Orientation to the Operating Room
As a clinical clerk, one of the most exciting and challenging experiences you will encounter is being in the operating room (OR). It is a unique environment where you will see medicine in action and learn alongside experienced surgeons, and other medical professionals!
However, the OR can also be an intimidating and overwhelming place, especially if its your first time. That's why we've put together this guide to give you an overview of what to expect in the operating room and help you prepare for your clinical clerkship.
Here we’ll cover:
Clinical Clerk Responsibilities in the OR
Who is in the Operating Room?
A Typical Day in the OR
Operating Room Setup
Sterile Technique in the OR
I. Clinical Clerk Responsibilities in the OR
As a clinical clerk in the operating room, your primary responsibility is to act as a surgical assistant. You’ll be responsible for helping the surgeon during the operation, you’ll have responsibilities before, during and after surgery.
Before Surgery
The Day Before Surgery
Review the OR schedule prior to start your OR day. See who you are assigned to, how many cases there are, what surgical procedures will take place.
Read about relevant anatomy and the purpose of the surgeries that will be performed. This is a great way to orient yourself to what is happening during the operative procedure before stepping foot in the OR. Read around relevant anatomy, conditions and the purpose of the procedure.
If there’s time: do a brief patient chart review. Learn about the patients who are having the procedure done. What is the story? Why are they here? What comorbodities are present that may affect the surgery and course of the hospital stay? Review the surgery consult note and any notes from consulting services (e.g. medicine, anesthesia, etc.).
The Day of Surgery
Arrive 15-30 minutes before the start of the first surgery (e.g. if the first case starts at 8 am, check in at 7:45 am)
Provide your Name, designation and glove size to OR nuses: Check-in with the OR staff, including the OR nurses who will include your name and designation (e.g. John Smith, Clinical Clerk) as part of the official OR documentation. If you are allowed, you can grab your gown and gloves.
Prior to the Start of Each Case
Check the patient in POCU: Go to the Pre-operative care unit (POCU) where the patient waits prior to being transferred to the Operating Room. You may go with the resident/fellow/PA/Surgical assist the first time to ‘check the patient in’.
Here you will confirm the patient’s name, date of birth, allergies, the medical procedure being down, the side.
The operative side/limb will be initialed using a marking pen by a representative of the surgical team (again the surgical resident/fellow/PA/surgical assist).
Pull up relevant imaging in the Operating Room: Once the patient is checked in, go back to the OR room. Pull up relevant imaging for the case (e.g. x-ray, CT scan, MRI). For example, when I work in Orthopaedic Surgery and we are doing a knee oint replacement, I will pull up xrays of the AP, lateral and skyline views that the surgeon can reference if needed.
OR room is done being setup, patient is brought from POCU to the Operating Room: Prior to surgery perioperative nurses are setting up the room and checking to see if all the equipment is available to start the case. The patient is not brought to the room until this setup is complete! As a clinical clerk you can help transfer the patient from POCU to the OR (usually this is a member of team from Anesthesia and a member of the surgical team).
Surgical Debriefing: A member from the surgical team will then perform the briefing to ensure everyone on the team is on the same page about the patient’s care during the surgery including the patient’s condition, surgical plan and any potential risks or complications.
Assist with patient positioning, and prepping: Once anesthesia is applied or patient is under light sedation, you can start to help with patient positioning and prepping. As a clinical clerk you will likely observe how this is done the first few times before you step in and help.
An example of a Surgical Safety Checklist from a Canadian hospital. Each hospital may differ.
During Surgery
Scrub in: As a clinical clerk you will function as a surgical assist (first or second assist). The scrub station is usually positioned just outside the operating room. Once you are done scrubbing you will re-enter the operating room. Be careful not to contaminate yourself.
Gown and Glove: You either may have to gown and glove yourself, or the scrub nurse will help gown and glove you.
Sterile Draping: This involves placing specially designed sterile drapes over the patient's body to create a sterile field that isolates the surgical site from non-sterile areas during the procedure.
Surgical Time out: A surgical time out is a brief pause before a surgical procedure begins, during which the surgical team confirms essential details about the patient, procedure, and other important factors to ensure patient safety and prevent errors.
Surgical Assist: Once the first incision is made, you will step up to help with retracting, suctioning or passing equipment (as instructed). Make sure to stay sterile the entire time.
Surgical Debrief: When the surgery is near the end, the surgical team will participate in a surgical debrief. This is a structured discussion that takes place after a surgical procedure, allowing the surgical team to review and analyze the procedure, discuss any complications or challenges, and identify areas for improvement in patient care and outcomes.
Closing: You may observe or participate in closing of the surgical site. This is where you may get to practice suturing and different wound closure techniques.
After Surgery
Dress the surgical incision: Once the surgical incision site is closed, you may assist with placing the surgical dressing.
Remove Surgical Drapes: You can assist the surgical team with helping to remove surgical drapes and place in garbage.
De-gown, and de-glove: Once surgery is done, you can remove your surgical gown and toss in correct bin for washing, and place your used gloves in the garbage. Be sure to sanitize after before you go to the next step to transfer the patient.
Transfer patient to stretcher/bed: It usually takes 4 people to move the patient from the operating table to the stretcher that will take the patient to the Post-Anesthetic Care Unit (PACU). Observe the first few times before you step in to help.
Take patient to PACU: One member of each team: Nursing, Anesthesia and Surgery will then transfer the patient from the OR to PACU.
Perform Handover to the PACU Nurse: After the PACU Nurse and OR nurse perform a “patient check” (ensuring correct name, DOB and hospital MRN number), each member of the team will then perform a handover.
From the surgical team this may sound like “This is Jane Doe, Clinical clerk providing handover from the surgery team. Patient underwent a Right total hip arthroplasty by Dr. X with spinal and light sedation. No complications. Estimated blood loss was 150 cc. We have ordered PACU x-rays, and orders are already in the patient’s chart. Plan to head up to 10B Orthopaedic ward.”
Room Turnover: The OR attendants will then spend the next 15-30 minutes ‘turning over the room’ which includes cleaning sanitizing the room prior to the next case. You will have a small break to grab food or water prior to the next case starting.
II. Who is in the Operating Room?
The operating room is a busy place, and you will encounter many different healthcare professionals in the OR. Each member of the surgical team plays a vital role in ensuring the success of the operation. Pay attention to what these different health care professionals do, and how they contribute to the patient’s journey during surgery.
Inside the Operating Room:
Anesthesiologist: the physician responsible for administering anesthesia and monitoring the patient's vital signs during surgery
Anesthesia assistant: the healthcare professional responsible for assisting the anesthesiologist in administering anesthesia and monitoring the patient's vital signs
Perioperative Nurses: Can perform both scrub and circulating nursing roles. They assist
Scrub nurse: the nurse responsible for maintaining sterility in the OR. Scrub nurses assist with draping of tables and patients, setup equipment in the sterile field, pass surgical instruments and call for closing and final counts. This HCP is scrubbed into surgery.
Circulating nurse: the nurse responsible for managing the OR and ensuring that everything runs smoothly during the operation. They perform a room and equipment checklist and ensure supplies and equipment needed for the surgery are in the room. This includes checking the surgeon “pick list” for the procedure which includes equipment required. The circulating nurse also does timely documentation of the procedure (including timing of anesthesia/medication adminsitration, start and end time of surgery, documenting who is in the surgery room, tracking medical equipment and implants used, etc.), and initiating counts (sponges, blades and other instruments).
Medical equipment representative: a sales representative for a medical device company who may be present to demonstrate the use of a new product or provide technical support for equipment used in the operation
Surgical assistant: the healthcare professional who assists the surgeon during the operation
III. A Typical Schedule in the Operating Room
As a clinical clerk, the expectation will be for you to arrive BEFORE the operating room day begins.
6:30 AM - Handover Rounds with Residents
7 - 7:50 - Surgery Teaching Rounds
8 - 5 pm - Day in the Operating Room: See sample OR day schedules below to see # of cases that can be booked in a day.
5 pm - Home: Change out of surgical scrubs and finish any remaining paperwork or administrative tasks.
The length of an OR day can vary (e.g. from 8-5 pm or 8-4 pm).
How many cases a day?
Here’s an example of different cases booked on a single day for different surgical specialties.
Although these cases are booked back to back, it takes time for the room to be cleaned and turnover (ranging anywhere from 15 to 30 minutes). This provides you an opportunity to grab a quick snack, put in orders for patients, or go for a washroom run.
OR Room 1: Neurosurgery (2 cases)
8:00 to 12:50 - Right Craniotomy
12:50 to 17:00 - Laminoplasty
OR Room 2: Orthopaedic Surgery (4 cases)
8:00 to 10:05 - Right total hip arthroplasty
10:05 to 11:55 - Left total knee arthroplasty
11:55 to 13:45 - Left revision total knee arthroplasty
13:45 to 15:35 - Left knee arthroplasty
OR Room 3: General Surgery (3 cases)
8:00-11:20 - Laproscopic Gastric Bypass Surgery
11:20 to 14:40 - Laproscopic Gastric Bypass Surgery
14:40 to 17:00 - Laproscopic Gastric Bypass Surgery
OR Room 4: Orthopaedic Spine Surgery (3 cases)
8 to 12:50 - Cervical Decompression and Fusion
12:50 to 15:20 - Microdiscectomy
15:20 to 17:00 - Microdiscectomy
OR Room 5: Ophthalmology (5 cases)
8 to 9:20 - Vitrectomy
9:20 to 10:40 - Vitrectomy
10:40 to 12:00 - Vitrectomy
12 to 13:20 - Vitrectomy
13:20 - 15:30 - Vitrectomy
It's important to note that this schedule may vary depending on the specific surgical team you are working with, the length and complexity of the procedure, and any unexpected events or complications that may arise.
IV. Operating Room Setup
The operating room is carefully designed to ensure a safe and sterile environment for surgical procedures.
Here are some key features of the OR setup:
Sterile Zone
The sterile zone is the area directly around the surgical field where all items must be sterile.
Only sterile team members, including the surgeon, scrub nurse, and any surgical assists (including you as the clinical clerk), are allowed in the sterile zone. These members are draped and gown.
Non-Sterile Zone
The non-sterile zone is the area outside the sterile zone where non-sterile team members, such as the circulating nurse, are located.
Non-sterile team members must not enter the sterile zone without appropriate sterile attire, such as a surgical gown and gloves.
V. Sterile Technique in the OR
A sterile field is an area free of microorganisms, and it is created using sterile drapes, gowns, gloves, and instruments. This helps reduce the rate of infection from surgery.
Prior to starting clerkship, PA school will review sterile technique, scrubbing, gloving and gowning in the operating room.
a) Before entering the OR Suite
Wear hospital-issued scrubs
Cover your head with a surgical bouffant or scrub cap (your own or hospital provided (whatever is provided).
Do not wear rings, earrings, or watches if you are scrubbing in for surgery.
Some hospitals have a strict policy on nail polish. To be safe, don’t wear nail polish during your rotation.
Advise the scrub nurse/surgical team if you have any open cuts on your hands. You cannot have bandages on your hands when scrubbing in.
b) Scrubbing into Surgery
Ensure that you are wearing appropriate attire, including scrub clothing, a cap to cover your hair, and shoe covers to maintain cleanliness.
Approach the designated scrub sink in the scrub area of the OR. Make sure the sink is clean and free of clutter.
Wet your hands and forearms with water. Use a foot-operated or sensor-activated faucet if available to avoid touching the handles.
Apply an appropriate surgical scrub solution or antimicrobial soap to your hands.
Rub your hands together, ensuring to scrub all surfaces thoroughly. Start from your fingertips and work your way up to your elbows, covering all areas, including the palms, backs of hands, fingers, and wrists. Pay special attention to the spaces between your fingers and under your nails.
Scrub each hand and forearm for the recommended amount of time, usually at least 2 to 3 minutes. Some surgical scrub solutions may require a longer duration, so follow the specific guidelines provided.
Rinse your hands and forearms thoroughly under running water, allowing the water to flow from your fingertips towards your elbows, ensuring that any residual soap or scrub solution is washed away.
Keep your hands elevated to prevent water from flowing back down towards your hands and forearms.
Dry your hands and forearms using a sterile towel or a sterile, disposable hand-drying device. Begin with your hands and move up towards your elbows, using a patting motion. Avoid touching non-sterile surfaces during this process.
Once your hands and forearms are dry, you are ready to proceed with gowning and gloving for the procedure.
c) Staying Sterile once you are Scrubbed In
Once you have completed the surgical scrub and are scrubbed into surgery, it is essential to maintain sterility throughout the procedure.
Here are some key steps to help you stay sterile in the operating room:
Avoid touching non-sterile surfaces: Once you are scrubbed in, it is crucial to refrain from touching non-sterile objects, such as tables, chairs, or your own face and body. Any contact with non-sterile surfaces can introduce contaminants and compromise the sterile field.
Maintain a safe distance from the sterile field: Be mindful of your position in the operating room and maintain an appropriate distance from the sterile field. Leaning over the sterile field or reaching across it should be avoided as it can lead to inadvertent contamination.
Follow proper gowning and gloving technique: Ensure that you have properly donned your sterile gown and gloves before entering the sterile field. This includes following the designated technique for putting on and securing the gown and gloves without touching non-sterile surfaces or your own skin.
Limit movements: Once you are scrubbed in, it is best to minimize unnecessary movements to reduce the risk of accidental contamination. Moving in a deliberate and controlled manner helps maintain sterility and prevents the dispersion of potential contaminants.
Be cautious with equipment and instruments: Handle all surgical instruments and equipment with care and in a manner that avoids contact with non-sterile surfaces. When passing instruments to the surgical team, use appropriate techniques to maintain sterility, such as utilizing a sterile transfer zone or requesting assistance from a circulating nurse.
Communicate effectively: Clear communication with the surgical team is vital during the procedure. Use appropriate channels and gestures to relay information or requests without compromising sterility. Avoid shouting or excessive movement that could disrupt the sterile field.
Alert the team to any potential breaches in sterility: If you notice any breaches in sterility, such as a torn glove or contact with a non-sterile surface, it is crucial to immediately inform the surgical team. Prompt action can be taken to address the issue and maintain a sterile environment.
d) Scrubbing out
After completing a surgical procedure, degowning and degloving are important steps to maintain hygiene and prevent potential contamination.
Ensure that the surgical procedure has been completed, and all necessary post-operative tasks have been addressed.
Begin by removing your gown. Start by unfastening any ties or closures at the neck and waist. Avoid touching the outside of the gown, as it is considered non-sterile. Carefully pull the gown away from your body, turning it inside out as you remove it. Use a controlled motion to prevent any potential contact with your skin or other non-sterile surfaces.
Once the gown is removed, discard it into a designated receptacle or linen hamper for soiled gowns.
Proceed to remove your gloves. Grasp the outside of one glove near the cuff and peel it off, turning it inside out. Hold the removed glove in your gloved hand. With your exposed hand, slide your fingers under the cuff of the remaining glove, avoiding contact with the outside surface. Peel the second glove off, turning it inside out as well. Dispose of both gloves into a designated receptacle.
Perform proper hand hygiene by washing your hands and forearms with an antimicrobial soap or using an alcohol-based hand sanitizer. Thoroughly cleanse all surfaces of your hands and forearms, including the spaces between your fingers and under your nails.
Rinse your hands and forearms under running water if available, ensuring that any residual soap or sanitizer is washed away.
Allow your hands and forearms to air dry or use a sterile towel or disposable hand-drying device.
Once your hands and forearms are dry, you can proceed to change out of your surgical attire.
Ensure that you have clean clothing available to change into. Remove your scrubs, cap, and shoe covers in a designated changing area. Avoid touching the outside surfaces of the scrubs as you remove them.
Place the used scrubs in a designated receptacle or hamper for soiled clothing.
VI. Tips on being a Surgical Assist
Familiarize yourself with surgical anatomy: Develop a strong understanding of human anatomy relevant to the surgical procedures you will be assisting with. Study anatomical structures, their relationships, and variations to anticipate the surgeon's needs and navigate the surgical field effectively.
Learn procedural steps and techniques: Gain knowledge about the specific procedures you will assist with. Understand the sequence of steps involved, the instruments used, and the expected outcomes. Review surgical textbooks, atlases, or online resources to familiarize yourself with different techniques.
Familiarize yourself with surgical tools and equipment: Familiarize yourself with surgical tools and equipment, as well as the tools’ purpose. This includes retractors, sutures, suctions, implants, scopes, imaging equipment, hemostatic instruments (e.g. electrocautery devices to control bleeding during surgery), etc.
Observe and learn from experienced surgical team members: Take advantage of opportunities to observe skilled surgeons and experienced surgical assistants in action. Observe their techniques, instrument handling, and overall approach. Ask questions and seek clarification to deepen your understanding.
Tips for Effective Retracting During Surgery:
Use proper hand positioning: Position your hands correctly to provide effective retraction without obstructing the surgeon's view or impeding instrument movement. Avoid excessive force that could damage tissues or compromise blood supply.
Maintain a stable and controlled grip: Hold the retractors securely but gently to provide stable and consistent retraction. Adjust your grip as needed to accommodate the surgeon's movements and changes in the surgical field.
Be mindful of tissue integrity: Retract tissues with care to minimize trauma. Avoid excessive tension or pressure that could lead to tissue damage or compromise blood flow. Be aware of delicate structures and adjust your retraction technique accordingly.
Anticipate changes in retraction needs: As the surgical procedure progresses, the need for retraction may change. Anticipate these changes by closely observing the surgeon's actions and the progression of the surgery. Be prepared to adjust your retraction technique or provide alternative retraction methods as required.
Develop suturing skills: Suturing is a fundamental skill for a surgical assistant. Practice different suture techniques outside the OR, including simple interrupted, continuous, and running sutures. Develop precision and speed while maintaining optimal tissue approximation.
Final notes
The clerkship experience in the operating room is a valuable opportunity for clinical clerks to gain firsthand exposure to the intricacies of surgical procedures and develop essential skills. As a surgical assist, clinical clerks play a crucial role in supporting the surgical team before, during, and after surgery. By understanding the responsibilities of a surgical assist, familiarizing themselves with the operating room setup, and mastering sterile techniques, clinical clerks can contribute to maintaining a safe and sterile environment for patients.
