1
Describe a typical day on a surgical rotation
As with other rotations, a typical day will vary from institution to institution and from service to service. Generally speaking, however, the majority of the time on a surgical rotation will be spent in the operating room (OR), in the clinic, or on ward rounds. The surgery rotation is very different from other rotations. The field is fast paced, and there is a lot of work to be done with relatively little time. Although this means that the student will have much less individual attention than a student on other rotations, this also means that the student has the opportunity to play a crucial role on the surgical team. A typical day on a surgical service is outlined in Table 8-1 . Many medical schools will also have weekly lectures, during which students are typically excused from clinical and OR duties.
| 5:00–5:30 am | Pre-rounds |
| 5:30–7:00 am | Morning rounds |
| 7:00–7:30 am | Breakfast/preparation for operating room |
| 7:30 am –6:00 pm | Operating room |
| 6:00 pm–? | Afternoon rounds/floor work |
2
How can one prepare for a day in the OR?
In general, there are several tasks that should be completed before one enters the OR. First and foremost, the patient’s medical record should be reviewed, including the patient’s history and presenting symptoms, the clinical diagnosis, and the procedure that is scheduled to be performed. It is important to identify the presence of any pertinent physical examination findings noted in the medical record. After this review is completed, background reading should be focused on the patient’s condition. The intern or resident can be a valuable resource for suggestions of appropriate reading material. Finally, the anatomical region that will be encountered during the operation should be reviewed in an anatomy atlas. Pay special attention to the nerve innervations, blood supply, and surrounding organs that may be encountered during the surgery.
3
Describe the role of a medical student in the preoperative (preop) area
The preop area can be very busy with many nurses, anesthesiologists, and surgeons evaluating patients and preparing them for surgery. Ideally, enough time should be allotted for the medical student to introduce himself or herself to the patient and perform a focused history and physical examination. For example, if the patient is scheduled to undergo a carotid endarterectomy, it is important to ask about any focal neurologic deficits and, if present, about the progression of these symptoms. On examination, it is important to listen for carotid bruits. As another example, if the patient has thyroid nodules, symptoms related to hyperthyroidism or hypothyroidism should be elicited, and the physical examination should include palpation of the thyroid. The key is to keep the evaluation focused because one will probably have only several minutes to spend with the patient.
After the evaluation is complete, double check any allergies (especially to latex or Betadine, which can be overlooked). If the patient is undergoing surgery that does not require hospital admission, it may be possible to prepare any necessary prescriptions and discharge instructions. Once these tasks are completed, the operative note can be started before the actual surgery.
4
How is an operative (op) note written?
Many prefer to skeletonize the op note before the surgical procedure begins. This involves making the outline and filling in any information that is already known. All other information can be added quickly to the note once the procedure is completed. Generally, the preop diagnosis, surgeon, and assistants are known before the start of surgery. Be warned that some surgeons do not like to complete the procedure portion of the note until after the operation, because plans may change at any time during the course of surgery. A completed sample op note is displayed in Table 8-2 .
| Preoperative diagnosis | Appendicitis |
| Postoperative diagnosis | Appendicitis |
| Procedure | Laparoscopic appendectomy |
| Surgeon | Patel (attending) |
| Assistants | Schneider (HO-III), Kang (medical student) |
| Operative findings | Grossly inflamed, nonruptured 2-cm appendix, no abscess present |
| Anesthesia | General endotracheal anesthesia |
| IV fluids | 2000 mL lactated Ringer |
| EBL | 200 mL |
| Urine output | 1000 mL |
| Drains/tubes | None |
| Specimens | Appendix |
| Complications | None |
| Disposition | Patient is stable and in recovery room |
5
What should be included in the operative findings section of the op note?
As a general rule of thumb, write what was observed, and this description will usually correspond with the correct findings. For example, if the patient is having a hemicolectomy for colon cancer, the medical student should think back to the surgery and describe the mass in his or her own words. The size and location of the mass should be noted. The appearance of the mass should be described. For example, if the mass is bleeding and ulcerated, this fact should be included in the op note. Next, note whether any potential metastases were found during surgery. It is important to document what was seen during the surgery. Completion of this section of the op note is difficult but becomes easier with practice. If there is any question regarding the operative findings, they should be discussed with the resident or attending.
6
Where are the values for intravenous (IV) fluids, urine output, and estimated blood loss found?
It is the responsibility of the anesthesiologist or nurse anesthetist to keep track of these values during the surgical procedure. Once the procedure is complete the anesthesiologist or nurse anesthetist can be asked to review the values for incorporation into the op note.
7
How should complications be recorded in the op note?
Asking a resident or attending for input before completing this section of the op note is always recommended, especially if an intraoperative complication occurred. This input is important because the op note may be used in future legal cases, and it is imperative that this section be recorded with extensive detail.
8
What is proper OR attire?
Medical students should always enter the OR in clean scrubs. Scrubs administered at another hospital or brought from home are generally not allowed. In addition, T-shirts should not be worn underneath scrub tops. Students should always wear a cap, eye goggles, mask, and shoe covers before entering the OR. Caps must completely cover all hair. Be sure to wear proper identification such as a name badge or ID card at all times.
9
What is the first thing a medical student should do upon entering an OR?
It is important to be aware of any sterile areas within the room, which are usually designated by green or blue towels. Typically these include the tables where the surgical kits have been laid out in preparation for the procedure. Also be aware of any staff members who are wearing sterile gloves and gowns. Anything these people touch must be sterile. It is important to be aware of these areas to avoid contamination. After locating the sterile zones, inform the nurse or technician that a medical student will be participating in the procedure. The nurse or technician will record the student’s name for record purposes. If the surgical procedure has already begun, the medical students should introduce themselves to the attending and ask for permission to watch and help out. Once the medical student has been designated to scrub in on the procedure, they should either pull their gloves for the procedure or ask the scrub nurse to pull their gloves.
10
Once the patient arrives in the OR, how can the medical student help?
There are many things that need to happen before the operation begins, but the particular tasks may vary by operation. Students should be involved in at least some of the following tasks: transferring the patient from the gurney to the operating table, positioning the patient on the operating table, placing a Foley catheter, placing sequential compression devices, shaving the surgical area, and sterile preparation of the surgical area. Any electronic or hard copy radiologic images should be prepared for observation before the operation. These are just a few examples of tasks that medical students can perform before the procedure begins. The resident, nursing staff, or technicians can be asked regarding necessary tasks that the student can help to accomplish. Medical students should not leave to begin scrubbing until they are sure that the required preop tasks have been completed and either the resident or attending surgeon has begun scrubbing.
11
Who are the members of the surgical team?
In the OR, the surgical team will comprise physicians (surgeons and anesthesiologists), nurses, technicians, and medical students. The attending surgeon, resident surgeon, medical student, and scrub nurse will be in the sterile field. Some services will also have a resident fellow within the sterile field. The circulating nurse and anesthesia team will work outside of the sterile field.
12
What are the different types of nurses encountered in the OR?
There are two types of nurses involved in every operation. Scrub nurses organize and distribute surgical instruments during surgery. These nurses need to be sterile, and medical students should pay special attention not to contaminate them. Circulator nurses are not scrubbed in, so that they may perform tasks that involve touching nonsterile items or retrieving equipment from outside of the room.
13
What are the main points to remember when performing the surgical hand scrub?
Surgical hand scrub policies will vary from hospital to hospital. Some institutions require that the surgical team scrub for a specified time period, whereas others require a minimum number of strokes on each surface of the hands and arms. A summary table of a timed scrub with Betadine is displayed in Table 8-3 . Before one begins to scrub, items such as pagers, caps, goggles, and masks should be appropriately adjusted.
| 1. Before beginning the surgical hand scrub, wash both hands and arms with soap and water. Arms should be washed 5 cm above the elbow. |
| 2. Open a package of scrub wash and use the nail cleaner to clean underneath the fingernails. |
| 3. Wet the scrub sponge and begin scrubbing fingertips, eventually working down the hands and arms and ending 5 cm above the elbow. Keep the hands elevated above the elbow at all times to allow water to drip from the hands toward the elbow. At the start of the day, this should last 10 minutes. However, if this is not the first scrub of the day, scrub for 5 minutes. |
| 4. Rinse the iodine off of the fingertips and hands first, again allowing water to drip from the hands down the arms and off of the elbows. It is important to avoid letting water drip from the elbows toward the hands. |
Many institutions are now allowing staff and students to scrub in using an antiseptic lotion. The technique required for using the antiseptic varies by hospital. Students should pay special attention to the proper techniques for using this method.
14
What are the main points to remember when putting on gowns and gloves?
After one completes the surgical hand scrub, it is important to avoid coming into contact with nonsterile objects and contaminating oneself. It is important to remember that at the beginning of the procedure, the nurses are very busy, so medical students should be patient while waiting to put on gowns and gloves. A summary of how to put on a gown and gloves is shown in Table 8-4 .
| 1. Back into the operating room, hold hands above the elbows allowing water to drip off of the elbows. |
| 2. Kindly request a towel from the scrub nurse. Using one side of the towel, dry one hand and work down the arm toward the elbow. Always dry in the direction from the hands toward the elbow. |
| 3. Using the unused side of the towel, dry the opposite hand and arm in the same fashion. |
| 4. The scrub nurse will then hold a gown open. Place both arms through the sleeves of the gown. Even though your hands are scrubbed, do not touch the outside of the gown with bare hands. The circulator nurse will button the back of the gown. |
| 5. The scrub nurse will also hold a glove open. Place the hand into the glove so that the glove covers the wrist and goes over the sleeve of the gown. Once one hand is gloved, one may use that hand to help the scrub nurse hold open the glove for the opposite hand. When wearing gloves, one may now touch the gown within the sterile zone and adjust the gloves without risk of contamination. It is always recommended that two pairs of gloves be worn on each hand. Although this practice is counterintuitive, the larger glove size should be worn on the inside. For example, first put on size 7.5 gloves, then cover with size 7 gloves. |
| 6. Each gown will have two strings to tie around the waist. These two strings are usually connected by a piece of paper near the naval. Disconnect the two strings and hand the longer string with the piece of paper to the scrub nurse. Spin in a direction so that the two strings collectively form a waistband that holds the gown snugly against your torso. Pull the string away from the scrub nurse, leaving the piece of paper in the scrub nurse’s hand. Tie the two strings together. |
15
Once one is “scrubbed in,” what is defined as the sterile zone?
The sterile zone includes hands, arms, and anterior torso from the nipple line to the waist. It is important to remember that one’s facial mask, goggles, and entire back, including the gown, are not sterile and therefore should not be touched by either hand. Any portion of the patient that is draped is considered sterile to the level of the tabletop. Anything below the level of the tabletop is not sterile.
16
Describe a surgical time-out
The surgical time-out is a safety precaution to ensure that the correct operation is performed on the appropriate patient. The time-out consists of asking the patient to state his or her full name, the procedure he or she is scheduled to undergo, and if necessary, the side of the patient that will be operated upon. This occurs several times, including in the preop area and before anesthesia is administered to the patient in the OR. The surgeon conducts another time-out before an incision by verifying the same information with the other staff in the room.
17
What kinds of questions are medical students asked in the OR?
Unfortunately, there is no concise and all-encompassing answer to this question. In general, students should prepare for each procedure by becoming familiar with the relevant anatomy for the procedure. For example, if the patient has pancreatic cancer, relevant anatomy includes all structures that will be encountered during the surgery, as well as the approach to the pancreas. So although one should know the blood supply to the pancreas and the structures immediately surrounding the pancreas, the attending may very well ask about the different muscles that make up the abdominal wall. If the surgical approach is not obvious, the resident assigned to the case can be a valuable resource for information. The student should also read about pancreatic cancer and understand the epidemiology, risk factors, signs/symptoms, laboratory findings, pathophysiology, and treatments for this condition. Finally, the student should read about the procedure that is scheduled. The attending may ask, “What are we doing today?” It is probably not necessary to be able to recite the steps of a complicated procedure from memory, but understanding the basic plan of the operation is important.
18
Describe the medical student’s role during surgery
Medical students have been long referred to during surgery as “human retractors.” Unfortunately, this description is somewhat true. Much of a student’s time in the OR will be spent retracting, but this is an important task. The attending and residents cannot operate without proper exposure, so while retracting may be boring to some, it is important nonetheless. One should pay close attention if a resident or attending asks for the retractor because it is highly likely that he or she wants the student to hold it but will not necessarily say so out loud. Students may also be asked to cut suture and provide suction, and sometimes they are even allowed to drive the camera during a laparoscopic procedure.
19
Describe proper use of suture scissors
To properly hold suture scissors, place the ring finger and thumb through the loops of the suture scissors and use the index finger to stabilize the scissors. Always cut with the tips of the scissors. Medical students should never grab the suture scissors on their own. Instead, politely ask the circulator nurse for the scissors and when done place them down for the circulator nurse to pick up. Do not place the scissors back on the circulator nurse’s tray.
20
Describe a method to provide suction
Providing suction is a very important task that will allow the resident and attending to clearly see the surgical field. The challenge is finding a balance between hindering the field of view with the suction and allowing too much blood and fluid to collect before suctioning. A commonly quoted general rule of thumb is to “get in and get out” with the suction device, meaning that the area should be suctioned until clear and the device should be quickly removed until fluid begins to collect again.
21
Why should smoke from the Bovie be suctioned?
It is often helpful to follow with suction at a safe distance behind the Bovie. This helps to improve the surgical view by clearing the smoke from the field. It also helps to decrease the smell created by the Bovie’s cautery. Be sure to maintain a safe distance from the Bovie.
22
What is the Bovie?
The Bovie is an electrocautery device used during surgery. It can be used to produce vessel coagulation as it cuts, significantly decreasing the amount of bleeding during surgery. When used in the CUT mode, it provides a continuous electrical current to help cut through fascia, but with a decreased ability to coagulate vessels. In the COAG mode, it uses an intermittent electrical current that provides more vessel coagulation but decreased ability to cut.
23
What are the different types of suture materials used during surgery?
Many different types of suture materials are used for various types of wound closure. Broadly speaking, suture materials are considered to be either absorbable or nonabsorbable. Absorbable sutures are temporary and are designed to be absorbed by the body after the wound has healed. Absorbable sutures are commonly used in skin closures. Nonabsorbable sutures are used when a permanent suture is required, such as in a hernia repair.
24
Describe the classification of the different sizes of suture material
The size of the suture is related to the number before the zero in the name of the suture. The larger the number, the smaller the suture is. For example, 3-0 suture is larger than 5-0.
Large sutures are generally used to close strong tissues and are generally either size 1-0 or 0-0. Smaller sutures are generally used for routine suturing techniques within the chest and abdominal cavity. They range from largest to smallest sizes as 2-0, 3-0, and 4-0. The smallest sutures are usually used for fine surgical procedures (such as sewing together two vessels) and range from largest to smallest as 5-0, 6-0, and 7-0.
25
What are the basic ties that a medical student should learn?
Medical students should become familiar with the two-handed tie and instrument tie. A square knot tie involves one loop in the final step of the tie compared with a surgeon’s knot, which has two loops.
26
Display an example of the two-handed tie
An example of a two-handed square knot tie is displayed in Figure 8-1 .
