You think you know the OR? As if.

We know the usual cast of characters in the room.

The circulating nurse who bosses everyone around and ensures that the patient has everything they need. Including activating an emergency team.

The scrub tech who is in the sterile environment with the surgeon and assists who knows what the surgeon needs before they ask for it.

The CRNA who ensures that the patient is comfortably anesthetized and is prepared for any emergency.

The anesthesiologist who supervises the CRNA, up to 4 rooms at a time and who pinch hits for the CRNA at times.

The patient without who none of the cast of characters would be there.

But, do you recall the most famous reindeer of all?

Just kidding; it takes more that the usual cast of characters to safely see a patient through surgery.

There is the pre-op team that makes sure the patient is prepared for surgery. They know all about the patient and is a source of comfort for them as they wait for the surgery to begin.

There is the post-op team that makes sure the patient is comfortable waking up from surgery. In the hospital where I work the pre-op and post-op teams are comprised from the ACU/PACU team.

But the one you hear the least about? The ones who cleans the instruments, readies the trays, sterilizes the instruments, and puts the sets back where they live so that the OR can find them.

The sterile processing department. SPD in the hospital I work at.

They know everything there is to know about the trays. They should they put them together from the jumbled mess that the scrub tech might leave. Depends on the scrub tech. If asked about a certain instrument that was dropped they might be able to point the circulator in the correct direction for a replacement instrument.

The first thing they do is decontaminate the instruments that have just been used in a surgery. There are washing machines, similar to a dishwasher, that are used. But, just like in real life, the gross bioburden has to be washed off many of the instruments. By hand.

They inspect all instruments that they get out of the washers. They make sure that the tips of the instruments meet and are not out of alignment. They make sure that all the lumens of instruments are clean with air or a brush prior to set assembly. They make sure that all the very fine instrument tips are not broken off because of mistreatment. Then they string the instruments together in the order they appear on the count sheet.

They double check the count sheet to make sure that everything is accounted for in a set. If not, they mark the set as incomplete and put on a bright orange sticker that indicates what is missing. If too many things are missing the set it taken out of use and set aside until the missing pieces are located and the complete set can be sterilized.

How does an instrument get lost? This is out of their control. Sometimes the instrument is thrown away (I tried to get a research project off the ground to decrease inadvertently thrown away instruments by using a metal detector. I maintain it would have worked too, but covid shut that down). And sometimes the instrument is in another tray from the same case, just misplaced.

They maintain a bin of lost instruments from the misplaced instruments that are retrieved after the sets are put back together. These instruments can be from the core, where there is an entire shelving unit full of sterilized single items. Sometimes it is a replacement for the scissor the surgeon just dropped, sometimes it is a replacement for the orange sticker. SPD puts these back up in single sterilizer packet. This is a down time occupation. The downtime of which there is very little because some of the sets are needed later in the day and the set from the 0700 first case has to be washed, inspected, put back together and sterilized in time for the case that starts at noon.

They know everything there is to know about the instructions for use of the sterilizers and the instruments that might go in the sterilizers. These are the IFUs. These indicate what is the best sterilization method for a given instrument, including parameters of time and exposure.

We’ve come a long way since the days of one set of instruments that was washed and flash sterilized for ALL the cases of the day. Or the care and maintenance of the Cidex, which is a semi-sterile instrument dip that was sometimes used the before times that would expire. Or the care and maintenance of the Steris machine, which used an acid bath to delicately clean scopes and cameras that could not be sterilized in the autoclave. Or the care and maintenance of the newer machines like the Sterrad that uses plasma to sterilize cameras and scopes.

They had to have all of that in their heads. Or at least readily accessible to look up on the spot. But in my experience, they kept it all in their heads.

SPD workers have to be efficient and know their stuff. And keep all the rest of it in mind as they do so.

No sterile instruments? No surgery can be done safely. There aren’t enough antibiotics in the world to cover that.