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Medical students and foundation doctors are notorious for not knowing how to behave in theatre. This is almost invariably because nobody ever bothers to tell you how it all works, what to expect and what to do with yourself; instead they just expect you to somehow instinctively intuit the rules governing what is a very complex working environment. This means most students and junior doctors get very little out of their often limited theatre exposure, and as a result are deeply uninspired by the whole surgical thing, which I find really sad.

To rescue you from potential awkwardness and embarrassment, I’ve put together a list of simple things I wish I had known when I was a student. Most of these are things that I got shouted at for not doing/not knowing and therefore learned about the hard way – my aim is to save you from having to go through this. It’s very easy to feel like little more than an inconvenience in theatre, but the informative tips below will hopefully help you learn loads, and you might even enjoy yourself!


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BEFORE THE OPERATION

Arrive on time; aiming to be about 15 minutes early is best. This is a simple point, but arriving late will make a bad first impression and the team may disappear off to the mysterious and inaccessible land of “theatre” without you. It is generally a good idea to be well-rested and not hungover.

Before going to theatre, the registrar or consultant will go and see the patients to take them through the consent form and mark them for the operation if necessary. It is best to go with them if you can. It will make a good impression on the team, and it also means that you will get to meet the patient while they’re actually awake and see their “patient journey” through. Pay attention to the consent process, as you will learn the answers to some common intra-operative interrogation questions, including what the procedure involves and any common or serious complications.

After all the patients have been seen and consented, it’s time to go and get changed. If you are going to be separated from your team at the changing room door – a common problem for female medical students – make sure you know which theatre you need to go to when you get to the other side! If you can’t get into the changing rooms, go to the main desk, explain who you are and where you’re going, and a nice person should let you in.

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Here are a few key points about theatre attire:

Scrub colours

On entering the changing room you will probably be confronted by a veritable rainbow of different-coloured scrubs. For example, my hospital has greens for general wear in theatre, dark blues for theatre sisters, light blues for general wear outside of theatre, orange for healthcare assistants, pink for obs and gynae, and grey for ITU doctors. The colours used will vary between different hospitals (I’ve rotated around a lot over the past few years and have also worked in places that only use royal blue, raspberry or turquoise scrubs), so check the local policy with someone if you’re not sure which ones you’re meant to wear.

Scrub sizes

There should be a coloured band around the collar of the scrub tops and the waistband of the scrub trousers to indicate what size they are. In my hospital, yellow is small, brown is medium, blue is large, white is extra large, pink is XXL and red is XXXL. Again, this may vary depending on which scrub company your hospital uses. There is often a helpful hand-made size guide that one of the nurses has stuck to the wall somewhere – check the toilets if you can’t find it!

Shoes

There should be a selection of rather unfashionable clog-like rubber theatre shoes available for you to put on. Don’t take any with people’s names or initials written on, as you will get lynched if they have to come looking for them! If there aren’t any spare shoes, don’t be scared to ask somebody at the front desk to see if they can find some for you. It is very important that you don’t wear your own shoes into theatre, for several reasons. Firstly, tramping mucky trainers into theatre is obviously not good for infection control. Secondly, theatre shoes are specifically designed to stop you from slipping on wet floors and from getting zapped by the diathermy. Finally, and perhaps most importantly, wearing theatre clogs protects your own shoes from getting covered in horrible theatre mess. As a fourth year medical student, I once had to squodge 2 miles home in trainers drenched with stinky amniotic fluid after assisting with an elective Caesarean section list. Trust me, once you’ve had that experience, you’ll never want to do it again!

There may also be wellies in the changing rooms. Don’t wear these – they’re for the urologists. I’ll leave it to you to figure out why.

Hats

You will need to wear a hat to cover your hair. Confusingly, these also come in an array of colours for different team members, which may or may not match their corresponding scrub colours in any way. Medical staff will usually wear blue hats, but sometimes students are asked to wear a different colour instead – again, there should be a handy guide stuck to the wall somewhere! There are two types: stretchy elastic-backed ones, and ones that tie in a knot at the back of your head. Generally the tie-backed ones are for boys and the elastic-backed ones are for girls, but see what works best for you. Ladies, make sure all stray bits of hair are tucked underneath your hat, otherwise you run the risk of the theatre sister being less than impressed with you. Gents, if you are manly enough to have a full beard, there should be special hats for you with a funny extra bit to cover the beard area.

Jewellery

The general rules for jewellery are the same in theatre as they are on the wards. You must be “bare below the elbows” with the exception of a plain wedding band if you’re married – apparently the holy and sacred nature of wedding vows prevents these rings from spreading any infections. If you’re wearing earrings, I would either take them off or tuck them under your hat, as they have been known to occasionally fall off into patients. If you have any other visible piercings, be sensible about what you wear to work. Necklaces are usually fine as long as they’re not massive or offensively blingy – I’ve worn one every day for over a year now and it’s never been a problem.

Magic gowns

For infection control purposes, you are not supposed to leave the theatre area wearing your greens. If you need to pop out for whatever reason, there is usually a stash of green gowns near the doors which will act to cover your scrubs and magically prevent you from acquiring any transmissable bacteria during your time away from theatre. These are also extremely comfy to wear and allow you to swoop dramatically around the hospital like some kind of cape-wearing surgical superhero. You’ll see most people wear them like a dressing gown with the opening at the front, but you’re actually supposed to wear them like a theatre gown with the opening at the back and the strings tied securely. Some hospitals may require you to actually get changed to leave theatre, so check the local policy if you’re not sure.

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It can be difficult to find somewhere to put your things when you’re not a regular member of staff – I’m a surgical trainee and I still can’t get a locker! Your clothes and shoes will usually be fine left in the changing rooms – I usually put them folded in a little pile under a bench or on a windowsill; avoid the tops of the lockers as things tend to get very dusty up there. However, you will want somewhere safe to keep your bag and other valuables. Most theatres will have lockers available for visitors, but you will often be on a tight schedule and it can take a while to find the person with the keys! Instead, I usually bring my bag into the theatre and ask the nurse in charge if it’s OK to leave it in a corner out of the way. This has never been a problem as long as I have asked first.

Each operating theatre will consist of several different areas; usually a scrub room with sinks where the nurses and surgeons get scrubbed up, an anaesthetic room where clever people put patients to sleep, a little store room with basic equipment like sutures and staplers, and the theatre itself. This means you will be confronted with several potential entrances when you arrive. Just remember that you should never open any doors that go directly into the theatre during an operation, as this could let in airbourne contaminants that might land in the patient. For simplicity, I always use the scrub room door whether or not an operation is taking place.

When you get inside your theatre, introduce yourself to everyone, explaining who you are and your grade or role. This will encourage people to look after you and might get you cups of tea and/or cake if available (anaesthetists tend to be awesome at baking). Make sure your name badge is clearly visible. Whatever you do, don’t cower silently in the corner looking like a lemon. The nurses and ODPs might seem stressed and scary, but in actual fact they are lovely hard-working people who will welcome anyone who seems keen and friendly.

This may seem obvious, but don’t use your phone in the operating theatre. Put it on silent and leave it in your bag – there will always be chances to check it in the coffee room between cases. Yes, I know the anaesthetist will be on Facebook on their phone for most of the day, but that doesn’t mean that you can get away with it.

This may seem even more obvious, but for God’s sake don’t even think of taking photographs!

Theatre lists should start with a “team brief” where everyone – surgeons, anaesthetists, nurses, ODPs, surgical practitioners, medical students, company reps… –  introduces themselves and their role. The team, led by the surgeon and anaesthetist, then discuss the cases for the day, including the order of the list, the positioning, drugs and equipment that are required, and any specific issues and risks for each patient. The team brief is often affectionately referred to as “the hug” or “the huddle”, so if anyone walks in and asks “shall we hug?” or “have we huddled yet?” this is what they mean!

After the team brief, the first patient will be “sent” for from the ward and most of the team will launch into action. The floor nurses and ODPs get the necessary equipment ready, and the designated scrub nurse for the operation gets scrubbed to open and prepare the instrument trays. Meanwhile, the anaesthetists and their assistants crack on with putting the patient to sleep. If you’re anaesthetically inclined, you could always ask to go in and watch this. The surgeons may loiter in theatre or go for a coffee depending on how long this is likely to take, which is dictated by the complexity of both the patient and the procedure.

ALWAYS have a bite to eat and something to drink before the first case starts, and ALWAYS bring lunch for an all day list. The surgeons go for coffee while they’re waiting for a reason! You will be surprised how tiring it is standing up and concentrating for long periods, and operations often take longer than expected for various reasons. Hunger and hypoglycaemia mean shaky hands, slowed reflexes and generally poor outcomes of intra-operative grilling sessions from consultants. The prolonged standing, heavy scrub gowns, gloves, masks and hot bright lighting can mean you also get overheated and dehydrated very quickly. Fainting is a genuine risk, and often happens to the last person you would expect (e.g. the six-foot-something rugby players) so make sure you look after yourself. If you end up going the whole list without peeing, you aren’t drinking enough!

Speaking of peeing, it’s always sensible to go to the loo before starting a long operation.


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PREPARING FOR THE OPERATION

PREPARING THE PATIENT

Once the patient is asleep and the anaesthetist has established all the necessary intra-operative monitoring, they are brought into the theatre. If a catheter is required, the nurses or surgeon will usually do this – if you’ve had some experience of catheterisation you could offer to insert it for them under supervision.

It takes several people to move the patient from their bed to the operating table with the anaesthetist giving instructions and controlling the airway, IV access and other attached monitoring. This is something you can help with which will make a very good impression. The process usually requires the use of a PatSlide, which is basically a plastic board used to slide the patient across from the bed to the table. Here is a charmingly 80s video from Ross Mannion on YouTube illustrating how this is done (nowadays we usually need two people on either side as our patients are getting fatter):

 

Once they have successfully reached the operating table, the patient is positioned for surgery. There are many different positions which provide access to different parts of the body, and the operating table can move and have parts added or removed to accommodate these. The patient needs to be securely strapped to the table so they don’t fall off if it gets tilted, and should have adequate padding provided to minimise the risk of pressure sores or nerve injuries. The surgeons usually help with this but they might go to scrub while the rest of the team do it. It is good practice to ask the anaesthetist’s permission before positioning the patient and to maintain the patient’s dignity as much as possible by minimising exposure of their naughty bits.

surgical positions

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SCRUBBING, GLOVING AND GOWNING

As a medical student or supernumerary member of the team, it is good practice to wait to be invited to scrub in. If you appear to have been forgotten about, you can always ask permission to scrub in and assist – the worst that can happen is that they will say no, but most surgeons will appreciate the initiative, and the ones who don’t are less likely to be keen on teaching anyway.

If you can’t scrub in due to there being too many people/an unenthusiastic surgeon, you can either stand on a step to watch, or go hang out with the anaesthetist instead. Anaesthetists are a friendly breed of caffeinated super-nerds who can teach you about all sorts of clever things that surgeons don’t have a clue about, such as breathing tubes, millimoles, sodium, ECGs and Poiseuille’s law.

Here is a totally awesome video by Celine Lakra on YouTube, wherein a lady with possibly the nicest voice ever shows you how to scrub, glove and gown properly:

 

Some key points that I would add to this are:

  • there are three main different coloured scrub solutions available: povidone iodine (Betadine), chlorhexidine (Hibiscrub) and triclosan (SkinSan). I always use iodine, as I find it the least irritant and it makes it really easy to see that you’ve covered every last bit of skin whilst you’re scrubbing. Whichever one you pick, stick to it, as mixing the solutions can lead to a really nasty dermatitis.
  • your first scrub of the day must always be a full five-minute scrub. After this, any subsequent ones can be an abbreviated three-minute scrub, provided you have not done anything in between procedures that could grossly contaminate your hands e.g. going to the toilet or eating lunch.
  • don’t ever rush scrubbing in or cut corners – theatre staff pay close attention to this, and as well as potentially earning you a bollocking it will put the patient at risk of a potentially catastrophic surgical site infection.
  • if you accidentally touch anything non-sterile at any point, you have to start all over again!
  • always wear a visor mask to protect your eyes – you will be absolutely kicking yourself if you end up getting an eyesplash! I speak from experience: when scrubbing for an emergency C-section once I couldn’t find where the visor masks lived and was too scared to ask, so I went without and got a faceful of blood.
  • most hospitals now promote double-gloving for surgical procedures, as it provides increased protection against needlestick injuries and blood-borne virus transmission. You can either put on two pairs of normal gloves (I would recommend one of your size and then one of the next size up) or there may be “indicator” gloves available with a green or blue underglove and a normal white top glove, so you can easily spot if your glove has been torn or pierced. A lot of consultants opt not to double-glove purely because it makes it much more difficult to feel delicate structures inside the body, but as an assistant it shouldn’t impair your function to any significant extent, so I would definitely do it.

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THE WHO SURGICAL SAFETY CHECKLIST

who surgical safety checklist jpg

The WHO Surgical Safety Checklist was introduced in 2008, and has since revolutionised patient safety and the whole culture of surgical practice across the world. It was designed to make sure surgeons operate on the right bit of the right patient with valid consent, as well as to reduce common preventable causes of operative morbidity and mortality such as badly administered anaesthetics, allergic reactions, bleeding and infection. To summarise, the checklist is completed at three key points:

  • “SIGN IN” before the patient is put to sleep in the anaesthetic room, the anaesthetist confirms the patient’s identity and the procedure they have been consented +/- marked for, as well as checking for any allergies or airway issues and making sure all their equipment is working.
  • “TIME OUT” (also known as the “knife check”) – before the operation starts, the whole team stops what they are doing to confirm the patient’s identity and check the consent form, as well as discussing a range of other variables such as bleeding risk, antibiotic requirements and VTE prophylaxis.
  • “SIGN OUT” before the patient leaves the theatre, the nursing staff confirm that all instrument counts are correct, all specimens are correctly labelled and any issues around the patient’s post-operative recovery have been addressed.

The checklist shown above is a guide, and in the UK each hospital tends to produce their own local checklist with extra items added as required. The team brief at the start of the day is also part of the process. If you want to learn more about it and why it’s so important, read “The Checklist Manifesto” by Atul Gawande. In fact, read everything he’s ever written, as he is a totally brilliant human being who will inspire you to be a better doctor.

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PREPPING, DRAPING AND THE STERILE FIELD

After the knife check, the patient is prepped and draped. This involves cleaning the skin with an antiseptic solution such as iodine or chlorhexidine, which is applied and left on to dry. Hairy patients often need to be shaved before the skin is prepped. If monopolar diathermy will be used, the diathermy pad is placed on an area of healthy skin. A warming device like a Bair Hugger might also be placed over the patient. Next, adhesive surgical drapes are applied to outline the surgical field (e.g. the abdomen or leg) and cover up the rest of the patient and the operating table.

Whilst waiting for the patient to be prepped and draped, stand with your hands clasped in front of you at chest or waist height to stop yourself from touching anything dirty. You will notice that most surgeons will actually stand with their arms folded, which seems to be a generally accepted alternative but carries a potential risk of contaminating yourself on the “dirty” back of your gown.

Always ask the consultant where they would like you to stand – they might want their assistant opposite them or next to them depending on the procedure.

Once the patient is draped, you can approach the table. It is important to be aware of the sterile field and what you are allowed to touch. Things you can touch include the front of your gown above your waist, the prepped surgical field, the draped area and any instruments the scrub nurses give you. Things you can’t touch include everything outside of this area. The most common mistake medical students make is to forget that their mask isn’t sterile and scratch their nose! Another common pitfall is the surgical lights, which sometimes have sterile handles on them and sometimes don’t – always check before touching them.

Before making their first incision, the consultant will ask the anaesthetist if they are “OK to start”. .


 

DURING THE OPERATION

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YOUR ROLE AS AN ASSISTANT

Speak clearly to other members of the team – don’t whisper or mumble as nobody will be able to hear you through your mask.

Being an assistant is easy. If you do exactly what you are asked to do and nothing else, it is very difficult to go wrong. Your main responsibilities are likely to include:

  • holding retractors – swap hands at regular intervals to prevent fatigue and cramps
  • cutting stitches and ties – always ask how long they want you to leave the ends, and whatever you do don’t cut the knot!
  • “following” suture lines to keep the tension – this is the same principle as putting your finger on a shoelace knot to keep it tight, but instead you pull upwards in the direction indicated by the surgeon
  • using suction (be gentle) and maybe the diathermy (be careful)
  • holding the camera during laparoscopic cases – try to stay as steady as you can, and keep the surgeon’s instruments in the centre of the screen so they can see what they’re doing

If you are asked to do something you don’t hear, don’t understand or don’t know how to do, don’t just guess. Ask the surgeon to explain exactly what they need.

No matter how confident you may feel about your knowledge of surgical instruments and procedures, never mess with the scrub nurses’ tables or trays. Depending on which nurse you are scrubbed with, this could lead to anything from a polite word in your ear to a slap on the wrist or even being told to descrub. This rule is part of general theatre etiquette, but is also of paramount importance because the nurses need to keep track of all the instruments for their final “count” to ensure that nothing gets left inside the patient. In most cases if you need anything from a tray, even if it’s just a mop that’s easily within your reach, it is good practice to ask the scrub nurse to pass it to you rather than grabbing it yourself.

If you accidentally touch anything non-sterile at any point, you will need to change your gloves, gown or possibly completely rescrub. Be honest if this happens, as the patient will be at increased risk of infection if you become desterilised and then go on to contaminate other things with your dirty gloves, such as surgical instruments or their internal organs. Sometimes you won’t even realise you’ve done it and the ever-vigilant scrub nurse will point it out to you – if this happens, apologise, thank them for pointing it out and go sort yourself out without touching anything in the sterile field. Unsurprisingly, poo counts as unsterile, so try not to get it on your hands if you can help it.

If you drop something or something falls off the table onto the floor – stray mops and forceps fall off all the time – don’t pick it up! Apologise and say clearly “mop on the floor” or “forceps on the floor” so a member of the floor team can come and pick it up. This is very important to make sure nothing goes missing for the count.

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SHARPS

Doing operations on people generally requires the occasional use of sharp objects such as scalpel blades, needles and scissors. Sharps safety is therefore absolutely paramount in theatre. Here are some tips:

  • scalpels and hollow needles are usually passed in a plastic kidney dish rather than directly hand-to-hand
  • suture needles are handed over readily mounted on a needle holder and should never be touched with your hands – use a pair of forceps to pick them up and adjust their position if necessary
  • when hand-tying knots, suture needles should always be “parked” with their point facing towards the needleholder, to stop you from stabbing yourself or somebody else while you tie
  • when passing sharps back to the scrub nurse, always park the needle and clearly say “needle back to you” or “sharp back to you” to ensure they take extra care
  • other things you might hurt yourself on include the diathermy, which can be sharp and/or burn through gloves, orthopaedic instruments and stapling devices – one of my registrars once got his finger stapled onto someone’s vagina, so don’t understimate them!

If you are unfortunate enough to get a needlestick injury – which can still happen despite everyone’s best efforts – say something about it immediately. You will need to descrub and manage it like any other needlestick by encouraging bleeding, washing it thoroughly and applying an antiseptic +/- a dressing. The same goes for eye-splashes. The floor nurses will help you if you’re not sure what to do. You will need to contact occupational health so they can co-ordinate risk assessing the patient and consenting them for blood-borne virus testing – never do this yourself. Occupational health will also take your blood for storage and arrange for you to be followed up and tested again in 6-12 weeks. Despite it being a genuinely massive ballache, it is very important that you attend occupational health follow-up as it’s your health at stake, and also your indemnity and payment protection insurance often won’t cover you if you don’t follow the process through properly.

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GENERAL INTRA-OPERATIVE SURVIVAL TIPS

FATIGUE

Long operations are very tiring, both physically and mentally, especially if you’re not used to it. If you’re on a placement where you’ll be in theatre a lot, one really important thing is to concentrate on your posture so you don’t get a sore neck or back – this is both surprisingly painful and surprisingly incapacitating. Most surgeons train themselves to stand with a straight back and bend only their neck to look downwards at the patient, as this minimises the risk of strains – try to copy how they’re standing the next time you’re in theatre. Don’t slouch or bend your lower back too much as this will get sore very quickly and you will rapidly start to get distracted, fidgety and grumpy. Bend your knees and stand on tip-toes every so often to stop your legs from going dead. If you end up being asked to hold something in a ridiculously uncomfortable position, speak up and say so, as otherwise you might drop things and more importantly might injure yourself or the patient.

If and when you start to get tired, it can be extremely tempting to take the weight off your feet for a little bit by leaning against part of the operating table. Please remember that there is a patient somewhere underneath all of those drapes, and they’ve already got enough problems without you squishing them.

If you’re completely knackered and your hands aren’t currently needed for an essential part of the operation, ask the nurses for a stool and have a little sit down at the side of the room for a few minutes. The nurses can also bring you a lovely cold drink with a straw (I personally recommend the ubiquitous NHS lemon squash) and will even manoeuvre the straw under your mask for you if you ask them very nicely. However, be warned that this process is often accompanied by gratuitous suggestive comments from the rest of the theatre team.

 

FAINTING

Working in surgery is a visceral experience, in a lot of respects! Bleeding, whether from tiny venous oozers or massive arterial spurters, is inevitable, so don’t freak out when this happens. Depending on the operation, you may also end up getting up close and personal with necrotic tissue, pus, poo or wee, which will obviously be unpleasant and smelly at times. The easiest way to cope with this in theatre is to concentrate on breathing through your mouth and be very glad that you’re wearing a mask. It is worth noting that if you want to succeed in any branch of medicine, not just surgery, bleeding and bad smells are something you just have to man up and deal with. If you swoon at the sight of blood you probably need to consider a different career.

If you start to feel unwell or like you might faint, DON’T ignore it and hope it will go away. In most cases it will pass and you’ll be fine, but it’s not worth the risk of either a) fainting backwards onto the rock hard floor and hurting yourself, or b) even worse, fainting onto a member of the team and hurting them, or c) worst of all, fainting into an open body cavity and potentially seriously harming the patient. The nurses are well versed in how to handle nausea and dizzy spells, and it may be that all you need is a quick sit down for a couple of minutes and some sips of cold water. However, they may take you away somewhere for a little lie down and some toast and tea. Don’t feel too embarassed if this happens – it has happened to all of us at some point, and the team will look much more favourably upon the assistant who acts honestly and sensibly than the one who tries to man up and power through then ends up faceplanting into the patient’s intestines.

 

OTHER DISTRACTIONS

If you need to go to the toilet, you’ll need to weigh up your options and make a tactical decision. Most of the time you’ll be able to manage until the end of the operation. However, continuing to assist whilst being distracted by a massively overfilled bladder might have implications for patient safety depending on the length and complexity of the procedure. If you’re really really desparate, it’s better to descrub and relieve your discomfort, regardless of the potential eye-rolling/sighing/mockery your request might invite from the theatre team.

Some bits of some operations are boring. This is unfortunately unavoidable, and even surgical trainees will sometimes get bored in the middle of a long faffy procedure. The most important thing is not to lose focus and switch off, as you might miss important instructions or be slow to react when something unexpected occurs. Try thinking through the anatomy and blood supply of the area being operated on or the pathophysiology of the underlying disease process, or asking the surgeon about these. Don’t start thinking about what to have for lunch or your upcoming epic night out on Friday, or you’ll end up irreversibly daydreaming and you will get caught out!

Banter is one thing that surgeons do to break the tedium, and this often involves a lot of imaginative swearing, distinctly un-subtle sexual innuendo and hilarious piss-taking out of one another. Don’t feel offended or upset if this includes you – this is usually a good sign!

 

There may be music playing in the operating theatre. If this is the case, bad karaoke is highly likely to occur and you may be expected to participate.

You will quickly learn that there are good times and bad times to ask questions. Most consultants appreciate students being interested in what’s going on and are more than happy to teach. However, if you want to ask something, the best time to do it probably isn’t when something big is bleeding, or when they are dissecting around something important or suturing up something very small. Don’t feel bad if you are ignored or rebuffed every now and again – it’s nothing personal, they just need to concentrate.

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COUNTS AND CLOSING UP

When the surgeon has finished messing about with the patient’s insides for whatever reason, they will need to close up the hole(s) that they have made. Before this can happen, the nurses need to perform their first count of all the instruments to ensure that everything is accounted for and nothing has been left inside the patient. This can take a little while, as the two people doing the count have to see every single instrument, even if it’s still in use. Try not to disturb the nurses while they’re doing this as you might make them lose count! When they’re finished they will tell the surgeon that the “first count is correct”, and the surgeon will verbally acknowledge this.

Once they know there’s nothing left inside, the surgeon can safely close the wound. This is often done in several layers with several different suture materials. For example, a midline laparotomy closure often uses a big continuous size 1 PDS for mass closure of the fascial layers, usually followed by some interrupted 2/0 Vicryl to the subcutaneous fat to bring the skin edges together, then either subcuticular 3/0 Monocryl or skin clips to the skin itself. You will be expected to help by retractingcutting knots and following the suture line. If you’ve practised suturing before and ask nicely, you might be allowed to suture the skin under supervision, which is very satisfying! If you’ve never used sutures before, don’t try to blag it, just say so – the surgeon may talk you through a couple of stitches or show you how to do it so you can have a go next time, which is much better than giving it a go by yourself and making an embarassing dog’s dinner of things.

When all wounds are closed and the operation is finished, the surgical field is cleaned up with wet and dry swabs before dressings are applied – these are usually OpSite dressings which come in various sizes, often endearingly referred to as “baby”, “toddler”, “teenager”, “adult” etc. The nurses often do this, but when I was a student I used to enjoy doing it as it meant I could tell myself that I had at least contributed something useful!

At the end of the operation, the nurses perform another “final” count of all the instruments to make sure nothing has gone missing since the first one, and inform the surgeon that the “final count is correct”. They again have to verbally acknowledge this. If an item cannot be found, the theatre is searched meticulously for it, and it usually turns up on the floor or underneath a drape or a shoe or something. If it still can’t be found, the patient needs an X-ray before they leave the theatre – this shows up pretty much all metallic instruments apart from microscopic suture needles, and can also show mops, packs and pledgets, which have an X-ray detectable stripe.


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AFTER THE OPERATION

When the operation is finished, you need to descrub properly. First, remove your gown by turning it inside out and rolling it into a ball before placing it in either the green laundry bin (for reusable gowns) or the orange clinical waste bin (for disposable gowns). Next, check your gloves for holes, remove them by turning them inside out to prevent blood from flicking everywhere, and place them in the orange clinical waste bin. Check your hands for any bloodstains or cuts that could indicate a torn glove or needlestick injury. Finally, remove your mask and place it in the orange bin too. Then go and wash your hands thoroughly for a minute or so – this is important for infection control and is also nice and refreshing if you’ve been stewing away in hot sweaty scrubs for a while.

The patient is moved back onto a bed using the Patslide. Again, it is common courtesy to offer to help with this. Unless they are very unwell, they usually stay in the theatre until they have woken up enough to be extubated safely, and are then taken round to the recovery area for a period of monitoring before they go back to the ward.

The surgeons will then prepare and label any microbiology/histopathology samples, write the operation note and sign off the WHO checklist and final count. They will need your surname to put you on the op note as an assistant.

Ask for feedback on anything you did well or could have done better, especially if you tied some knots or did some suturing. It is useful to discuss any learning points and interesting aspects of the case to help you to understand what was done and why.

Thank the team for having you and say goodbye before leaving.

If you’re on a placement for a few weeks, try and follow patients up after their operation. Go and have a chat with them on the ward to see how they’re doing, and follow up the results of any histopathology or microbiology from samples taken in theatre. This will give you a better understanding of normal post-operative recovery and common surgical conditions.

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LOGBOOKS

My logbook – these entries are from my fourth year of medical school (and yes, they are all actually real! I got to work with badass surgeons who FIX BROKEN BABY HEARTS)

Keep a logbook of operations you go to, especially if you think you might be interested in a surgical career. Remember that your list needs to be confidential, so don’t put patient names on it! You can either keep your own handwritten/computerised list or use an online logbook – the best one is the Intercollegiate Surgical eLogbook by the Royal College of Surgeons shown above, which is used by all UK surgical trainees. You need two unique identifiers for this, usually the patient’s hospital/NHS number and their date of birth. It is very satisfying to keep a log of procedures you’ve seen, assisted with and performed under supervision – even little things like stitching up a wound count! You can also log more ward-based “medical” procedures such as catheterisation, arterial line and central venous line insertion, pleural/ascitic taps and lumbar punctures – again, I really wish I had known this as an F1! You can print out logbook summaries to put in your CV or portfolio, which will make you seem very switched on and professional in undergraduate times of need, for example if you are applying for a competitive summer school, elective or intercalated degree programme, or a nice juicy bursary to cover elective expenses. It is also relevant for job applications for a multitude of specialties, not just for surgery. For example, medics need to perform ascitic taps and lumbar punctures, A+E docs need to be competent at suturing and chest drains, anaesthetists need to be able to put in lines, and GPs can independently perform a whole range of minor surgical procedures provided they have the necessary basic surgical skills.

Most teams are happy to have students along outside of scheduled teaching lists, so if you fancy a bit more exposure don’t be frightened to get in touch and ask. Most surgeons are friendly creatures who are used to students being instantly switched off by their specialty, so they will be overjoyed if you want to come and keep them company for a bit.


SUMMARY

I hope this has been a helpful guide to the magical world of the operating theatre, and that you will find your surgical placements less intimidating and more fun as a result of reading it. If not, I hope that at the very least I’ve covered all the major mistakes that people make so that you won’t get in trouble – please let me know in the comments below if I’ve missed anything, or if there is anything else you’d like to know about.

May the forceps be with you…

 


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