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Cutting Sutures and other OR issues

Discussion in 'Clinical Rotations' started by tkatchev, May 9, 2007.

  1. tkatchev

    tkatchev 2+ Year Member

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    The problem is basically this: I'm doing some assisting in the OR and am having some trouble with some of the details of working there. The problems are as follows:

    A) I'm scrubbing 3-4 times a day and my arms are getting red and raw, is there anything I can do?

    B) I'm a rather short guy, 5'3'' and when I put on my sterile gown I can't ever get my hands out far enough and so when the scrub tech helps me put my gloves on the white sleeve of the sterile gown get's in the way and it takes me forever and a day to get my gloves fixed. Should I ask her to pull down the sleeves before she helps me with the gloves? I don't want to be a pain in her ass.

    C) I've inadvertently scrubbed out on at least 2 occasions. Once I touched my gown to adjust it before I had gloves. A second time I forgot my mask after I had scrubbed, gowned, and gloved so I had to scrub out to put my mask on. These were both kind of embarassing. Does it just take time to get in a habit of doing this correctly?

    D) I do a lot of cutting sutures and I can't ever seem to get the length of the tails right. One surgeon wants them one way, another surgeon wants them another way. One time I cut to short, another time to long. Sometimes I can't visualize where the knot is very well, so I can't judge where to cut. This happens often when the surgery is oral.

    E) Non of the other surgeons wear masks that have eye shields but when I'm assisting, blood and other materials often hit me in the face/eyes (probably again because I'm short and very close to the surgical field). This happens a lot when power tools are used on bone (things spray everywhere). Should I stand out and put on a mask with an eye shield or just keep doing what I'm doing. Can you get a serious infection by way of your eyes from a patient? I should probably know this.

    F) With the surgical masks I can't ever get them to sit right on my face. Sometimes it pushes up against the bottom of my eyes, or scratches below my neck. Is there some trick to putting these on so they don't irritate or obstruct your vision?

    I've literally only been doing this for about a week, but I want to do the best job I can. I know a lot of this will come with experience but any suggestions anyone could offer would be much appreciated.
     
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  3. Bubb Rubb

    Bubb Rubb Woo woo! 2+ Year Member

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    A) don't use betadine (or your "wet" scrub cleaner of choice) after the first scrub, if that's acceptable in your institution. use whatever "dry" alternative is sanctioned

    B) by all means ask to have your sleeves pulled up. don't go grabbing blindly if you're still unsure of what's sterile and what's not. eventually you should develop the technique of scooting the sleeves up by grabbing through the gown

    C) yes, time will help. just be conscious of what you do, and don't scratch your nose without thinking :D

    D) such is life. the suture is always too short or too long. it really does help to hold the blades nearly closed, tilted at an angle with the bottom one resting on the knot. also, ask how long the suture ends should be if it's unclear. if you're using a super slippery single filament synthetic for a deep closure and the surgeon is putting 8 throws in, then it's probably a safe guess it should be longer rather than shorter...

    E, or C #2 i suppose) yes, wear a mask!

    F/D#2) you are scrunching the nose piece to fit your face before putting it on, no? some level of discomfort is inevitable, but mask fitment shouldn't be overly difficult to get down.
     
  4. Bertelman

    Bertelman Maverick! 7+ Year Member

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    a) don't be so vigorous. You're not trying to abrade skin, just rub the sutff in

    b) you can use your left hand, through the impermeable (blue) part of the gown to advance your right hand. Once your right hand is gloved, use it to advance your left hand to present to the circulator.

    peek into an OR and get a couple gowns that were unwrapped but never used- you should be able to find these in just about any OR. Practice at home. Ask a nurse to show you.

    c) yes- it takes constant vigilance in the beginning, but soon becomes second nature. Rare is the med student who doesn;t make these mistakes. Every nurse in that room made those mistakes when training, so don't let their glances and snide remarks affect you.

    d) advance the scissors to the knot, then angle 45 degrees. this will consistently get a good tail. Different sutures and different locations, however, often demand different tails. Ask the surgeon before you make the first cut, but after that specfic cut, remember what he wants in that situation

    c) hell yes, wear the shield, or at least very good goggles. The assistant NOT operating the instrument is much more likely to get the spray. What are you more concerned about- their perception of your attire, or blood in your eye?

    d) depends on your face. I find it best to start by pinching the nose piece about mid-nose, then tie the top tie around my occiput, near the lambdoid where it meets the parietal. Next, I tie the bottom tie around my neck, not too tight. Basically, the top tie is suspending the mask while the bottom keeps it loosely against my head. The key is finding the sweet spot on your nose, and pinching the mask to fit. Amateurs don't know you are supposed to pinch.
     
  5. dilated

    dilated Fought Law; Law Won 10+ Year Member

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    You should be wearing a face shield in anything where there's the possibility of getting sprayed. They're mandatory for us a lot of the time and you'll get the WTF-scrub-back-out if you don't have goggles or a mask with shield.
     
  6. Tired

    Tired Fading away 7+ Year Member

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    Hmm, that hasn't really been my experience. For the cases that "lower-risk" for splashing, I normally just wear my glasses. In the messier cases, I usually take one of those surgical masks with the built in face shield, and flip it upside down and tie it around my forehead (better ventilation).

    To date, I have never been told to scrub out because I wore my glasses instead of a face shield (although if I'm unsure what the case will be like, I always take the time to ask which they think I should use).
     
  7. njbmd

    njbmd Guest Moderator Emeritus 5+ Year Member

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    Moving to the Clinical Forums where medical students who are on Surgical rotations can post their tips and suggestions. Pre-clincial students can follow and post there.
     
  8. tkatchev

    tkatchev 2+ Year Member

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    Thanks for all the advice so far, especially the first post about how to get my hands far enough through the gown... I never thought about doing it that way.

    Sorry about the lettering mix up. I fixed it.

    If anyone has any more advice I'm all eyes.
     
  9. tkatchev

    tkatchev 2+ Year Member

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    bump...
     
  10. Dunce

    Dunce Senior Member 10+ Year Member

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    I'll just echo a few points that have already been touched on:


    Staying sterile is awkard at first but quickly becomes second nature with practice and careful attention to detail.

    I hate the raw skin feel too. I usually started the day with a normal scrub with the brush. I like to use the red/pink chlrohexidine solution if it's available. Then after that I would just use the scrubless technique. My hospital has a "water-aided" scrubless solution. It's basically this white soap that you lather up for 90 seconds or so and rinse off. There is also the waterless option that you might see, but for some reason I never quite felt clean without the water. The point is that there is really no need to use the harsh brush five times a day.

    I'm a big fan of the sleeve technique Bertleman mentioned. Slip both arms in but not out of the white part of the sleeve. Use your left hand (while inside the sleeve) to pull your right sleeve down so that you fingers are just starting to peek out. Then let the scrub tech glove your right hand. Next, use the gloved right hand to pull your left sleeve down so that your fingers are sticking out and then glove that left hand.

    Cutting sutures:
    Cut with the tips. Just ask if you're not sure how long to make the cut. I've found that a quick "short or long?" usually does the trick. In my opinion:
    Short = tips down to the knot, 45 degrees, and snip
    Long = 1 cm tag

    Glasses are traditionally accepted at my institution, but you should always have something covering your eyes. I hate the face shield masks because they have a tendency to fog up on me. You could always invest in a cheap pair of safety glasses. However, I was not ballsy enough to be the only third year student sporting my own pair of those. Maybe next year.

    Grab a few masks and try them on to see which ones you like best. My hospital has at least 3 or 4 different ones available.

    Good luck
     
  11. Tired

    Tired Fading away 7+ Year Member

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    Reminded me of a story.

    On Surgery, I was in a case with an attending who told me to cut short. I did (just as described above).

    So he yells at me, "What are you doing?!"

    "Cutting your sutures, sir."

    "Why are you tipping the scissors?! And why are you cutting with the tips?"

    "So I don't cut the knot sir, and because I was taught to cut with the tips."

    "That's ridiculous! Who the hell taught you that crap? You cut with the base, because that's where the majority of your cutting force comes from. And don't tip the scissors! You're not going to cut the knot, and I don't want any damn tails on my deep sutures."

    "Yes sir."

    Next suture, I cut exactly as he told me.

    And of course I cut the knot. :D
     
  12. tkatchev

    tkatchev 2+ Year Member

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    Haha, yeah. One thing I picked up quickly is that deep sutures need to be cut short. But I was lucky enough to have surgeons who told me to run the tip up against the knot and then cut. S - l - o - w - l - y catching on.
     
  13. AmoryBlaine

    AmoryBlaine the last tycoon 7+ Year Member

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    Are you in Ortho cases where they don't wear masks?!?! Man whenever bone was to be sawed we got to wear those awesome space helmets with the built in fans!
     
  14. Tired

    Tired Fading away 7+ Year Member

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    I've only ever seen those in joint replacements. Simple osteotomies our guys usually just use face shields.

    I'm dying to get in the space suit. I did a month on hand, a month on peds, and a rotating month with a lot of trauma, but have yet to do a total joint. The first time I get the suit on, I'm going to do the "slow motion walking on the moon" thing in the OR, just to get all the 'you're a dumba$$' looks from the OR staff. :D
     
  15. tkatchev

    tkatchev 2+ Year Member

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    It's pediatric plastics and craniofacial.
     
  16. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    I'm not much taller than the OP and rarely have trouble getting the cuffs caught in the gloves. While the "tricks" above work, frankly all you really need to do is to really jam your arms into the sleeves and then flex and unflex your hands, several times, and the cuffs should work their way up to your wrists. Once you get the gloves on, use your hands to pull the sleeves up a little more if you need.

    Are they giving you an Extra Large gown by accident? The sleeves are longer in those; unfortuantely, the smallest gown I've ever seen in an OR is a Large which can be pretty comical on some of the smaller students.
     
  17. dilated

    dilated Fought Law; Law Won 10+ Year Member

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    Sorry, yeah, I meant "any kind of glasses" by "goggles". I don't wear glasses so if I don't grab the mask with shield I don't have anything over my upper face/eyes, which apparently is (at least in some opinions) not cool. I think it probably depends on what you're doing, the shields are kind of annoying so I wouldn't wear them if I didn't have to.
     
  18. tkatchev

    tkatchev 2+ Year Member

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    It seems like the "trick" is simpler than "jamming and flexing and unflexing." Less energy expenditure with the trick it seems.
     
  19. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    Perhaps, but I've been doing it since 3rd year of medical school, nearly 10 years now...so maybe its easier for me. It doesn't really require a lot of energy expenditure, really. Believe me, if I can avoid any exercise, I will!

    I do think there is less chance that the OP will contaminate himself doing it my way, but <shrug> whatever works (although I'm still confused as to why the sleeves seem so long on him and not me...I must have ape like arms).
     
  20. Bertelman

    Bertelman Maverick! 7+ Year Member

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    I forgot that I do that, too, when I don the gown. It is pretty simple, OP. Once you've been tied, flex at both elbows and push your shoulders forward. Instant sleeve retraction. You still may need a little help, but this gives you a head start.
     
  21. AmoryBlaine

    AmoryBlaine the last tycoon 7+ Year Member

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    Dude, they are amazing! No mask, no worries.

    The only thing is that I had the battery packs die a few times, once when I was holding up a big fat leg (THA). It is not fun, you feel like you're in a freaking plastic bag. Actually you kind of are...
     
  22. Noeljan

    Noeljan Senior Member 7+ Year Member

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    Kind of off topic but OP were you a gymnast by any chance? Your screen name is a skill on the uneven bars in gymnastics named after a Russian gymnast.
    ok back to topic:)
     
  23. tkatchev

    tkatchev 2+ Year Member

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    I am a gymnast. But men's gymnastics; it's also a skill on horizontal bar.
     
  24. SLUser11

    SLUser11 CRS 10+ Year Member

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    Maybe I have been contaminating myself repeatedly over the last 3 years....please explain the break in sterile technique to me if this is true....BUT:

    As long as your hand is in the gown, you can adjust your other sleeve with your good old useful hand/pincer grasp. No elaborate flexing of fingers and elbows should be required. The only things touching are the 2 arms of the gown, which are touching before you open the gown as well.....

    I just tried to draw a picture of it and post it here, but apparently the internet is smarter than I am.....
     
  25. Noeljan

    Noeljan Senior Member 7+ Year Member

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    Oh of course, it was invented on the high bar, but us women had to steal it and bring it over to the uneven bars:) :)
     
  26. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    It is not a break in sterile field IF you do it correctly. My post says there's probably more of a risk because if the OP's fingers accidentally slip out of the cuff, you've contaminated yourself.

    Perhaps its the way I described it, but I hardly think flexing your arms is lots of "energy expenditure" or "elaborate". I am just unsure as to why the OP has a problem since its relatively easy to work your hands out of the cuffs without even touching them. Not that your technique is wrong or breaks sterile field - it frankly is more "elaborate" and "energy expending" than just wriggling yourself to the end of the gown, IMHO.

    Either way works, I just find my way easier and the "trick" unnecesaary.It also seems to be the same way most people I work with do it as well. In general, if there's a problem (ie, you've been given an Extra Large gown by mistake), the scrub should assist you in pulling up the sleeves...at least they always have for me if I need the help. :confused:

    Any way, I don't think you need to draw a picture, because I'm pretty sure everyone knows what you're talking about in using the pincer grasp to pull up the opposite sleeve with the fingers safely esconced in the cuff of the opposite side. I guess I'm just still confused as to why the OP has gowns with such long sleeves that his fingers are routinely getting caught in the cuffs and tangled in the gloves.
     
  27. tkatchev

    tkatchev 2+ Year Member

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    It's a mystery. It’s probably just inexperience. I'll figure it out eventually, but in the mean time it's nice to have the technique we're referring to as the "trick" to help me out if I get stuck.


    I'm really enjoying this thread. Thanks for everybody’s input and advice.
     
  28. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    You're probably right - its likely inexperience and I'm sure you'll figure a way that works best for you (just as we all did before you).

    best of luck...
     
  29. SLUser11

    SLUser11 CRS 10+ Year Member

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    I wasn't taking a shot at you...just the responses from people that made your move sound like an up-up-down-down-b-a-select-start type of complexity.

    Now, here's where we legitimately differ....I need at least an extra large gown. Anything smaller and I immediately rip/un-snap/un-velcro the back when I bring my arms forward.....I'm too much of a meathead....maybe I should have gone into ortho.....

    I don't think it's common knowledge, honestly. A lot of people are afraid to do anything when they start out, deathly afraid of someone saying "you've just contaminated yourself....please leave....and you fail this rotation."
     
  30. Tired

    Tired Fading away 7+ Year Member

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    Or worse: "Scrub out, and go stand in the corner where you can't see anything, because I'm not done humiliating you yet."
     
  31. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    I didn't think you were - was sort of suprised that you would describe it as "elaborate" as well. Once again, sarcasm doesn't transfer well over the net.



    Yeah, how do you keep from contaminating yourself with those ape-like arms and knuckles dragging on the ground?! ;) I was actually referring to the OP who stated that he's 5'3" so I thought perhaps he was occasionally given the XL gown and having more trouble than usual getting his hands out of the sleeves.



    Its probably not common knowledge, I just figured everyone could draw themselves a mental picture. But you're right - I remember when I was scared of all the scrubs and my potential for contaminating myself and the field!
     
  32. MadameLULU

    MadameLULU Saucy Moderator Emeritus 10+ Year Member

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    I hate when the lead gown straps fall off my shoulders. The other day I did a little dance to try to get them to try to get them back on my shoulders. The nurse in the room saw me squirming around and put the back on. Grrr. I wish my hospital had smaller lead gowns.
     
  33. Tired

    Tired Fading away 7+ Year Member

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    And even when they're the right size, the velcro is so trashed it ends up sliding off anyway. :thumbdown:

    Anyone know what lead costs? A little early to buy my own, but maybe in two or three years.
     
  34. SLUser11

    SLUser11 CRS 10+ Year Member

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    Actually I do. The decent lead aprons cost around $200-300, and the thyroid shields range $40-60. Of course, there's cheaper and more expensive ones available.

    The only reason I possess this knowledge is that the trauma nurse yelled at one of my co-interns for leaving a lead apron on the ground, stating that they cost $2,000 apiece. I felt obligated to prove her wrong in my co-interns honor.
     
  35. Hard24Get

    Hard24Get The black sleepymed 7+ Year Member

    Isn't that the code for 10 lives on SuperC?
     
  36. Zuwie

    Zuwie Member 5+ Year Member

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    When cutting sutures, you have two choices: too long or too short. :laugh:
     
  37. AmoryBlaine

    AmoryBlaine the last tycoon 7+ Year Member

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    You doing ortho? Does any other field need their own lead?
     
  38. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    Interventional Rads, Vascular if they do lots of Endovasc procedures.
     
  39. tkatchev

    tkatchev 2+ Year Member

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    I have some success to report. Last time I was in the OR I managed to get my gown on just fine; very exciting stuff. The nurse told me that I could use waterless scrub after my first regular scrub of the day so that really helped. And I'm starting to get the hang of cutting sutures, although I'm still getting conflicting direction from the different surgeons.

    I have one additional question. What is the general policy of being in the OR if you have, or suspect you may be developing, a cold? I have allergies too and sometimes it's difficult for me to tell the difference between the allergies and a cold until I actually develop a fever or a cough. I don't want to put any patients at risk, but it also doesn't seem right to call in sick every time I get a sniffle or scratchy throat.
     
  40. Bertelman

    Bertelman Maverick! 7+ Year Member

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    As long as you wear a mask, and don't drip into the field, you'll be like every other nurse and resident who shows up to work sick. I actually wouldn't worry too much about transmitting a respiratory Dz during surgery, as the ET tube tends to shut out the airborne particles.
     
  41. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    Congrats! We knew you'd get the hang of it.

    Well, that won't change, just get used to the mercurial nature of surgeons.

    No policy that I am aware of. If you are really sick (ie, vomiting or with diarrhea) you might consider not scrubbing but only if you feel really bad; otherwise, a cold is not something I'd really worry about unless you have a fever and purulent sputum (and even then, its going in your mask..just keep your hands washed).
     
  42. Tired

    Tired Fading away 7+ Year Member

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    Yeah. And plus when I did my sub-i at my new program, all the lead was the really old and heavy vests that make me sweat and give me a sore back after a couple hours. And of course the velcro was all jacked up, so it continually slips down, creating a real pain when I'm already freaked out and trying to do a good job. I hate that.

    Definitely something I'm going to look into after I finish internship.
     
  43. dpmd

    dpmd Relaxing Physician 10+ Year Member

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    Tape. Lots of it. Around your waist so it stays put (and takes some of the weight off your shoulders), and around the back of the arm holes so the stupid thing stays on. No more worrying about velcro. I learned this from one of my residents, then added the arm hole trick because I have narrow shoulders.

    Tired, I don't know how eager you want to be to get in those space suits. I have done a lot of scrubbing in those and the helmet can get very uncomfortable after a while (due to the weight and depending on how tight you adjust it). It is much better than being sprayed with assorted particles though (and once I got a faceplate full of blood after the inadvertant nicking of the popliteal trifurcation-fun stuff).
     
  44. NKMU

    NKMU Senior Member 10+ Year Member

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    I hate scrubbing in. It's hot, itchy, and my eye protection fogged up no matter what I tried.

    Concerning the suture cutting, just ask how long and prepare to be wrong no matter what. One of my favorite preceptors, an ENT, told me when he said to cut the suture I should ask him, "Should I cut it too short or too long?"

    OB and GS yelled at me if I didn't tilt the scissors. Ortho freaked when I DID tilt the scissors, saying that was GS crap and I'd better not do it again. :rolleyes:

    My surgery rotation advice is this: stand there (with your hands on the field, damn it!) and do NOTHING unless told.
     
  45. Anka

    Anka Senior Member 7+ Year Member

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    I know this is standard advice, and I followed it until I had a saw dropped on my hands... I recommend keeping your hands off the field unless you're using them, even though the RN and MDs will try to get you to do otherwise. Just not worth it.

    Anka
     
  46. Dr JPH

    Dr JPH Banned Banned 10+ Year Member

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    Youre never going to do everything right. :)

    I have been told:

    "pick up the suction"

    "put down the suction"

    "get your hands in the field, youre hear to learn!"

    "hands away from the field"

    I have found the best policy is to ask the resident before the case what the attending likes...hopefully they know and can guide you a little bit.

    I have also found that helping to prep & drape gets you brownie points most of the time, eventhough you will likely do it wrong.

    If you are working with a good scrub they will help you out sometimes as well.

    Hmm. After posting all this I just realized that there is NO right way.

    Agree with above. Just stand there! :laugh:
     
  47. twood

    twood PGY-5 5+ Year Member

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    I'll share a couple of tips I learned on my Vascular/Transplant rotation last month:
    1. cut absorbable sutures short and non-absorbables long. As previously discussed, some attendings like suture scissors, others like using the Metz tips, still others will kick you out for using the tips.
    2. Don't throw the green hand-drying sterile towel anywhere. It's better for the circulating nurse to be mad at you for dropping it on the ground than for the whole case to be delayed because you tried to throw the towel into the dirty bin but missed (and came dangerously close to contaminating the ice meant for the donor kidney). I did this one on the first Transplant I scrubbed for. Just drop the towel, or drape it on the trash can without re-contaminating your hands.
    3. practice tying, sewing, releasing hemostats, and using scissors with both hands if you want to be any good at it when the "pressure is on" -- two-hand ties on your Ethicon suture box at home in front of 24 are very different from when the resident throws a stitch and then hands you the ends of the suture.
    4. Most important: DON'T PASS POINT if they let you Bovie. I was initially confused and thought this meant "don't go past the tips of the hemostat in the coronal plane" but it actually means "don't go past the tips in the anterior-posterior plane." Violating this crucial rule is a good way to lose all future Bovie privileges.
    5. If you're not scrubbed, try to answer pages for the attending/resident if they like to stay "in the loop" while in the OR. However, be prepared to get in the middle of a resident/nurse fight (or an attending/attending fight which is much more high-stakes).

    -thomas
     
  48. ESPNdeportes

    ESPNdeportes Member 7+ Year Member

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    I'm just relishing in the fact that I'll likely never have to do a full scrub in again in my life. Ah......
     
  49. BlackSails

    BlackSails 2+ Year Member

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    Matched into anaethesiology? Psych?
     
  50. scuba5794

    scuba5794 Banned Banned

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    I have always purchased my x-ray protection products at universal medical i actually found them on this forum when i did a google search for lead glasses. They should have any type of lead apron and thyroid shield i think their lowest is around 28 bucks and highest is around 48 or so hope this helps!
     
  51. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Administrator Physician Faculty Lifetime Donor Classifieds Approved 15+ Year Member

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    Apr 9, 2000
    hSDN Member
    Hmmm....I checked the sites and the prices are around $250-$300 for the lead aprons. Thyroid shields (extra) are much cheaper, but I couldn't find any aprons for $48. Or did I just misunderstand your comment above?:confused:
     

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