When we last left the patient, and the call team, the patient had just gone under anesthesia.
This is when I call the PACU nurse in.
Some might say that it is too soon, I would not. Depending on the surgeon, the case might only be 20 minutes long, plus wake-up time, equals 30 minute response time. For this particular surgeon, call PACU in sooner than later, otherwise you will be chilling in PACU, not knowing the next steps, until they get there.
As I am calling the PACU nurse in, I am pulling back the top blanket to expose the abdomen and preparing to tuck the left arm. As part of my preparations, I have pulled out 1 egg crate ulnar pad, and the clipper and clipper head, plus tape.
After I hang up with the PACU nurse, I tuck the left arm snuggly against his side, placing the egg crate under the elbow, and tucking the overhang of the draw sheet, thereby securing it. I pull off the armboard at this time.
I nearly forgot the electrode grounding pad. I grab it from my desk and go back to the patient’s side.
Depending on who it is, the surgeon may clip the abdomen and remove the hair with the tape. Again, depending on the surgeon, this may be all on me.
With the patient’s abdomen freshly clipped and the hair removed with the tape, I open the chloraprep stick in a sterile manner. Chloraprep is to antiseptically prepare the skin. It is a combination of alcohol and chlorahexadine. And it is bright orange, so that it stands out against pale skin and you can see what area has been prepped. . I have read of a blue chloraprep but that is not available in my system. I leave the stick’s packaging open, making it easy to grab.
I pull on sterile gloves and open and activate the stick. I am waiting for the solution to saturate the sponge on the end of the stick. Once it has, I scrub the abdomen at the umbilicus, or belly button for 10 seconds in a back and forth manner. I “paint” the abdomen with the rest of the solution. From nipples to pubic bone to bed on both sides. You always want to prep more area than you think you need. After all, in the OR, exposure is everything.
But, you may ask, why am I prepping without putting on the grounding pad? Because the chloroprep has alcohol in it and needs to dry, thoroughly, prior to draping. Three minutes total is dry time. It is part of our documentation.
But, Kate, you didn’t put on the grounding pad that you pulled out a little while ago. While waiting for the chloroprep to dry, I apply the grounding pad. As long as I am seen to be doing something, surgeons don’t try to hurry me up, as if I can make time move faster. At least, they don’t try much.
I am known to be strict about this. Alcohol is part of the fire triad as fuel and is very flammable. I do not want any drape fires in my OR, thank you.
As a delaying tactic I often do not tie the surgeon’s gown until the grounding pad has been applied.
I tie the surgeon’s gown at his neck and his waist. And then he will “dance” with either me or the scrub tech to completely surround him sterilely with the gown. Fun fact, anyone who is gowned and gloved for the OR is only considered sterile from two inches above the elbow to the stockinette cuff, which is covered by the gloves. And on the front to the level of the bed.
Finally, the seconds drag on and it has been 3 minutes, despite my ignoring the visual whining/pleading from the surgeon. Often I use this time to talk movies, or sports, or books; whatever I know the surgeon enjoys. This often takes up the entire time.
Draping can begin. It begins with blue towels delineating the operative field. The squaring off. Sometimes the corners of the towels are secured with penetrating towel clips, it is why the instruments are named that.
Direct communication that would feel coded happens between the surgeon and the scrub tech. Stickies or sticker on indicates to the scrub tech if the surgeon wants the stickers left on the fenestrated drape. The scrub tech complies, on or off, and places the window of the drape squarely on the operative field. Once this is placed it is not to be moved. The drape is unfolded, like a flower, to cover the patient entirely. There should be a decent hang off of drape on the sides and end of the bed and enough drape to create a wall by their head. Anesthesia does that bit, securing the wall with their non sterile clips.
The mayo stand, which has been prepared and draped out by the scrub tech, is brought into position at the patient’s side or over the patient. Some of this depends on the surgeon’s preference.
Once the mayo is situated, the surgeon and the scrub tech begin throwing off lines. There are several: the light cord, the camera cord, the CO2 cord, the bovie cord, the smoke evacuator cord, because bovie use creates smoke and smoke is bad, and the secondary electrical unit cord for the ligasure or the harmonic. Both of these machines are made to cut tissue or burn it to control bleeding or to ensure the surgeon can see what he is doing.
I plug all of these cords in. Three on the bovie side, 3 on the tower side. As these are on opposite sides of the patient I need to move quickly, but safely. As I go by the spots, or the overheads, I turn them on. These will allow the surgeon to see what he is doing and it is focused light.
The surgeon asks for the knife. I stop them and remind them of the pause. This will be talked about in the next section. We pause, everyone in the room stopping what they are doing and confirming the surgery, the supplies are sterile and accounted for, the antibiotic has been given. So many things.
You’ll see in What Does it Mean to be Called in Part 4.
The scrub tech hands the surgeon the knife and incision is made.