Introduction to the Operating Room

Fig. 1.1

An example of a road sign directing traffic toward the nearest hospital

If this is your first trip to a new hospital, be familiar with the entry requirements for the facility you are visiting. For example, do you have to sign in at a security desk? Does the hospital use a third-party vendor credentialing service that has a self-service kiosk for you to obtain a badge? Maybe you need to visit the hospital biomed department to have your machine checked before bringing it to the OR. When in doubt, ask for assistance from hospital volunteers or security personnel. Once you have obtained a badge and had your machine checked (if required), you are on the lookout for the operating room. Begin by following signs to pre-op, post-op, or surgery.

The OR suite has multiple areas that you will learn to navigate, including the individual operating rooms. Most operating suites have a similar layout (Fig. 1.2). Among the areas you will encounter are changing rooms (usually connected to a staff lounge), a control desk (also called the front desk or bridge), offices, a sub-sterile corridor connecting the individual operating rooms, and pre- and post-op holding areas. It is important to become familiar with which areas are restricted to personnel in scrub attire and which are not. These areas are often indicated with either a sign or a strip of red tape on the floor.

Fig. 1.2

Floor plan showing the layout of a typical operating suite

When first entering the OR suite, the first room you may come across is the locker room. Inside the locker room, scrub pants and tops will be available. You should arrive in professional clothing and change into hospital-provided scrubs upon entering the operating suite. Sometimes you will find empty lockers for visitor use. If you are concerned about the security of your valuables, you may wish to carry your own padlock. There is often an exit door into the OR corridor once you are dressed out in scrubs. Either inside or just outside the locker room will be bins with scrub hats and protective shoe covers. In the OR corridors, scrubs, hats, and shoe coverings are required; however, masks are not needed until entering the sub-sterile corridor or an OR that has open sterile equipment or a surgical procedure in progress.

Once dressed out, the first stop you should make is to the control desk to look at the board. The board may be either a traditional whiteboard or more sophisticated panel of LCD monitors. No matter if simple or sophisticated, the board contains all of the information on surgical procedures being performed in the operating suite that day. It will show information on the scheduled start time, room number, the procedure, and the surgeon. The board may indicate the current status of the procedure (in progress, delayed, etc.). You should always check the information on the board against the information you had prior to coming to the hospital. It is common to discover that the cervical fusion you thought you were monitoring is really a lumbar fusion or even that your case has cancelled or been delayed.

Now you are ready to go back to the room. If there is a sub-sterile corridor, you should enter the room from here. This is to limit the entry of air from the non-sterile corridors, which are generally only used to bring the patient into the room. If possible, get a cart and set your machine up in the sub-sterile area and bring it into the OR, leaving your machine case in the corridor. Remember your machine case has been sitting in your house and car as well as rolled through the parking lot. It might have dirt, pet dander, etc. on it. No one wants your cat’s hair contaminating the room. If you are the first member of the OR team entering the OR, you do not necessarily have to have a mask on as nothing in the room is sterile yet. Once the equipment to be used during the surgery has been opened, all members of the team must have their masks on. This equipment is easily recognizable by the blue sterile packaging it comes in. Remember: in the OR blue equals sterile, which means that masks should be on and covering your face.

The individual operating rooms are well lit, slightly cooled, and humidity controlled to decrease the spread of infection. They have specialized air handlers that filter air and keep the pressure slightly raised. The positive pressure environment serves to push air out of the room when the door is opened in order to keep germs and insects out of the room.

Once inside the operating room, you will see many pieces of equipment. The room is set up strategically to maximize efficiency and minimize the chance for infection. For example, the sterile table of instruments will be located on the opposite side of the room from the doorway. The operating table (sometimes called the bed) is usually in the middle of the room, and the anesthesia machine is located at the head of the operating table. Microscopes, neural navigation, and X-ray equipment (C-arms and O-arms) remain against the walls. They need to be brought in close to the bed. Remember that these larger items will be covered with a sterile drape before being used. It is permissible to touch these items before they are draped but not after.

When you first enter the OR, you should identify an appropriate place to set up and monitor the case. Always introduce yourself to the circulating nurse and politely ask where you should set up. Generally it is best to set up adjacent to the anesthesia machine. This location gives you good access to the patient as well as to the anesthesiologist or CRNA. By monitoring from this location, you avoid having to get up from your station to gather anesthesia information.

Pre- and Post-op Areas

Prior to being brought back to the operating room, the patient is held in a pre-op staging area. The period of time before the patient is brought to the room is a hectic one with all members of the team trying to gain access to the patient before the patient is anesthetized. It is during this time that consents for treatment (including monitoring) and past medical and surgical histories are obtained. The neuromonitoring clinician uses this opportunity to confirm the surgical procedure and levels as well as to identify any pre-existing pathologies that may affect the monitoring data. At the conclusion of the procedure, the patient is brought to the postoperative area, also called the recovery room. It is here that the monitoring clinician will assess the patient’s postoperative neurological status.

The Surgical Team

Surgery should be considered a team sport. There is a unique cultural undercurrent that is present in the operating room that you will find no matter what part of the country you are working in. The surgeon is first and foremost the team captain. All members of the team must carry out their responsibilities with attention to the wishes of the surgeon. To help ensure consistency, each surgeon has preference cards that are reviewed by the surgical staff prior to the start of the procedure. Preference cards have information such as how the surgeon likes the patient positioned and prepped along with information on types of instruments that should be available.

If the surgeon is the team captain, the circulating nurse is the team manager. The role of the circulating nurse is to make sure the procedure runs safely and smoothly. The circulating nurse is in charge of how the room is to be set up (including on where the neuromonitoring team will do their job), prepping the patient, and making sure that all of the equipment, instruments, and supplies are readily available during the procedure. The circulator also performs the time out prior to incision. The time out is a pause in activity allowing the team to confirm that the correct patient is in the room, the correct site of surgery has been marked, and if there are any known drug allergies. The circulating nurse is responsible for the medical care of the patient until the recovery room staff takes over.

The anesthesiologist is a physician responsible for putting the patient to sleep, maintaining the patient in an anesthetized state during the procedure, and waking the patient up after surgery. The anesthesiologist is responsible for the medical care of the anesthetized patient. An anesthesiologist may be responsible for multiple rooms simultaneously and must be assisted by a member of the anesthesia team that is always present with the patient. This may be an anesthesiology resident (an anesthesiologist in training) or a nurse anesthetist. A nurse anesthetist is known as a CRNA, which stands for certified registered nurse anesthetist. The neuromonitoring team must communicate effectively with the anesthesia team. The choice of anesthetic may greatly affect the success of neuromonitoring. It is important to remember that the priority lies with the anesthesiologist keeping the patient anesthetized and medically stable. With that in mind, it is paramount that the neuromonitoring team communicates clearly with the anesthesia team and shows deference to their critical responsibilities.

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