Inside the Operating Room

The operating room, usually called the OR, is an extremely busy place.  For a new person first coming in it can be intimidating with lights and monitors hanging down from the ceiling, multiple tables filled with equipment, an OR bed and numerous other equipment for both the surgeon and the anesthesiologist. 

Most surgeries have a specific staff which can be larger, but never smaller.  There is the surgeon who performs the case, the anesthesiologist who is responsible for putting the patient to sleep and monitoring their vital signs during the surgery, the surgical scrub technician and the circulating nurse.   Many times there will also be a surgical assistant. 

The surgeon is the “captain of the ship”. This term has been used through the years and it essentially means that he or she is ultimately responsible for everything that happens during the case.  That being said everyone works as a team and everyone realizes that the case cannot proceed without each team member. 

The anesthesiologist is also a physician who puts the patient to sleep. Most surgeries these days are done with patients asleep. There are situations when a regional nerve block is used and the patient will be awake, but usually under some type of IV sedation.  The anesthesiologist may also do a nerve block before or after the surgery to make the patient more comfortable.  He or she will also take the patient to the recovery room and give the recovery room nurse a report on the surgery and the patient’s condition.

All surgeries have a circulating nurse.  They are all registered nurses who have additional training working in the OR.  They are responsible for making sure that everything is in place for the operation to proceed safely. This includes a “time out” where everything stops and the nurse identifies the patient, the operation being performed and the correct surgical site. Everyone in the room must agree before the surgery can start.  The circulating nurse is responsible for all counts being accurate.   All supplies are counted especially sponges and needles before being used. At the end of the case the nurse will count all the items used and make sure that the counts are the same.  Since the circulating nurse is not scrubbed he or she will sometimes have to bring in instruments or supplies that are necessary. 

A scrub tech is someone who hands off instruments to the surgeon and may or may not act as the first or second assistant. They all have gone through training and there are various certifications that they may have.  The minimum training now requires an associate’s degree.  Scrub techs are responsible for setting the room up and making sure that the proper equipment is present and available. They have an extensive knowledge of surgical equipment which is complicated as each specialty is different.  If they also perform the duties of a first assistant then they need to know about the procedure and anticipate the surgeon’s needs.  A good scrub tech can make a difficult surgery easy and in reverse a simple surgery difficult.

Many cases especially in orthopedics use quite a bit of equipment and are complicated. It has become more common now for a surgeon to bring a first assistant to help.  Their background can vary from being a certified scrub tech all the way to being a nurse first assistant or physician assistant.  The first assistant will assist the surgeon with exposure of the surgical site. If the case is being done with using video equipment they often will hold the camera positioned for the surgeon.  Most first assistants will help with wound closure allowing the surgeon to complete the chart and dictate the op report.

As you can see an operating room is not unlike a sports team.  Everyone has a specific job to do and responsibility.  A successful surgical outcome depends on the team performing as one unit. 

Bruce I. Prager, M.D.

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