Surgical Clerkship 101 (Part 2)

This is the second of a three-part series to help you get the most out of your third-year surgical clerkship. Since this is one of the most important required clerkships, I thought I would spend some time on this one. The subject matter of this essay will be scrubbing and assisting in the OR along with handling some of the “pimp” questions that frequently come during the cases.

Your first tour at the scrub sink need not be intimidating as long as you keep a couple of things in mind. First, you need to be dressed properly. By proper dress, I mean clean hospital scrubs with no T-shirt sleeves below the level of the scrub sleeve. You need to have your hair completely covered (no bangs sticking out ladies) by scrub cap or “shower-type” cap. These caps should be clean and ideally, disposable. You need to have eye protection that covers all around. The goggle-type glasses are the best but you can pick up the disposable “Angel Frames” which are better than nothing at all. Blood spatters in the eyes are no laughing matter and you need to be protected. After your eye protection is in place, you must don a mask that completely covers your mouth and nose. If you have a beard or large bushy mustache, you can wear one of the hooded type devices that serve as both cap and mask. Finally, you need to don shoe covers that completely cover your shoes including the laces. Blood and other fluids often drip down onto your shoes. If you have shoes without laces, so much the better. I have shoes that I do not wear outside the OR that I cover with two pairs of shoe covers. When I am done with the case, I dispose of the outer cover and keep the inner cover for the recovery room.

You need to put on your hat and shoe covers before you enter the operating suite. These are usually at the door or near the door of the locker room and within easy reach. You need to be sure that your scrubs are clean before you leave the locker area (no blood or coffee). At the scrub sink, you need to don your mask and eye shields. Make sure that your mask is under the rim of your eye shield and tight. If moisture gets through, your eye shields will fog during the case and you won’t be able to see. Place a small piece of tape if you can’t crimp the mask for a custom fit. (Some people will tie a face shield-type mask upside down on their forehead to prevent fogging. This works well and you don’t need the eye shields if you do this. Another advantage of the upside-down face shield is that the rolled up mask part acts like a wick if you sweat or are doing a peds case in a very warm room.

Before you begin to scrub, go into the operating suite, introduce yourself to both the circulator and scrubbed personnel and write your name on the board and your level (MS-III). Also, if you are wearing a pager, place this on the desk with a pen/small note pad clipped to it. You can’t answer your pages when you are scrubbed in a case. Obtain your gloves and gown and place them on the table where the circulator can open them and hand off to the scrubbed assistant. Be sure to obtain both pairs because you want to be double gloved. Be sure you have chosen the correct size (have one of the nurses/techs size you if you don’t know). I wear size 7.5 gloves (big hands) I place my 8 undergloves next to my skin and put size 7.5 on top. Gloves that are too tight will be miserable on a long case. Gloves that are too loose do not permit good tactile skills such as suturing.

Once your mask, hat and eye protection are in place, you should be standing in front of the scrub sink. There are two types of soap solutions available (the waterless and water requiring). If you use the waterless scrub, make sure that you have done at least one water-based scrub before you use this material. On vascular cases, I never use the waterless scrub alone and usually do a full scrub between cases. If a graft gets infected, the patient usually dies from that infection. I take no chances and always err on the side of caution. If you are allergic to iodine (and I am allergic to iodine) don’t use the povidine solution for scrubbing. You should have gone through a “scrub class” before you actually scrub but the short version is here.

Take the nail cleaner and scrub brush from its packet. Turn on the water with your foot (may be automatic) and wet your hands and arms starting with the hands and going up to the elbows. Be careful not to touch the faucet. Use the nail cleaner to clean under each nail and dispose of it. Scrub each surface of each finger with plenty of soap and the brush. Divide your arms into four quadrants and clean them using 25 strokes for each finger surface, the nails of each hand, the surface up to the elbow. Once you have scrubbed an area, don’t re scrub. Toss the brush into the trash can and rinse starting with the hands and letting the water drip at the elbows. Keep your hands up at all times. If you accidentally touch the faucet, start over with the scrub.

You will drip water but hold your hands up and open the door of the operating room with your rear end. The scrubbed person will give you a sterile towel. Allow them to drape this towel over your wet hands. Grasp the towel at one end with one hand and dry from hand up to elbow. Take the other end and do the same. Drop the towel across the laundry hamper or where you are told to drop it. You hands should be dry and continuously held up. The scrub person will hand you a gown or drape a gown over your shoulders (stand still and close enough) pulling up the sleeves. The circulator will tie the gown. The scrubbed assistant will place your under glove on your right hand (left first at Mayo) and then you use your index and long finger to stretch the second glove so that you can place it on your second hand. This is repeated for you outer glove.
You then “spin” and tie the outside ties of your gown.

At this point, if you are not doing anything, cross your arms and stand out of the way. The resident and attending surgeon will be draping the patient and will tell you where to stand and what to do. Keep your arms folded and once you are in place, keep your hands “in the case” meaning let them rest on the OR table in complete view of the scrubbed assistant. When the surgeon gives you a retractor, hold it as instructed and try not to move. Keep your mind on the case, step by step (you should review the procedure before entering the OR). The surgeon may ask you to do a couple of ties or throw some sutures. Be sure that you are totally familiar with whatever you are asked to do. If it’s your first time, speak up and someone will talk you through. Try to close the skin at the end of the case. At this point, you and the resident can share this duty and it’s a good time to learn.

If you are driving camera on an laparoscopic case, try to keep the instruments in the center of the visual field. Believe it or not, you have the most important job on the case. Good camera drivers usually get excellent evaluations from the residents and attendings so learn this important skill. In the event of an emergency and you lose gas pressure, remove the camera as quickly as possible. The light on the end of the camera can cause a very serious burn so you need to be sure that you don’t touch any tissue with the light and that you remove the camera efficiently if told to do so. Keep your eyes in the case and listen to instructions. If you make a mistake, correct it but don’t take anything personally. When a case isn’t going well, surgeons can get frustrated. It isn’t personal and don’t let it throw you.

At the end of the case, help the anesthesiologist, resident and technician move the patient to the stretcher and push the stretcher to the recovery room. Again, just do what you are told if you don’t know. Step up and volunteer your assistance if needed. Watch tubes and IV lines on transfer and remember that the anesthesiologist directs the move because he/she is in charge of the airway. Be sure to thank the OR scrub staff when you leave the OR for the recovery room. It’s just common courtesy. Once in the recovery room, be ready to write the ”Brief Op Note”. You can get all of the components from the anesthesiologist and the OR nurse. At the beginning of your rotation memorize the components of the Brief Op Note and be efficient at getting this note written. Again, ask to do this and ask the resident to help you if you can’t find something. Don’t leave this note incomplete. When I am dictating the case, I will use this note in my dictations so listen to the resident’s dictation (I dictate my cases in the RR at the end of each case) if nothing else.

Every patient that you assist on that is coming to your service will be your patient. If you have seen the case, you know what the incision looked like at the close of the case and you know what went on during the case. Keep these things in mind as you follow your patient. Be sure to read the anesthesia notes on your patient and ask questions if you don’t understand something. These notes can be invaluable in terms of fluid management of your patient post-op.
Answering those “pimp” questions. Most questions asked during a case will be directly related to the pathology of the patient or the anatomy of the region that involves the pathology. Be sure that you have reviewed these things before scrubbing the case. It’s a good idea to review the anatomy of the biliary system, the GI system and the chest before you start your rotation. Be sure to read and review common emergency cases such as appendicitis, acute abdomen and vascular anatomy. After that, read about the types of patients that you will be seeing on your service. Finally, cover trauma (unless you are on trauma service). Again, the Lawrence text is great for reading and total mastery of this book can take you a long way toward doing well on your shelf exam.

You also need to be sure that you skills are adequate. Practice with a knot-tying board until you can tie a secure two-handed knot without thinking about it. Be sure to bone up on your fluid and electrolyte information as pimp questions will frequently come for this subject matter. Stick close to your resident and don’t whine. If you are tired, your intern and resident is more tired. There will be times where you are just exhausted. The first thing you should grab is a bottle of water (dehydration makes exhaustion worse). Stay away from loads of caffeine and sugar and learn to “cat-nap”. Be upbeat and remember that no matter how bad the rotation, the clock is ticking and it will be over soon. For most people, this is their only brush with surgery and the most important thing to take away from the rotation is a solid knowledge of when to consult a surgeon. Next essay, when things go wrong and how to do “damage control”.