Coming Soon To A Theatre Near You

Andrew Kennedy-Dalby, Year Five Medical Student, Salford Royal NHS Foundation Trust
andrew.kennedydalby@doctors.org.uk

Adjusting from the pre-clinical curriculum of textbooks and cadavers to the 3rd year environment of cannulas, ward rounds and stethoscopes can be daunting for even the most confident medical student. The opportunities available to us during our clinical years of medical school are a valuable resource that may help us shape our carer choices. For those that aspire to a surgical career, there is no better resource than getting to theatre and getting hands on experience of surgery. In this blog I’ll share some of the things that I wished I knew before going to theatre for the first time.

When should I go to theatre? There are some placements that make it easier to spend time in theatre. If you are attached to a surgical firm there may be a system for students attending theatre. For instance, some students may be expected to work a shift with the on-call team, and this could include going to theatre for emergency cases. These cases don’t just happen out of hours either – the on-call team for the day will also be operating between 8am and 8pm, so attaching yourself to this team for the day is a valuable, underused resource. If you would like surgical experience but have not had an opportunity through your placement, I would suggest having a look on signup page on Medlea as many consultants provide opportunities this way. If you do signup to theatre I would definitely recommend that you find out the procedures that will be happening. This can be done by either going to the theatre reception and asking the staff there, looking on the intranet (depending on your hospital) or by emailing the consultant and asking. In any case, I would also always email the consultant to confirm that the list is actually going ahead, and that they are still okay with you attending. This is always worthwhile as lists may not be running every week and signups tend not to match what actually goes on in the hospital! You can also ask the consultant if there’s anything particular you should look up, and what time you should arrive. Don’t worry if they don’t email back – just make sure you know what operations are going on in the session you are attending.

Once you know which cases are going ahead it is worthwhile doing a few things:
1) If the patient is already in hospital, go and talk to them. Take a history and examine them. Read the notes. Some surgeons expect this, and it is likely you will get asked about their symptoms and previous history by the team.
2) Read about the procedure. There’s no point going to watch a pancreaticoduodenectomy if you don’t know what to expect. Don’t worry about the ins and outs of the actual operation, I would just have a quick google to see what it’s all about – including the risks and intended benefits.
3) Read up the relevant anatomy – blood supply and innervation are favourite quiz topics. I always seem to get asked about the layers of the abdominal wall – definitely worthwhile knowing!

On the day: Most morning lists officially start at 8am. But no patient is ever on the table at 8am. If the patient is arriving that morning, it is worthwhile going with the surgical team to see them in the admissions lounge. Patients are normally asked to arrive for 7.30am, and are seen by the surgeon and anaesthetist prior to going to theatre. Find the surgeon and stick with them, this is a good chance to find out about the patient, and you might even see some surgical communication skills in action! If you have already seen the patient, or once you are give the go ahead by your senior, make your way to theatre. Find the changing rooms and get a pair of scrubs. Unless you have your own clogs then you will need to borrow a pair – often staff will discard old clogs for students to wear. It is a low point of the day rooting around in box to find a pair of matching, stained clogs, but it’s cheaper than buying a pair from that place in the Arndale! Theatre caps may be in the changing room too, make sure you cover all of your hair. Some places such as Salford ask that students wear green caps, whilst paid staff wear blue caps. Once you’re ready, head into theatre. Each theatre has three ways in: the anaesthetic room, the patient EXIT and the scrub room. Go in through the scrub room, where you will find masks and all the various scrubbing paraphernalia. Go through into the main theatre and introduce yourself to the scrub nurse, who will be preparing for the case. Tell them why you are there as well as who you are.  Often it is useful to introduce yourself to the anaesthetist as well, and you can get involved in putting the patient under – this is a really good place to practice intubation if you are with a friendly anaesthetist! Once the patient is under, stay with them. Help the theatre team move the patient (they will tell you where they need you), and once the surgical team arrives go and say hello. Be confident, if you don’t tell them who you are they will assume you are with another team!

– Go with an objective in mind: There is absolutely no point in going to theatre to stand in a hot room, under bright lights, getting grilled by a surgeon about the embryology of the foregut when you get nothing from it that you wouldn’t from reading wikipedia and smacking yourself in the face with a brick. You may wish to get something signed off, or you may wish to get a grasp of clinical anatomy – but it is a waste of your time to go and stand there, not seeing much.

– Don’t go with a friend: There is only a limited amount of space for the surgeon and their assistant around the operating field. If you go with your clinical partner, it is likely that you will not both get opportunities that you would if you went on your own. And more often than not you will end up chatting as you get bored of having nothing to do or see.

– You will feel in the way (to begin with): If you are not scrubbed in, it can sometimes feel a little futile to be in theatre. But stick with it if there is something specific you would like to see. Most doctors like to teach, and it is a useful learning experience. If you cannot see what the surgeons are doing, ask if you can scrub in so that you can get closer. You can also ask for a stool to stand on so that you can get above the action and peer in, just make sure you are wearing a mask if you are getting close! Also, take time to spend time with the anaesthetic team as they are a really useful learning resource and normally are keen to teach.

– Make yourself useful! Help move the patient at the beginning and end of the procedure, offer to cannulate and catheterise. If you are scrubbed in, hold anything you are asked to hold (you might feel like a human retractor at times), cut sutures, suction various bodily fluids. Most of all have a good time, I personally like feeling useful in theatre. Why stand and watch – you can sit and watch operations all day long on YouTube (http://www.youtube.com/watch?v=yhORvX-4Bx4)

– Prepare to be grilled: Most consultants were taught by being grilled, and so will take time to test your knowledge. This can be challenging, and don’t worry about getting things wrong or not knowing. They are not going to shout at you, or ask you to leave! And remember, the worst thing you can do is make something up!

– Reflect: This isn’t the point where I rip off my mask to reveal a portfolio tutor (honest!), but it is really useful to keep a reflective log of procedures you have seen. Also keep a log of any feedback you are given in theatre, and your response to it. How else will we improve?

Here are some useful resources for going to theatre:

1. http://student.bmj.com/student/view-article.html?id=sbmj.c3274
The above is a great guide to theatres and scrubbing up

2. http://videos.med.wisc.edu/events/65
Really useful anatomy dissection videos

3. http://ect.downstate.edu/courseware/haonline/quiz.htm
Anatomy spotter Quiz: this website got me through anatomy in 1st and 2nd year

4. http://www.elogbook.org
Use this logbook from the Royal College of Surgeons to record each procedure that you have attended, and assisted in. This will get you brownie points in job applications in the future.