Intraoperative Case Management. Reading Assignment You are responsible for the reading material The operative sequence will be more thoroughly explained.

Intraoperative Case Management

Reading Assignment

• You are responsible for the reading material• The operative sequence will be more thoroughly

explained next class, but is the largest part of the intraoperative case management

Critical Thinking

• Involves organizing your thoughts and actions which allows you to make case management decisions

• Identify goal or issue• Gather info and evaluate it• Generate responses to issue or goal and

consider implications for each (usually a series of actions)

• Implement, act on, or produce best response

• Assess results of your actions and make adjustments if needed

Anticipation

• This is the ability to implement your critical thinking skills

• You are able to predict or anticipate the needs of the patient, surgeon, and other surgical team members

• The surgical technologist must be observant, organized, efficient, and able to think clearly

• The success of the operation depends largely on the STSR and his or her ability to anticipate the needs as they present themselves

Anticipating the Sequence of Events in Surgery

Example: An incision requires a knife blade (#3 handle with #10 blade), patient will bleed, surgeon needs a raytex or lap and cautery to cauterize bleeders. All of this is anticipated and the surgeon does not need to ask you for them because you know or can anticipate the needs as the situation presents. If you have passed a tie, you anticipate the surgeon will need another tie, then metz to cut the structure ligated, then straight mayos or suture scissors to cut the ligatures. None of this should have to be requested of you. Most of you actions will directly follow the operative sequence which you will learn backwards and forwards.

Operative Sequence

• Pgs. 372-373 St for the ST book

• By the Book• Incision• Hemostasis• Dissection• Exposure• Procedure• Hemostasis• Irrigation of wound• Closure• Dressing application

Communication

• Do not engage in idle chit chat• Do not participate in inappropriate conversation or

commentary • If you don’t have anything nice to say, keep your mouth shut• Speak when spoken to• Respond when surgeon speaks to you

– If he or she asks you for something and you don’t have it, let them know you’re getting it (ask circulator)

• DO NOT get defensive or argumentative EVER!• You are a surgical team member and will act professionally at

all times• Be advised surgeons yell and cuss when they get frustrated

sometimes. Remember, 99.9% of the time they ARE NOT yelling at you but at the situation. DO NOT take it personally.

• This is NOT about you, this is about the patient!

Communication

• The Intraoperative phase is when most verbal communication occurs (and sometimes least!)

• Provide what the surgeon asks for quickly and efficiently

• If you anticipate the surgeon will need something you do not have, ask for it from your circulator or make sure they have it available in the room

Conflict Management

• If you have an issue with a circulator or other team member– Ask that person if you guys can talk after the case– Choose a quiet, private area– NEVER deal with issues in an OR room in front of others

especially the patient!– Approach the person by stating that you felt they were

upset with you during the case. Do they have suggestions for ways you might improve? Yes, take the responsibility for the situation even if you didn’t create it. Often times, folks just get frustrated and take things out on whoever is available. They may apologize and say you haven’t done anything. They may give you feedback on ways to improve. Either way it’s a win-win situation for you. None of us are perfect and we can always improve!

Safety

• Use bovie holster even if the surgeon doesn’t. Keep it in front of yourself and reholster when not needed. If you see minor bleeding, anticipate the surgeon needs the bovie and have it ready to pass to him or her.

• Safe transfer techniques• Cautious/proper handling of sharps• Double glove• Protect self and patient from radiation (lead

aprons) and laser (appropriate goggles for type of laser being used)

Passing Instruments

• Know how to pass instruments correctly

Order and Neatness

• Keep your mayo and back table orderly and neat at all times

• Put things back in their original place after they are used

• This will help you find them next time you need it

• Nothing is worse than an unorganized STSR• Surgeons do not enjoy working with these folks

as they impede the progress of the procedure• Keep instruments clean after used• Do not give surgeons bloody instrumentation to

work with (keep a lap handy to wipe prn

Counts

• Initial• First count (closing 1)• Second count (closing 2)• Final count• Anytime there is a change in scrub or

circulator personnel (lunch relief or end of shift relief)

• TOTAL NUMBER OF COUNTS – 4 (ON STANDARD BELLY CASE)

• How many on a C-Section?

Counting

• Initial counts are done prior to the procedure when all items are on the back table

• Count instruments, sponges, laps, kittners/peanuts, miscellaneous

• Items close together to prevent items being overlooked• Be organized when counting, do not jump around• Additional items are counted as added to the field with the

circulator• Items and instruments must be visible to both parties involved

in the count• Count members must include an STSR and an RN circulator• Any time a cavity is entered instruments must be counted

in the initial and first count!

Counting

• First count (closing 1) Instruments

Begin at the field, move to mayo stand, to back table, then to off table (in kick bucket or other-case cart if an instrument dropped - is where it is usually placed)

Sponges, laps, kittners/peanuts Miscellaneous (blades, suture, bovie tip, etc,)

• Performed prior to or as the cavity that is being worked inside of is closed or being closed – Abdominal cavity– Pelvic cavity– Chest (thoracic) cavity– Cranial cavity (facility dependent)– Any time a cavity is entered instruments must be

counted in the initial and first count!

Counting

• Second (closing 2)Begin at the field, move to mayo stand, to back table,

then to off table (in kick bucket or other-case cart if an instrument dropped - is where it is usually placed)

Sponges, laps, kittners/peanutsMiscellaneous (blades, suture, bovie tip, etc,)

• Performed after a cavity has been closed as fascia or subcutaneous layer is being closed

Counting

• Final count• As skin closure initiated• Begin at the field, move to mayo stand, to back

table, then to off table (in kick bucket or other-case cart if an instrument dropped - is where it is usually placed)Sponges, laps, kittners/peanutsMiscellaneous (blades, suture, bovie tip, etc,)

Counting

• If something is missing: It is your responsibility to let the surgeon know immediately

• Do not reach in front of a surgeon• Do not grab items form a surgeon• Point to items counted that may be in their

hand, by saying “forceps, one up (point to his or her hand)….

• Let surgeon know immediately when item is located that may have been missing

• Patient cannot leave room until all items accounted for

Incorrect Counts

• Radiology technicians come to take x-rays for incorrect counts• Sterility must be maintained of yourself, your tables, and your

field• You may need to cover the patient with a separate sterile

drape to protect the filed should the x-ray be positive for a missing item and you need to retrieve it prior to transport of the patient

• Occasionally a patient is too unstable to stay in the OR for this• Surgeons may request the patient be moved to ICU in these

situations• Reports are delivered by phone or hard copy x-rays may be

returned to room for surgeon inspection

Specimen Care

• You may pass off specimens ONLY IF the surgeon says you may do so

• You must identify the specimen as the surgeon presents it to you and again prior to passing it off to the circulator so that he or she may record it correctly on the laboratory paperwork

• You must verify with the surgeon and circulator how the specimen is to be sent to the lab1. Permanent (In formalin)2. Fresh/Frozen

• With or without margins• With margins determines if all of a tumor has been cut out (clear margins

indicate all of it is excised)• Unclear margins indicate further excision is required• DO NOT break down set ups when awaiting frozen results with margins!

3. Culture • Specific microbiology tests to be run: Acid Fast Bacillus (AFB), fungal,

aerobic, anaerobic, etc.

Medication Handling

• Ask circulator patient allergies if they do not tell you what they are

• PCN allergies: typically will not used cephalosporins such as Kefzol or Cefazolin

• Ask surgeon prior to putting it in your irrigant!• Six med rights• Verify medication with circulator before allowing it

onto your field– Identify medication– Identify expiration date

• Keep up with amounts used of all medications that are solutions including irrigants

Dressing Application

• Do not receive dressings until FINAL count is complete (4x4s can be confused with raytex)

• Ensure that dressing is protected from becoming wet during drape removal

• Place a dry towel over the dressing that you apply, hold in place with one hand and remove drape with other hand

• Remove outer gloves and assist circulator prn with taping or securing dressing

• Continue/move on to post-operative case management