Advice for when in the OR

[dizzle69]

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Here's the situation:

I had been shadowing this thoracic surgeon when applying for medical school. We had kept in touch since (easy to do since I attend the school and he works in the associated hospital), and now after MS-I, I have been doing clinical research under him and his research associate, for the summer. I just found out from the associate that a surgical procedure (Ivor Lewis esophagectomy) will be performed by the surgeon and they want me to actually scrub in and assist since this rotation has only 1 MS-III. While I have watched these procedures before and whatnot, I am still fairly nervous about this because this time I get to actually participate. I am excited and nervous (as you can probably tell lol). Anyway, any advice/tips for me for tomorrow? I can use any and all advice you all may have. I know about the sterility issue -- he is a major stickler over sterility, as he should be. Do not touch anything unless instructed and don't touch your own gown and keep your gloved hands within the surgical field (in front of you) at all time. However, besides this basic advice, do you guys have anything else to offer? I greatly appreciate this. Thanks in advance!

 

[Anka]

It will probably be quite benign, since you are a volunteer and not even on the service. Just be prepared for everyone to watch you like a hawk (as they should, you're new), let things roll of your back, and go with the flow. Arive early (when the patient hits the room, if possible), introduce yourself to the scrub tech, circulator, and anesthesiologist or anesthetist ("Hi, I'm XXX, I'm a first year medical student here with Dr. YYY). Sometimes there is a board where you should write your name and glove size. Ask the nurses if there is any way you can help out; they usually appreciate it even if there isn't anything you can do. An epidural is often used for an Ivor Lewis; you might offer to hold the patient for the epidural so the nurse can attend to other matters. Even if you don't know how to put in the foley, when the nurse/resident/PA does it, you should watch courteously as you'll be doing it a lot once you're on your surgical rotations. She may be willing to teach you how to do it if you ask.

Since you know what the procedure is, you should read up on it (Sabiston is available online through MD Consult at most medical schools; an esophageal surgery book or Sabiston and Spencer may be available at your library or the department of surgery library and will have more detailed information) and review the relevant anatomy in whatever atlas you used for your gross course. It is also useful if you review the indications for surgery for your patient -- but that might be difficult given that you're not on the service.

Have fun! This is a great opportunity.

Anka

 

[Winged Scapula]

I"m suprised you will actually be allowed to scrub. Every hospital I've worked in has not allowed anyone to scrub that hasn't had the "scrub lecture and demonstration". But congrats if you are.

All the advice above is good... I would add:

- never argue with anyone who says you have contaminated yourself; even if you don't think you did
- never argue with the nurses
- don't touch the Mayo stand (the tray of instruments)
- no swift movements on the field when there are sharp instruments around
- ask where they want you to stand; get a step stool if you need one
- eat a light breakfast, slightly fluid restrict; I-E take awhile, you don't want to have to leave to pee in the middle, nor do you want to feel lightheaded because of low blood sugar
- bend your knees, move around a bit - see previous threads about not getting sick in the OR (it will be different actually being scrubbed in than watching)


have fun!

 

[Dr JPH]

Return PM sent.

Also just like to re-iterate what someone said above. I didnt realize this would be your first time in the OR.

When you first go in the OR (before the patient is even brought back) make sure you let everyone know who you are.

Circulating Nurse, Scrub Nurse and even Anesthesia if you can let them know before they get busy.

Get your gloves and give them to the Scrub nurse in a sterile fashion. Kow your glove size...try on a few beforehand.

DOUBLE GLOVE, or use some sort of under-glove. The scrub nuse & circulating nurse can help you get the right gloves. Most people do 1/2 size larger underneath. You can also ask for Ortho gloves which are a bit thicker...tougher to feel things but perfect for someone who might not be doing a whole lot. Plus Ortho gloves look cool. 🙂

If you dont know how then ASK.

You should also know how to scrub, gown and glove in a sterile fashion. If you are pleasant and let people know youre a rookie they should help you out.

Remember, in the OR BLUE = STERILE!

Keep your hands below your shoulders and above your waist. No armpits, no arms at your side. Keep your hands folded in front of you.

Dont touch anything unless you are told to do so. Dont reach for instruments, dont try to "help" unless asked.

Keep your hands on the surgical field.

Dont lean on the patient.

Ask for a stool if you cannot see. There is nothing worse than someone holding a retractor who cannot see the field.

Save questions until after the case.

After the case help remove the drape and stay with the patient. Attendings will usually go talk with the family or dictate the OP note, but unless told to do so you should remain with the patient.

As I said in my PM...know WHY they are doing this procedure.

Read up on the procedure a bit more.

And know about the serosal layer. 👍

Have fun. Ivor Lewis is a great procedure to watch.

 

[dizzle69]

I definitely appreciate the advice and tips received from you all. All of you are valuable to this forum and I'm glad you all are here. I especially appreciate JP's PM response and response on here, too.

This is going to be my 1st time actually scrubbing in, but it is not my 1st time being inside the OR. I probably had spent close to 100-150 hours observing while I was shadowing as a soon to be med student. However, I very much agree that watching and actually scrubbing in are 2 different beasts. I can't wait. I was definitely surprised, but I think this will be great experience for when I'm actually on service as an MS-III.

I know that thoracic surgeons perform esophagectomies when a patient comes because they can't swallow or have a hard time doing so (dysphagia) and barium swallow is used to diagnose this (can't swallow solids and eventually can't swallow liquids, I believe). Surgeons prefer I-E because it best allows for margins to be effectively measured, along with the best view for coregional lymph nodes, which he often removes. This is something the transhiatals don't provide, but are often used in patients that are weaker and would face a tougher recovery. The surgeon I work with immediately calls for integrated FDG PET/CT as a means of clinically staging the tumor and determining uptake, which I believe helps in confirming the stage of the esoph. cancer. Anyway, they open up the abdomen and use certain techniques, I remember him talking about the Kocher maneuver in order to allow increased mobility of the stomach from the intestine (especially the duodenum). They separate the stomach and use the stomach as the gastric conduit for when the resect the middle to distal region of the esophagus using a thoracotomy-like procedure. I remember him talking about the fundus one time. I'm not absolutely sure if that is the part of the stomach that is brought up and removed -- although anatomically it makes sense that it would be. The only thing I don't understand is 'anastamosis' -- but I have read his op notes before -- something about forming an anastamosis of the conduit (stomach) and the mid-upper esophagus. It sounds like a "connection" that is surrounded by the omentum. I'll look that up. I could ask him why the colon is not used as a conduit in place of the stomach.

Okay, wow. Now I'm rambling the aspects of the procedure that I remember. I'm going to get to reading. I'm so excited!

Thanks again everyone! I'll let you all know how it goes, especially you JP!

 

[dizzle69]

repeat.

 

[Dr JPH]

The only thing I don't understand is 'anastamosis' -- but I have read his op notes before -- something about forming an anastamosis of the conduit (stomach) and the mid-upper esophagus. It sounds like a "connection" that is surrounded by the omentum. I'll look that up.

The anastamosis is exactly that, the connection of the two tissues. Often omentum is placed around the anastamosis as a form of protection.

I could ask him why the colon is not used as a conduit in place of the stomach.

Sometimes it is. Perhaps knowing when and why the colon would be used would be a good question for after the case. If you know the answer and can make a discussion out of it, even better!

Thanks again everyone! I'll let you all know how it goes, especially you JP!

I am sure you are going to do well. Get a good nights sleep...these cases can run very long.

 

[busthwt]

it is important to watch out for the blue, do not touch unless you've scrubbed in. know your glove size and remember you can't adjust your mask or you'll be contaminated so make sure your mask is comfortable before you go in. if your gonna wear a mask with a face shield make sure that it won't be to tight or you'll be prespiring like crazy and you'll have to scrub out to adjust it. umm know a little bit of the anatomy that you'll be going through just so you know what nerve, any cutaneous nerve you might need to avoid. once you get the hang of it, it's not big deal it's usually the attending and the resident will do all the operating and you'll probably be retracting or helping the resident with the sutures at the end. just remember to keep your hands in the surgical field the tech's really get riled up if you forget about that

 

[dizzle69]

The anastamosis is exactly that, the connection of the two tissues. Often omentum is placed around the anastamosis as a form of protection.

Great. Sometimes it's best not to overthink it and think in terms of function. Thanks!

Sometimes it is. Perhaps knowing when and why the colon would be used would be a good question for after the case. If you know the answer and can make a discussion out of it, even better!

I'll take a stab at this, (no I haven't seen anything on this) but if a patient had esophageal cancer (i.e. adenocarcinoma) due to long-term GERD then the surgeon could use the colon as the conduit to prevent the acid from the stomach from causing esophagitis? That's the best I can think of, unless there's another reason behind it.

I am sure you are going to do well. Get a good nights sleep...these cases can run very long.

Definitely. I get off work in a little over an hour and then I have to be there by 6:45am! The procedure is expected to take 4-5 hours!! 😱

Thanks again everyone. I'll also take the last poster's advice and look up the nerves, as well.

 

[alesdu1]

I work for an eye bank and i spend about 4 hrs a week in ORs recovering corneal tissue from organ/tissue donors. (just finished 3rd yr of undergrad...submitted amcas last week). nevertheless, i have one "technical" kind of tip I thought id share:

I really hated the mask/eye shield combos because no matter how i adjusted it, lots of moisture accumulated and id end up hardly being able to see. so after some frustration, i started to wear a normal mask w/ safety glasses. i found that this fogged up too, but then i once saw someone doing this i havent had any problems since:

Tape the top part of the mask to your face. youll need a good 7 in piece of tape or so, but if you go all the way across, cheek bone to cheek bone, and completly seal it so no air can get out from the top of your mask, you wont have even a droplet of condens. on your mask. ive helped on a few organ recoveries that lasted 3-4 hrs and even then it wouldnt fog. use paper or the medical rubbery/plastic kind. depending on the brand, paper tape might not stick to your face after a few hrs, so play around w it.

some people dont seem to have any problems with the combo mask or even glasses. for me it was (haha maybe i breath too heavily!) but taping it down it down really took care of it...

id also recommend investing in a good pair of safety glasses. Keep them in a protective covering of some sort. I hate having to look through any scratches or "corners" (many safety glasses are box shaped????). my glasses are the "seamless" wrap-around kind. paid like $6 off ebay. i think theyre actually shooting glasses...i believe theyre called Smith and Wesson Code 4 (the disposable glasses youll find are kind of flimsy....so another reason to consider just buying a half decent pair) i had another pair (that was a bit scratched up) that i used for ems. if i was on site at a shooting or some really bad trauma, i found that i was much more approachable to the patient(s), family members, bystanders, etc if i was wearing the slightly pricier/fashionable glasses then the typical glasses you might find for said purpose. might be something to consider when you start your EM rotation, also....best of luck

 

[Anka]

Hey, don't forget to let us know how it goes!

 

[dizzle69]

Hey, don't forget to let us know how it goes!

I certainly have not forgotten! I attempted to get on yesterday evening but I suppose SDN was down? I couldn't get into the forum site.

Anyways, wonderful experience. I did not feel nauseated, nor did I have to use the restroom. I was still pretty surprised that I could scrub in. The attending surgeon said technically I couldn't, but due to no med student on this rotation, he'd allow me to serve as the med student. This meant basically holding the retractors, doing as he said exactly, and not getting in his and the resident's way! I did a little bit of epidermal suturing (I didn't suture the stomach or the serratous or latissimus dorsi, etc.), but I was able to suture the skin a little. It was great getting to see up-close the different organs and the way he made his incisions and the procedures done. I had a great time. I also rounded with the surgeon and the team following all 6-8 procedures he had done. The I-E procedure we completed in 3.5 hours. Amazing. He encouraged questions during the case, so I asked some questions. Particularly about the use of colon as a gastric conduit and his use of botox in the place of the pyloroplasty. I'm glad I knew about the serosa layer, as he asked me why esophageal CA cases were relatively difficult cases, and I mentioned the lack of serosa layer allows for rapid spread of lesions, making it a more advanced case in certain patients by the time of detection, and the surrounding lymphatics and nodes allow for greater spread of cancer -- this impressed him. Thanks JP for the tip. Anyway, I maintained sterility so that was good. I followed just about everything you all mentioned -- I appreciated all the tips and advice you all provided!