Speaking of pet peeves....

For all of you up and comers to the sterile field, I present you with some not-so-sterile techniques that I pray you never choose to follow. Now I know that there are those who shun the "old" ways. If you look long enough you will find a study to support any theory you choose, often contradictory to what you may have believed for years. I know one anaesthesiologist who jokingly asks why I bother to scrub my hands. "You're just going to put on two pair of gloves anyway." I hear that there is a study that proved that it makes no difference if you take a ring off before you scrub. Yet I have only ever seen one surgeon wear his ring under his gloves.

There is a tech who, in her efforts to see into the belly, will actually lean her face on my arm. She happens to be short and I happen to be tall. Now, I know that your sleeves are only considered sterile to a couple of inches above the elbow, and her non-sterile face is plastered just below my shoulder, but in my opinion, my sleeve is now contaminated. Period. "May I have a sterile sleeve, please!?" She doesn't seem to think that it matters. While many of these things may be benign when it comes to creating an infection, why take the risk? Don't get complacent. Don't be lazy. It is your job and duty as the scrub to be vigilant over the sterile field. If you see or cause a break, tell the surgeon. Ninety-nine percent of the time the surgeon will thank you for letting them know.

Sometimes you may have to physically keep or take something away from the surgeon so that it won't get used again. Then, they'll just have to wait. I work with one orthopod who throws the bovie down on the field instead of trying to put it in the bovie bucket when we are doing total joints. I cannot count the number of times that I see the bovie tip burn or rip through the drapes. I know that he has this habit so I often spot the hole long before the scrub does. I grab the bovie, remove the tip with a hemostat, notify the circulator to come take the contaminated tip, open a new tip, and ask for a medium tegaderm to cover the hole in the drape. The whole time my surgeon is standing there gritting his teeth and holding his hand out in the I wanna' bovie! position. In all honesty, there are three drapes down and the tip has probably only gone through the top one, but it would be remiss of my duties not to point out the break and correct it. Maybe one day he'll make it to the bovie bucket!

Women scrubs, oh wait, I guess this applies to men now too, don't wear earrings when you're scrubbed in!! This rule isn't meant to punish you, it's meant to protect the patient. Consider the following scenario: A first assist to the surgeon is questioned halfway through the procedure about the fact that she is missing one earring. No one can find it before the case is over and the patient gets an x-ray. Fortunately, no retained foreign body. Facilities have become far too relaxed in enforcing this standard in my opinion.

From the scrub sink:
If your facility allows alcohol foam or alcohol gel scrubs. Your first scrub of the day should still be a standard six minute scrub with a nail pick scraping out the gunk under your fingernails. You should also do a complete scrub again after eating meals. If I go from one hospital to another I scrub again. I was taught that if we left the OR suite for any reason upon returning you start over with a complete scrub.

Now that you have finished your six minute scrub and your neatly trimmed, UNPAINTED fingernails are squeaky clean, and you walk from the sink to your gown, KEEP YOUR HANDS UP! I see so many dudes (yeah, sorry, I've only seen males do this) walk in like they think they're a gunslinger with their hands down and "dirty" water rolling down from their "dirty" elbows to their used-to-be clean hands. When did this become okay? I must admit though that I do struggle with the concept of religiously scrubbing properly and then rinsing off with some tap (:^O water from the scrub sink.

If you are opening a room, keep the O.R. doors closed. Ever hear of positive ventilation? It's not very efficient with a big gaping hole leading out to the hall. And if you are opening a total joint please be even more compliant and limit the amount of traffic in the room and have team members enter through a sub-sterile area if possible, not the common hallway. I often see rad techs at one facility I go to prop open the OR doors to an already open room and then wander off down the hallway to retreive the c-arm and roll it into the room. Then they wander back down the hallway and fetch the monitor all the while leaving the doors wide open. NOT OKAY! A better technique would be to roll all of the equipment to the OR before opening the door and then push both pieces into the room at once. Of course the best technique would be to have the equipment in the room before sterile the supplies are open, but this isn't always possible.

The surgical techs that I have mentored were all taught to pull up their back tables and mayo stands up (closer too but safely away from the undraped patient) when they begin to drape. This solves two issues that I commonly see. Number one, walking back and forth across the room to retrieve each drape. The sequence goes something like this: Grab the first down sheet, walk across the room and lay it on the patient, walk across the room and grab the blue towels, cross the room and hand the towels to the surgeon, walk across the room again to get the laparotomy drape, cross the room and hand the drape to the surgeon, walk across the room one more time and bring up the mayo with suction and bovie. While the suction and bovie are being thrown off, the back table is still across the room.

Now the tech has created two sterile fields instead of containing the field in one area. Issue number two, Walking between sterile fields. I see this infraction more than anything and it irritates me the most. If you create a space like this you are inviting axillary staff in the room to walk between sterile fields. Even though most of them know better, very, very few of them will go around the head of the patient or ask you to pull up your back table. I have seen x-ray techs take this opportunity to wheel the entire C-arm and monitor between fields because they realize they are on the wrong side of the room. This is unacceptable! Circulators, DON"T DO THIS! Scrubs, DON"T LET THEM!! I have been to so many places and there are so many nurse and techs who have, in my obsessive compulsive opinion, become way to complacent on this standard.

Well in the interest in getting this posted-I started it in July- I am going to end here for now. I'm sure I have insulted somebody, but I feel it's both my obligation and my hope to make others vigilant.

Off again, on again.

Everybody that knows me knows that I like to work. You can usually count the number of days that I'm not on call in any given month on one hand. Every now and then (today for instance) one of my ortho docs uses a PA when he's on call. The local trauma center employs a PA from 0700- 2000 every day but Sunday for Ortho trauma. On those occasions when the orthopods tell me they are going to use the PA, I'm fine with it. In fact, I kinda like the break when I regain one more precious day for myself. What's a little bit annoying is when I think I'm off and then get called in anyway because the PA can't stay. Like last night, and like this morning.

Another Surgery Addict

This email comes from Jackie. Jackie craves surgery as much as I do.

I'm a 21 year-old pre-Med student from Phoenix, AZ. I'll be graduating in May, and due to economic and personal concerns, I will not be able to pursue my medical education at a 4-year Medical School.

I ran across your blog while looking for alternative, and I found that we are very much alike - I am also addicted to surgery, using my internship with a Kidney Transplant surgeon as an opportunity to get into the OR at every turn. I believe that a career as a 1st Assist is something that I would greatly enjoy!

However, I have had difficulty pinpointing the best way to go about this. I have found that the best way to go would be to become a CST. However, what is the quickest route to 1st Assist from there? Do I need to take more courses, or simply amass enough cases to qualify? Is it necessary to become certified as an assist, or can I be a CST and, with experience, become recognized as an assist without additional certification?

I am by no means interested in the "easiest" way, I would just like to get back into the OR as soon as possible after school, as well as possibly begin working, so that I can, in the future, accomplish my goal of medical school.

Any tips? I find your writing and blog inspiring, and I am looking forward to your insight!

- Jackie

Jackie,
First let me say that while I respect your concerns, it's unfortunate that you will be unable to pursue med school at this time. If I knew then what I know now, as the saying goes, I most certainly would have pursued med school and a surgical (trauma?) residency while I was in my youth. It seems as time goes by and our lives becomes increasingly full of responsibilities, it becomes harder to devote such an enormous amount of time and money to such an endeavor. If it is truly what you want though, you will find a way.
In the meantime..... the quickest way back into surgery would certainly be as a surgical technologist. You can complete a certificate program in about 9 months, sit for your certification upon graduation, and off you go scrubbing as a certified tech. In fact, the clinical portion of your school will be spent scrubbed in. From there it is simply a matter of taking a first assist course. Most programs consist of didactic, usually offered by distance, a 6 day (min) hands on skills workshop, completion of a suture and tying course, and completion of 350 supervised clinical cases in a variety of specialties. There are several schools out there but I would say the average time of completion is 18-24 months. While there is nothing that says you must become certified as an assist, I would highly recommend it. Legislation is always changing and soon it may be required. Best to sit for the test while it is fresh rather than waiting and having it forced upon you several years later.
I'm not sure what your long term goals are but if you enjoy the whole gamut of patient contact, from clinic to surgery to post op, why not look into P. A. school? If you are graduating pre-med, I believe you would have the pre-reqs out of the way. The tuition is much less than med school and there are (were anyway) certificate, Bachelor's and Masters PA programs. A little more time to dedicate (2 years?) but if you land the right job, you will be more valuable to your surgeon, eligible for Medicare reimbursement ( as minute as it may be) , and hopefully still get to go to the Operating Room two or three days a week.
RNFA is another option. You are probably looking at four years, if I remember correctly- two year BSN, 2000 hrs of circulating (for CNOR eligibility) , and an RNFA program. If I don't have those facts straight, I apologize. I do remember being faced with the same dilemmas when I decided that assisting was the way for me and, next to med school, I remember RNFA was the longest route. If you decide on RN, I would also recommend continuing on to APN for reimbursement and advanced knowledge though I don't have a clue what attaining those titles entail.
I will say this about what I do. For me, it is the best job in the world. I do all of the fun stuff and don't have to deal with any of the not-so-fun stuff. That is, clinic, pre and post-op, phone calls from the floor, etc. All I do is OR all the time.
What I find missing from what I do? Knowledge. I crave more medical knowledge. The pathophysiology of trauma, diagnosis, in depth pharmacology, anaesthesia, what it feels like to put in a chest tube. OK, I'll never know the last one. I am self educating myself as best I can from books but it's certainly no substitute for an organized formal education. Heck, I can't even get lab values memorized!
Well Jackie, I hope that gives you some answers or at least a general idea of what to expect. If you do choose surg tech, be sure to go to a CAAHEP accredited program or you will run into roadblocks for certification. Generally, you must be a certified ST in order to be approved for hospital privileges which you will need in order to be able to assist.
Thank you for enjoying IntraopOrate and feel free to ask any other questions.
Best of luck to you,

MMT

Q and A

Went and dusted the cobwebs out of my in-box and found this letter from Ryan, a prospective student of surgical technology. While I have already replied to him via email, he was kind enough to allow me to post his questions on the blog. So, an entry for me, and perhaps answers for others with the same questions.
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I have been reading thru your blog and I love it. Thank you for much for writing it.
Thank you so much for reading it!

I have some questions about becoming/being a surgical tech. I have been researching several health care related careers including surgical tech, RN and respiratory therapist.

Since you are a surgical tech I will focus and this field and my questions for you:

First, let me clarify that while I will always be a surgical tech, I'm currently a self employed first assist. I did scrub for seven years.

Have you found being a surgical tech rewarding?
I loved to scrub. If you have a touch of OCD (obsessive compulsive disorder!) I think it's helpful. I found it both rewarding, especially the first time I was involved in a surgery that actually saved someones life, and challenging. I constantly challenged myself to set up faster, anticipate better,know the anatomy involved, count an entire set of instruments with the circulator and still keep up with the closing suture, etc. I liked to identify the patterns of certain services, mark-inject-cut, drill-measure-tap-screw, clamp-clamp-cut-tie-tie, heparin in for two minutes-eleven blade-potts scissors, clip-clip-clip-scissors, right angle-vessel loop-hemostat, the list goes on and on and almost never varies....did I mention OCD?

How is the job market for surgical techs right now? ( I have read contradicting things about this some say good some say bad)
Since I have been out of the market for a few years, I'm not sure I know the answer. I would say that some regions, and even different hospitals within certain regions, prefer to use RN scrubs. I would definitely research your region before jumping in. Perhaps look at the on line job openings with your local hospitals, that should give you an idea. I will say that in my experience, there always seems to be a shortage of Certified techs.

Did you find the schooling/program difficult?
I did not find any of my school or training difficult. I did a combination of OTJ and an Associates program (2 yr). My interest was so great in the subject matter that it was fairly easy to grasp. I will say that clinicals can be very stressful depending on your demeanor. The OR is most certainly NOT for everybody. Unfortunately, some students don't discover that they are not able to handle the environment until they are doing clinical cases in the OR. There are various programs available, the shortest route would be a certificate program. Word of warning....be sure the school you choose in CAAHEP accredited or you will find it very difficult to get your certification.

How is the pay?
The pay can vary greatly between regions and hospitals. I started at $9 something an hour (way too low!) and when I quit, $24 an hour with an additional $2 shift differential. Trauma centers typically pay more and some hospitals will pay an extra percentage if you become a specialty tech for one of the services, say General or Ortho. If you need extra money, someone is always willing to give you their call. Call pay can be anywhere from 3-6 dollars an hour, and if you get called in, you receive time and one half.

I see on your blog that you work a lot of call hours, is this the norm for this position or do you choose this? The call hours I work as a first assist are excessive because I take call with so many different surgeons. The most call I've had to take as a tech was 176 hours every month. More typically, in a large hospital with more than one shift, call should average about 48-72 hours a month. Plus, as I've said, you can almost always find someone to who is willing to take it from you.

I am 34 and changing careers is this to old to start training for surgical tech?
I began scrubbing when I was 40! You can complete the course in 18 months or less depending on which one you choose (certificate programs are typically 9 months), sit for your certification at the end of the course and off you go. Once you start working, you can take that career anywhere in the country and find a job. You may decide to become a traveler, go into nursing, or assisting, or, you may even decide to go to med school. I find it very exhilarating to work at a major trauma center. Others are more suited to out patient surgery centers where there is typically no call required and you don't work holidays or weekends.

I am sure I have a million more questions, but these are the basics.
If you have any more questions, feel free to ask.

Thanks in advance for your insight.
Ryan
You're welcome. Thanks for enjoying the blog and look for more frequent entries as the weather gets colder and I get back on track!

MMT

Neglected!

I have been badly neglecting my blog. So many excuses I could give to you. In a nutshell, I'm gonna blame it on summer. Imagine my surprise to finally log in after two months and see that the faithful have actually increased! Talk about feeling guilty!
I find it hard to blog about actual cases because I am paranoid about the Hippa police. I suppose it is just as easy to change the gender and age, I would never give a name, although I suppose all males could be Joe's and females could be Jane's. I could give age groups, 0-18, 19-30, 31-5o, etc. I'm quite sure patients don't read my blog and when they are asleep I'm sure they don't appreciate the details of their surgery. We'll see how it goes.
I have been considering a change of direction for the blog, perhaps gearing it more towards future surgical technologists and/or first assistants. I do love to share what I know and feel about surgery. Perhaps some sort of question and answer format drawing from emails through my gmail address?
My love affair with trauma may be dwindling to a trickle. My beloved *FTS is giving up the call rotation. We have only a few days left together! It feels like the end but he will be still be taking ER call and on a rare occasion, a trauma call day. Whenever I lament to the other surgeons about MY (!) loss, they look at me funny and remind me that he's still going to have regular call. But we all know it's not the same......seldom is there that urgency from non-trauma patients. The other trauma surgeons think they are being considerate. I cannot seem to convince them that even if it's 0230 and the sumdood with knife stuck in his chest or the bullet lodged in his flank isn't gonna pay me a penny, that I want them to call me! I WANT to come in!
There is a new trauma surgeon just starting. I have asked the others to pimp me out! He is still being mentored. I am trying to get to him before the cowboys do. I call cowboys the trauma docs who, #1- don't think they need any help at all, and #2- only call for help when they feel the case is technically challenging enough to require another surgeon. I fully understand #2 but come on guys, an extra pair of hands to help provide exposure and free up your scrub isn't going to help you? That's really all I'm asking, I don't need to do anything fancy, just want to bo part of the team/experience.

Patient

I've been having some unpleasant pressure in my right ear and a couple of episodes of vertigo over the last six days. Today I had an appointment with my ENT Dr. He entered the exam room, we shook hands, he looked at my throat, looked up my nose (but doc, it's my ear that troubles me!) looked in my right ear and while rolling across to look in my left ear, he said "We're gonna have to get that hair out of there."
The first thought that went through my head was that he meant my long hair was in the way. I found it odd that he didn't move it out of the way in the first place. Then I suddenly had an embarrassing epiphany. "You mean I've reached the age of hairy ears?!"
"No, I mean that there is either a dog or horse hair in there that needs to come out."

That's DOCTOR to you

Here's a pet peeve of mine. Calling doctors by their first names. Now if I were a peer, that is a doctor myself, I wouldn't have a problem with it. When techs and nurses take it upon themselves to call the doctor--in my world those are surgeons and anaesthesiologists--by his or her first name, I take offense. I think that no matter how familiar you think you are with those doctors that you may work with week after week, you are not familiar enough to disrespect them by calling, "Hey, Jim!" or "What's new Michelle?" Even if you are best of friends outside of the OR, or you happen to be dating outside of the OR, inside the OR the proper title is still DOCTOR. The ONLY exception to the rule (maybe it's only my rule?) is if you have been personally invited by the doctor to refer to him or her by their first name. There is one doc here in town that told everybody he met when he first came to town to call him by his first name. Everybody has and will most likely continue to do so. I too call him by his first name but you know what, I don't really respect him. If I did, he would still be Doctor even though he's asked to be called by his first name. The doctors closest to me that have invited me to call them by their first names have given up asking me to do so because I just can't do it. It isn't respectful.

Just catching up a bit and reading Sterile Eye's entry "Breaking the Ice" made me think of the way I interact, or don't, with patients whose surgery I assist on. I wish I was better with patients. I'm fine if I find myself forced into a face-to-face with them but typically I avoid any interaction before they roll into the O.R. Deep down (or maybe not so deep) I am a sociophobe. I seldom go to pre-op and meet the patient. Once in a great while if I am talking to the surgeon or anaesthesia before the case, and they happen to be in pre-op, I may inadvertently meet the patient. Thank goodness for consents which inform said patients that surgeons may utilize assistants during surgery.
Once the patient rolls into the operating room I am fine with interaction, I often introduce myself there, if the circulating nurse doesn't do it for me, and I stand by the patient during induction, holding a hand or touching their arm. If a patient is having some anxiety, I can see it in their faces even if they don't verbalize it and I try to give some reassurance either in words or a smile and a squeeze. I think knowing that our conscious interaction has a time limit makes me more comfortable.
There was an incident some time ago that had me promising to myself that I would never again get familiar with patients or their families pre-operatively.
Our case was delayed while we waited for the surgeon, I was still scrubbing at the time, and my good friend was the circulator on the case. We both spent time waiting in the pre-op area and, while I never spoke to the patient or the family, they knew that I was involved with the surgery in some aspect. There was a lot of eye-contact made and some smiles exchanged and when their loved one was finally rolled down the hall to the O.R., I helped push the bed. This was a very emotional case for me. The surgery was to be a palliative one to try and give the patient and family just a little more time together before the inevitable. I held the patients shoulders during the epidural. From a local tribe and allowed to carry a talisman into the operating room, the patient chanted in Native tongue while the epidural was placed. I helped to lay the patient down and stood there holding an arm during the anaethesia induction. I said my own chant in my head for the patient before I let go to go scrub in.
Unfortunately there was nothing that could be done for this patient and it still brings tears to my eyes whenever I think about it. We simply opened and then we closed. For several days afterwards, it seemed that I would see the patients family in the hallways of the hospital and they would recognize me. My stomach would do one of those chemical flip flops when we made eye contact because I suck at condolences and somehow I felt so helpless to help them, as if it had ever been on my power to do so, and because I was afraid they would want to speak to me, and because I didn't want them to see me cry.

photo credit

O.R. Chatter

During a case last week, our anesthesiologist was recounting an experience he had on a recent red-eye flight. The flight attendant walked through asking if there was anyone in the medical field on board. He hesitated because he thought it odd that she didn't ask specifically for a doctor. Curiosity got the better of him though, so he motioned to her. She came over and asked him how he was related to the medical field. When he told her that he did anesthesia she asked if he would follow her. So he got up and followed her through the airplane until they came upon a man sitting in his seat reading a book. Perplexed, our anesthetist asked how he could help.
The man in the seat asked, "What is it that you do in medicine?"
"I'm an anesthesiologist", he replied.
"Oh good! I'm a surgeon, would you adjust the light?"

Reply to Candice/Lap Chole Basics

Candice said...I'm only in my second week of my Minor Surgeries class but I'm going to take a stab at this one.
First Question: Artery
Second Question: The ST should have already anticipated the need of the clip once the bleeding started
Third Question: (I think) that the ST should be asking if the surgeon needs a larger, more durable clip or if another clip applier should be loaded(?)There you have it (maybe). Even if I'm wrong on all three questions, I just wanted to say thanks for posting this because it was a lot of fun. I love reading your blog and learning the things that I will most likely encounter one day. Keep em' coming!

Candice- Sorry about the HUGE delay.
You are right, number one is an artery as projectile, pulsating bleeding indicates, but more specifically it is the cystic artery. With all of the edema and inflammation it is often difficult to identify any structures and while dissecting, sometimes the artery finds you.

Number two. Again you are right. The surgeon should not have had to prompt the tech into action. Whenever you see bleeding, you should be thinking of what the surgeon is going to need to stop the bleeding. Now of course in order to see the bleeding, you have to PAY ATTENTION!! This tech was dozing off at the mayo stand and not even looking at the monitors.
You often won't be able to see bleeding, as in an open abdominal case where the bleeding may be out of your sight but if you are PAYING ATTENTION you will probably hear something like, "S*#t!", or "Where is that coming from?", or "SUCTION!" or maybe even, "Are we typed and crossed?" If it is a surgeon you often work with, you will probably be familiar with the favorite method of hemostasis and have already opened those supplies. It may be a DeBakey and a clip, a clamp and a stick tie, a clamp and a free tie, and for laparoscopic cases, a horizon clip, or a multi-fire endoclip applier, or even an endo loop, all depends on preference, and the size of the bleeding vessel.

And, number three, you are on the right track. One set of green Horizon clips equals six clips. Four clips had already been applied and there is still bleeding. Stay ahead of the game, ANTICIPATE! The last thing a surgeon wants to do while a patient is trying to lose blood, is nothing, standing there waiting while the tech asks for, the circulator gets (often leaving the room) and opens more supplies. Even if two more clips do the trick, we still need at least six more clips to clip and cut the cystic artery and cystic duct proper (when we actually find them in the giant gooey mess), so what was the tech waiting for? Scrub a vascular case and don't stay one ahead with your 5-0, 6-0 or 7-0 prolene and see how far you get without being less than cheerily chastised!

Great job Candice!