THE UNSPOKEN RULES OF THE OPERATING ROOM THAT I WISH SOMEONE HAD TOLD ME

Heres the thing about the OR: There are lots of unspoken rules that you don't necessarily learn about in school. When I first started, I wish someone had warned me about this stuff because it would have saved me years of messing up to learn these lessons.

When working in surgical settings you tend to learn these rules in a trial by fire as in messing up a bunch, getting yelled at or getting treated passive-aggressively, and just learning by negative reinforcement lol. But not you! In over 12 years of working in surgery, I have extracted my best tips, that you can't get from any class or books so that you can forego the learning pains, and get better, faster. Here is exactly how to navigate the unspoken rules of surgery, and thrive in this blue & green jungle.

UNSPOKEN RULE # 1

THE OR FRONT DESK IS NOT CUSTOMER SERVICE

Assuming you are properly credentialed through HR or Medical Staff, your first pit stop after arriving in the operating room should be the good ol' OR front desk. If you are improperly credentialed, get that sorted out first, as you will not be allowed entrance if you are not properly vetted by the hospital.

I recommend1arriving 1hr to 45 mins before your case starts, so you have plenty of time to find where you're going, change and prepare for the case. Once you arrive, hit up the ORFD and have a look at the big board of cases for the day. The board is usually organized by room, surgeon, time of surgery, type of surgery, and staff assigned to the room or OR suite. The board may be in the form of a massive TV screen or a simple dry erase board.

PRO TIP: TRY AND FIND THE CASE ON THE BOARD YOURSELF

Figure out what room you’re in. If you can help it, try not to ask the front desk staff what room you are in, and try instead to find it yourself on the board so that you familiarize yourself with the format of the board so that going forward you can quickly get the info you need and move on.

Understand that the staff at the front desk are super busy, answering phones, dealing with staffing issues, delays, surgeons calling, pharmacy, blood bank, lab, etc. They tend to highly dislike having to stop their workflow, to tell people what surgery is where because the information is right up there on the board for all to see. So if they seem a bit inhospitable, cut them some slack because they are usually dealing with many things at once. I've met a lot of ORFD staff across many hospitals over the years, and every now and again you'll get a person who is warm and welcoming, and its the best, but for the most part, expect to be treated transactionally. Keep in mind that their role tends to be less a customer service role, and more of an air traffic controller with their hair on fire type role.

Politely get the attention of a front desk staff member, and introduce yourself. They will likely check your credentials. Tell them who you’re working with that day, then ask these important questions:

Where can I get and change into OR approved scrubs?

Oh yea, you very likely won't be able to wear your fancy Instagram scrubs or any sweater that is not OR approved. The OR is very cold because most bacteria prefer warmer temps to flourish, so the very cold temperature is in an effort to keep infection rates at bay. Some ORs provide jackets so you don't freeze to death, but many do not, and this is when you may have to wear an extra layer of clothing underneath, lest you go into hypothermic shock.

Where can I leave my valuables?

You may be assigned a locker or an office where you can leave your valuables.

How do I find the room I’m in today?

OR suites or rooms are usually organized by number, and they are usually clearly displayed outside of the room. Most ORs also have signs in the hallways to let you know which direction what room numbers are.

Where is the CORE located?

Pay attention to this last one, because this one has the potential to will earn you mad brownie points later. The core may also be called central supply, sterile supply, supply room among other similar names.

UNSPOKEN RULE #2

GET YOUR OWN SUPPLIES

The CORE is a big storage place where they keep a lot of disposable sterile surgical stuff, including gloves and gowns. You'll definitely going to want to know where this is. They are usually located in between ORs or at the end of the hallway, but sometimes they're on the same floor, or God forbid another floor. There may also be other sub sterile rooms, little satellite cores, or supply closets sprinkled about the OR. These house typical surgery essentials like gowns, gloves, drapes, dressings, etc.

PRO TIP: NEVER, EVER FORGET TO GET YOUR OWN GOWN AND GLOVES

If you are scrubbing in, pick up your own gown and gloves in the CORE before you show up in the room. Sometimes you get lucky and they have extra ones in the closet in the room, but more often than not those are limited in supply.

While you're in the CORE, have a look around and notice where things are. Things like sutures, foley kits, dressing, suction tubing, etc. You'll want to have some idea of where things are, because later if the team needs help running to get something, you may step in and save the day by offering to get it for them.

In the OR, showing up with your own gown and gloves is the equivalent of saying to the OR staff members "I respect you so I will not make you stop doing your job to get my supplies that my unresourceful ass couldn't figure out where to find. I come in peace, and I will try and make your job easier, not harder."

This small action will be a huge act of mutual respect comradery and will let the team know you pull your own weight and are ready to help the team. It will help you start off on the right foot with the staff, it will put them at ease about a new person being in there, and this will earn you brownie points with them.

A lot of surgical techs and circulating nurses I have known over the years, find it kinda disrespectful for new people to show up and expect the staff to stop what they're doing in the case, and have to go fish your equipment for you. Yes, it's their job to have the surgeons gloves and gown, but not anybody else's. So please do not expect surgeon treatment if you're still in training.

UNSPOKEN RULE # 3

IF YOU DO NOT INTRODUCE YOURSELF TO OR PEOPLE, ITS A SIGN OF DISRESPECT AND INSUBORDINATION

Once you get to the correct OR suite, please introduce yourself to everyone in the room. Typically there is 1 circulating nurse, 1 surgical technician, 1 anesthesia provider such as an anesthesiologist, a nurse anesthetist, or an anesthesia assistant. If possible, I like to introduce myself individually, as its more personal, and it also gives me a chance to catch people's names.

PRO TIP: WRITE YOUR NAME ON THE BOARD

Most ORs are equipped with a dry erase board, locate a dry erase marker (not a sharpie!! that happened to me once and in retrospect it was the most obnoxious thing a newbie could have done.) Write your name and credentials on the board, in small, legible letters, being conscious of not taking a lot of space on it, because the nurse needs to use the board for patient info and instrument counts, etc, usually. If there isn't one, kindly write your name and credentials down on a small piece of paper or cardboard sterile gown slip and give it to the circulating nurse, so that your name may be appropriately documented in the patient's chart.

Proceed to present your gown and gloves and ask if they prefer they open them, (highly

recommended if you have never done it), or if you have experience with this, offer to open them yourselves on to the sterile field. If you have never done it before and there is time, watch how they open your gown and gloves on to a sterile field and ask them if they have any extra time to walk you through the process so that you can learn for next time.

UNSPOKEN RULE # 4

IF YOU’RE NOT HELPING, EXPECT TO BE IGNORED.

This one sounds easy, but it can be challenging at first to know how and when to help without causing harm or overstepping your bounds.

Many OR newbies start being present only when the surgeon shows up and make the fatal mistake of being uninvolved in the setting up process of the surgery, or worst, take to sitting or standing in the corner of the room being on their phone. THIS IS NOT GOOD

As a preceptor, if I observe this behavior in any of my students ill be honest with you it immediately pisses me off. Anytime anyone steps in the operating room its a privilege not a right. To see anyone squander this sacred opportunity to be present at a patient's most vulnerable, and learn from surgical professionals by being on your phone is beyond me. Please don't do it, cuz you might not realize how much of a jerk it makes you come across as. Leave your phone in your locker.

The most beloved surgeons and staff are usually the ones with a “I’ll do whatever it takes, even if its technically not my job”- mentality. If you have the privileges to do so, for the love of all that is good, put some gloves on and help us move/ tend to the patient!

Think of it this way, if you and another person had the same project to finish, and you were working your butt off on it and the other person is sitting next to you on their phone and doing nothing, how infuriating is that?

Imagine if you were invited to observe how a busy restaurant runs during rush hour, and you arrived at the kitchen and saw everyone hustling, and waiters being overwhelmed, customers complaining about long waits, and things being spilled on the floor, would you just stand there and be on your phone? I hope, that you are the kind of person who can understand whats going on, and be able to figure out how to help out, without anyone having to spell it out for you, or give you constant direction. This is what goes on in the OR sometimes. Everyone wants to move faster and more efficiently because according to JAMA Surgery, every minute in the OR costs $37. So assume its always restaurant lunch rush in the OR, and that if you're not helping you're unhelping.

Don't know exactly what to do to help? Ask for guidance. Ask, is there anything you need that I can get for you? Would it be helpful if I do _________?

Sometimes it's not even about the help itself, its about having the awareness and ability to understand team goals, and then taking the initiative to offer your help, contribute to the cause and be a part of the team.

Not knowing how to help is not an excuse not to help. Be resourceful and figure out how you can add value. Ask for guidance if you need to.

If you’re observing you might not have privileges to touch the patient, but you can certainly, run out of the room to get things for the nurse, the tech, or the anesthesiologist. Learn to navigate the CORE really well, so that you can be useful to the team.

Some people might believe that nothing can be expected from students or new staff and I respectfully disagree with that school of thought. I believe the more involved they are from the start the more they learn and the faster they can be onboarded.

If you have scrubbing privileges, Get ahold of the surgeon's preference card, -ask the scrub techs for it, and it will tell you every instrument they use. Make sure the scrub a had everything they need. Consult with the first assistant, as far as patient positioning surgical technique, draping, prep preference, etc. You can help with all of this.

You have the ability to be an asset from day 1 if you're resourceful and motivated enough.

UNSPOKEN RULE # 5

DO NOT TOUCH THE MAYO STAND

This is a huge one!!! I cannot stress enough how much surgical techs HATE anyone touching their Mayo stand or any of the instruments on it without asking.

I learned the hard way. I did this in the beginning too, and I want to save you from committing this error. You wouldn’t otherwise know this unless you made the mistake of touching it, but understand that the instruments on a mayo stand are strategically organized by the scrub tech in a particular order to maximize the efficiency of the operation in all ways. The surgical tech's job is so much more than passing instruments, the entire flow of the operation, and making sure that the patient, the assistant, and the surgeon stay safe are just some of their responsibilities. They know the surgical technique and pay very close attention to the procedure, and I've seen surgical techs catch fatal mistakes many times in my career.

I know it is tempting when you're new to want to be helpful and do the only earthly thing you think you know how to do and help the surgeon by passing a simple instrument, but trust me when I say, that in surgery there is even a right and a very wrong way to pass instruments.

There is a reason why surgical technicians have degrees and require certification in many places. They know the safest and most efficient ways to organize and move surgical instrumentation for the maximal benefit of the surgeon, the team, and the patient. To interfere in their process, and workflow by touching anything on the Mayo, or taking instruments back from the surgeon is to mess with the efficiency and safety of the team and the patient so just don't do it!

UNSPOKEN RULE #6

IN EVERY STERILE FIELD THERE IS A SHARPS PASSING ZONE, AND EVERYONE INTUITIVELY KNOWS WHERE IT IS

Ok so in the last rule we spoke about patient safety, now let’s move on to team safety. In every surgery, there is a sharps passing zone. This is the place where the surgeon or assistant get handed dangerous sharp objects that can inflict harm to its handlers, such as scalpels, suture needles, syringes, hooks, and basically anything with pointy ends.

In the SPZ, surgeons will lay down knives and needles after they use them, and the tech will retrieve them from this place to be organized back on their mayo or table.

This zone tends to be in a neutral place in between the surgeon and the scrub tech aka surgical tech. The SPZ may be a container, a magnetic drape, or simply a designated place on the patient's body like the belly.

Unfortunately, this is place is usually exactly where many new students are placed and the students usually make the following unsafe mistakes:

1. They place their hands right in the sharps passing zone, so when the surgeon places a knife down it has the potential to stab the student by mistake. Seen this happen. Also, surgeons will sometimes throw down instruments while working fast and sometimes can be heavy and bruise your hands too. I almost broke a finger once from having my hand in the SPZ and the surgeon putting down a heavy mallet.

2. They try to help by being the go-between, in between the surgeon and the scrub tech. So instead of a surgeon or tech placing the sharp the SPZ for the other to pick up, the student mistakenly picks up the instrument and tries to hand them back to the surgeon or tech, like a go-between. This increases the chances of sharps injury to everyone, not only the student because it takes the sharps out of the SPZ where everyone expects it to be, interrupts workflow and increases the chances of making mistakes that can be detrimental to the patient and staff like losing needles, or someone suffering a needle stick injury.

To avoid all of this first identify the SPZ, bu observing, or asking where it is. Then keep your hands softly on the patient away from the SPZ and do not move them, unless directed to do differently. This way everyone stays safe, and as a newbie, you have the opportunity to keep your eyes on the procedure and get the most out of your Surgical learning experience.

UNSPOKEN RULE #7

IF YOU TALK TOO MUCH OR MOVE UNPREDICTABLY YOU MAY BE PERCEIVED AS A THREAT TO THE PATIENTS SAFETY.

Try your best to minimize all distractions for the surgeon and staff. A good rule of thumb is to not speak unless spoken to. Save your questions until the end unless someone is actively teaching you, or asks if you have any questions. I can’t tell you how many newbies I’ve seen over the years who are maybe nervous and don’t stop jabbing, and it drives the surgeon and the staff nuts, because it can be highly distracting, and ultimately takes the focus off of the patient. Some surgeons love to have conversations throughout, others can’t even stand to have music in the room, or any beeping noises, so just be safe at first and stay low key, while you learn the vibe with the team over time.

Avoid making unpredictable movements, like walking around, pacing, or aggressive rubbernecking. Sometimes it will be hard to see the operation, but please do not bump your head into other people trying to see. It can block the light and also it hurts!

Try to avoid focusing your attention on anything outside of the surgery itself. We love surgery and think it’s really cool and we’re proud of what we do and want you to appreciate it as much as we do. We are also dedicating time to you and we are going out of our way to make room for you and teach you tricks of the trade, so please, please show us and the patient respect by staying focused on the operation. We know there’s lots going on outside the field too, but keep your eyes on the patient first, not your phone, always.

Know that looking away from the field is distracting to us because Its human nature to want to look at anything that someone else is looking at. It happens almost like a reflex. I'm sure it's almost like a survival thing, where once our tribe had to be collectively vigilant of any danger.

Believe it or not, when working in close proximity to other people such as in a sterile field, if one person fixes their gaze on anything outside the field, a lot of times, reflectively everyone will do the same, and instantly the focus is of the patient unnecessarily. It might just be seconds at a time, but having breaks in focus like that, interrupt the brain, then the brain has to work harder to refocus. Having repetitive breaks in focus may cause increased mental fatigue for the surgeon and staff, and that's not good for us or for the patient.

Being still by keeping your hands on the patient is a very safe move, any time you're not actively involved in the surgery. This will put the staff at ease from having to babysit you for any possible breaks in sterile technique. We understand it takes time to get the do and do nots of sterile technique while scrubbed in, but it can be a bit stressful to have students because it is our responsibility to supervise you and make sure we keep the patient safe from any breaks in sterility and an increased chance of post-operative infections. Keeping still will allow us to take the focus off you and on to the patient where it belongs, while still allowing you to enjoy participating.

PRO TIP: DO NOT LEAN ON THE PATIENT. ALMOST EVERY STUDENT DOES THIS AT FIRST

While you rest your hands on the patient, and the patient is heavily draped, it's easy to forget you're leaning on a person and not a table, so please be conscious of the pressure you use. Very light pressure does the trick. In the past, patients have woken up with large bruises from people leaning on the patient too hard during surgery so keep this in mind.

NOW YOU'RE WELL EQUIPPED TO THRIVE IN THE OR

Taking on the role of team member by being polite, respectful and introducing yourself, offering genuine help by being resourceful and putting yourself in the game, not only will foreshorten your learning curve and make for a much more enjoyable teaching experience for you and the staff, but it will also make you into a valuable member of the team, even if you are there temporarily.

When OR team members feel like your presence lightens the load and makes their job easier, they are much more willing to take the time to teach. Also, you will earn their respect and admiration and they will enjoy having you and vice versa.

Now that you have the tools and knowledge to thrive in the OR jungle, you are well poised to learn faster, add value to your team, and get the most out of your experience in surgery. My hope for you is that you become a talented, valuable and beloved member of any surgical team you wish to be a part of, so that you can reach the very top of your pay scale and become the kind of person that when you show up to the OR, everyone knows their day will be much better because you're there.

I know the COVID-19 pandemic might prevent you from currently putting these things into practice. I also understand that because of safety + social distancing protocols and the catastrophic shortage of PPE or personal protective equipment many healthcare professional students have been pulled from attending schools and their rotations. Similarly, many folks who perhaps just entered the surgical workforce as new grads or career changers have also been affected in this way.

Let me remind you that all this is temporary. And as humans, we each do our parts to keep each other safe, consider that although we may not have the gift of working towards our goals in the setting which we intended, we have been blessed with the gift of having extra time to hone our skills and optimize our mindset so that when everything reopens we may be better prepared to serve the rush of patients that have been patiently waiting at home.

My hope for you is that when the time comes and you are called to serve as a student or professional in the operating room, you are ready to handle anything that gets thrown at you so well, that the challenges reward and invigorate you. My hope is that you thrive in medicine and that you grow to love your work so much that you consider yourself fortunate to be able to have a career where you change the world, one patient, at a time.

The One Surgical Rotation Pro-Tip That Will Change Everything

How to Best Prepare for Observing or Scrubbing into a Surgery