amount of time washing each part of your arm. Since in theory, your arms get more dirty as you get closer to the elbows, you aren’t allowed to wash your elbows and then go back to your hands; it always goes from hands to elbows. You then rinse all the soap off your arms while being careful not to touch the sink, and you back your way into the OR with your arms up in front of your face, almost as if you’re an umpire in a football game.

Once inside the OR, the scrub technician will help you put on a gown and two pairs of gloves; you’re not allowed to touch anything until you have gloves on your hands. Once your gown and gloves are on, you’re scrubbed in! But there’s one more rule; if you’re not doing something with your hands, you have to keep them near your chest area, as that is the most sterile part of your body. Some people fold their hands as if they’re going to pray; others fold their arms like a bored teenager in line with his mother at Nordstrom’s. Whichever way you do it, if your hands are idle, do not just drop them down your sides! Also, once you’re scrubbed in, you can only touch the “sterile” parts of the operating room, such as instruments or the drapes the patient is covered in. It’s a bit of a laborious process, but scrubbing in is worth it in order to get a prime view of the surgery. You won’t be allowed to scrub in for every surgery; if this happens, don’t be too upset. That means you’re free to do things that the sterile, scrubbed-in people can’t do, and believe me, having a non-sterile person comes in handy!

During the operation

The operation itself is probably the hardest part as a medical student, especially if you’re scrubbed in. You get to watch everything that’s happening, but since you’re not a surgeon-in-training just yet, you usually don’t get to do all that much. You might hold the suction or the drain or cut small sutures with the suture scissors, but most of the time, you stand there and watch…for several hours.

I have learned from experience several tips that help with standing in the OR for a long time:

-Make sure you eat a lot and drink lots of water beforehand.

-If you know or have a suspicion that you’re anemic, take iron supplements and make sure to eat food with iron (spinach, meat, beans) before going into an operation. This will prevent you from getting lightheaded.

-Don’t lock your knees when you stand; make sure to bend your knees a little bit, so that circulation to your head isn’t cut off.

-No one is looking at your legs, so subtle movements (shifting from leg to leg) is okay and will help with circulation.

-As far as exercise, having strong core muscles (such as abs) and strong leg muscles will help a lot.

-And if you get too tired and have to sit down after a while the first couple of times, don’t worry! They may not tell you, but many of the surgeons have likely had similar experiences before. The endurance comes with time.

-If you feel lightheaded/as if you are about to faint or like you are about to throw up, do not hesitate to take off your gown and gloves and sit down and even leave the OR for a little bit if needed. It won’t make you look good in front of the surgeons, but you’ll look much worse if you faint or throw up onto the sterile field and ruin the surgical setup. And again, plenty of surgeons before you have had this experience multiple times, so don’t feel too bad.

-And of course, focus on the surgery! It may be a bit painful but it’s worth it to see lifesaving work being done.

Sometimes the surgery might start off a bit anticlimactically as the surgeons are accessing the body part that they’re operating on, but once they get where they need to go, usually the surgery is pretty exciting to watch. At the end, you might get to practice your suturing skills by closing up the incisions the surgeons made. Try and practice suturing outside of the OR as well; it’s a little stressful trying to suture on a real person when time is of the essence and your residents are watching you. But again, you don’t need to be perfect; that’s why you’re a student!

If you’re not scrubbed in, you often get the liberty of sitting down and walking around, but you’re still expected to pay attention and help when you can. Make sure to not touch anything sterile; generally, staying away from the scrub tech is a good idea (not because they’re mean, but because they have a job to do).

After the operation

After the surgery, everyone takes off their gowns and gloves and gets ready to go to post-op. Again, as the med student, you get to help with post-op, so take every chance you can. Jobs that you have include getting a transport bed for the patient, taking down anything in the setup that was not there before, and moving the patient from the operating bed to the transport bed when anesthesia is done. Depending on your team, you might accompany the patient to the post-operation recovery room, or you might stay with your team in the OR while they finish documenting the operation. If you have another operation, you then eat lunch quickly and prepare to do the same thing all over again!

After the operations are done for the day, you may go with your resident to the post-op recovery room to see your patient and make sure they’re doing okay. Then you write their post-op check note (we write LOTS of notes in medicine), and after that, you’re on your way home. Good job! You made it through an OR day, and hopefully this blogpost gave you the advice you need to not only survive, but enjoy your time there. :)