Surgery 101 | Operating Room Reality & Expectations


Have you ever wondered what it’s like to be in the operating room, elbow to elbow with surgeons, using the latest in cutting edge surgical technology to save lives? You’ve seen it on TV shows, but perhaps never stepped in the OR yourself. It seems mysterious, intense, even a little intimidating. Here’s what to expect when you first enter the operating room.


Understand Operating Room Etiquette

For many medical students and aspiring surgeons, the first time you enter the operating room will be in your third year, during your clerkship rotations. The common theme of your third year of medical school is that you want to learn, be helpful, and not get in the way. This is most apparent in the operating room, where it’s difficult to help and easy to get in the way.

When you enter the operating room, always introduce yourself, and usually, it’s best practice to write your name on the whiteboard. This is because the circulating nurse needs to chart in the computer who all was in the room.

Do your best to not get in the way. Your first few times in the OR, you may be confused by all the moving pieces. That’s fine, as long as you don’t slow other people down in doing their job.

Avoid being on your phone. Even if you’re trying to be useful or studious, it looks like you’re texting and not paying attention.

Surgery is often high stress, and there will be moments of high tension where you may be yelled at or not like how someone talks to you. Don’t beat yourself up, and don’t take it personally. It’s more often a reflection of the situation or the character of the individual, and surgery tends to have a higher proportion of more abrasive personality types.

Your aim as a medical trainee is to learn, and you should be asking questions, but timing is critical. You don’t want to be the annoying student that asks too many questions, and you also don’t want to be the student who asks questions at inappropriate moments. During times of high stress and tension, refrain from asking questions and allow the various members of the surgical team to resolve the situation. The more you work with a particular surgeon and other members of the surgical team, the more you’ll get a feeling for what is and is not appropriate. Timing is important, as you don’t want to interrupt their focus during moments of higher acuity.


The Holy Sterile Field

The single most important thing is that you don’t contaminate the sterile field. Doing so won’t make you any friends.

The purpose of creating a sterile field around the surgical site is to reduce the number of microbes and therefore the risk of infection and complications.

How do they decide where to draw the line on sterility? Well, making the whole operating room sterile isn’t practical, nor does it confer improved infection risk. On the other hand, sterilizing only the immediate area of the incision would still introduce microbes from movement and touching surrounding unsterilized structures.

For this reason, the sterile field generally includes the drapes over the patient, down to about your waist height. If you’re scrubbed in, meaning you are wearing a surgical gown and gloves, then your hands and arms, and anterior torso from your chest down to your waist are in the sterile field too.

If a sterile object makes contact with a non-sterile object, we call that contaminating the sterile field. If your nose is itchy and you’re scrubbed in, too bad, as touching it will contaminate the sterile field. You’ll have to wait for it to pass, as touching your face, glasses, mask, or anything that isn’t sterile is a big no-no. If your mask is fogging up or you’re having issues seeing, then ask one of the nurses who isn’t scrubbed in to help make adjustments.

Standing by the operating table, your hands should either be resting on the drapes on top of the patient, or you should hold your hands in front of you. Do not drop your hands below your waist or to your sides, as doing so would contaminate them.

If you’re going to sneeze and you’re standing at the sterile field, then take a step or two back and sneeze directly into your mask, facing toward the sterile field. Do not raise your arm to cover your mouth, as that would contaminate your sterile sleeves, and do not turn to the sides, as doing so will allow microbes to escape from the sides of your mask and toward the surgical field.

The first time you’re in the operating room, you likely won’t be scrubbed in, meaning you’ll just be wearing regular scrubs and no part of you will be considered sterile. In this case, you always want to maintain a safe distance from the sterile field as to not contaminate it.


Be Prepared

Surgery is still very much an old boys’ club, and even as a student there will be several unspoken expectations of you, and you should always come prepared.

If it’s your first time and you’re not scrubbing in, still make sure you wear a mask and eye protection. Everyone inside the operating room must wear a mask to reduce airborne microbes, and once you see fluids squirt around, you’ll understand why eye protection is paramount.

If you are scrubbing in, make sure you know proper scrub technique and follow it closely.

To reduce interruptions, use the bathroom prior to entering the surgical suite. It’s generally frowned upon to excuse yourself to use the bathroom, particularly if you’re scrubbed in, and even more so if it’s a shorter case. It shows you simply weren’t prepared. You should also avoid chugging a gallon of water right before surgery for obvious reasons.

In line with reducing interruptions, put your phone on silent or vibrate, as you don’t want to distract the surgeon while your Drake ringtone blasts at max volume.

Complications and unexpected delays in the operating room are common, and you should be prepared to stick around longer than expected. No food is allowed in the operating room, so be sure to fuel yourself ahead of time.

If you’re a medical student rotating on the surgical service, be ready to be pimped, meaning quizzed by your residents or attending. You should absolutely know the patient, why the surgery is indicated, the nature of the surgery, the anatomy you’ll be seeing intraoperatively, and other relevant details. Expectations will vary depending on your stage in training and whether or not you’re pursuing a surgical specialty for residency. A third-year medical student on their first day in the OR will have different expectations than a fourth-year who is doing a plastic surgery sub-internship and hoping to match into the field.


Be Helpful

After a few cases in the OR, you should start to form an understanding of how things work. The room is prepared, the patient is rolled in, anesthesia begun, time out is performed, and the first incision is made. After the incision is closed, the site is properly bandaged or dressed, the patient is woken up and extubated, transferred to a hospital bed, and wheeled out to post-op.

Depending on whether or not you’re scrubbed in, there will be different tasks you can help with. By being attentive and observant, it won’t be difficult to figure out where to be useful.

If you’re not scrubbed in, you can help the patient get transferred to the operating room table, grab supplies from the back supply room, help gown others who are scrubbing in, pull up imaging on the TV screen if the surgeon needs to reference something while operating, and anything else you’re asked of. After closing, you can grab the gurney, which is usually outside the room, transfer the patient, and so on.

If you are scrubbed in, do your best to not get in the way, don’t contaminate the sterile field, and get great at retracting, since you’ll be doing a lot of it. Retracting is when you help hold back organs or tissues, usually with one of many tools, allowing the surgeon to more easily view and operate on the exposed area. You may need to suction, apply pressure, cut sutures, and do other minor tasks too. By first demonstrating proficiency in these basic tasks, you’ll then be allowed to close, meaning suture the incision, and even do other simple techniques with the scalpel or bovie.

Also, understand that each surgeon will have different preferences. Some will appreciate you helping to drape the patient, while others are more particular and would prefer you stay out of the way. When it comes to cutting suture, if you cut the tails too long, then there’s excess material in the patient which can lead to inflammation and increased risk of infection. If you cut the tails too short, then there’s a higher risk of the knot failing. The running joke amongst medical students is that you’ll always cut too long or too short, but never just right. That’s fine, just do your best to learn the surgeon’s preferences and take all feedback in stride.

If you found anything in this article helpful, check out my piece explaining the various members of the surgical team. And if you want to learn about the History of Surgery, be sure to check out this article.


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