Theatre

Its a beautiful summer's day and I'm strolling down the long, almost half a mile long corridor to the 'west wing' theatres and I think to myself that the name 'theatre' to describe what goes on in and around this place is perfectly apt. I call it 'the dungeon' as its basically a cold box with no windows that I sit in the corner of feeling slightly sorry for myself - 'oh woe is me!' - I shouldn't really complain. There is a local town that sits in a valley and is famed with the title of the coldest place in the county, but I would bet a month of my NHS salary that that corner of theatre where I sit shivering - with thermals, two sets of scrubs, a 'warming jacket' and lead apron - is, in fact the actual coldest place in the world! he he. 

Note 1: a warming jacket is a kind of cardigan made out of paper which staff wore over their scrubs due to theatres being kept cold, but the hospital have stopped supplying them now to cut costs. The theatre is kept cold because the surgeon & 'scrub staff' have to work under the lights and get extremely hot.

I arrive outside theatre 9 at the allotted time of 8.30 am. This is when the 'WHO' takes place. I chat to the instrument rep - ha! he or she is always there early - and if I'm lucky they'll have brought some food with them, for the theatre staff or i may wangle a free coffee. 8.35 am - people wonder in and out. Its a hive of activity, people pushing brollies of equipment piled up, moving beds around and X-ray machines. I poke my head into the anaesthetic room to say 'hi' to the anaesthetist. I'm just checking really that it is our usual anaesthetist (not some Muppet). Well, its not the usual one but I have worked with her before and she's alright and she tells me we don't have a bed yet. The ODA is still drawing up the drugs into syringes and fixing them into the infusion pumps, all ready. If our case doesn't go ahead they'll no doubt use them for another more urgent case. As 'elective' surgery we are nearly always the bottom of the list for an ICU (Intensive Care Unit) bed, which is required, as after this type of serious back surgery, the patient needs to recover for at least one night in ICU - its not just the availability of an actual physical 'bed' but the need for there to be a qualified and appropriately trained nurse and other specialist staff on hand & all the machines and equipment - Otherwise the case will be cancelled. (one of the many possible reasons) You may think if an operation is scheduled then surely the bed would be booked, and it is, but sometimes the beds are taken in the night with emergency patients coming into the hospital, so its a juggle to get patients through theatre and out the other side - the thankless task of the 'bed manager' - who'd want that job!?

8.40 am I wonder round to check my equipment hasn't been carted off somewhere by some 'well meaning' person, and let a terrified looking medical student into the changing room as they don't have that access on they're swipe badge. Checking I've got enough consumables for the day I wonder back round to the front of theatre 9 and have another nice chat with the cell salvage guy or girl. Today its the lady who's roughly the same age and build as me and we joke about the fact that when clothed in our theatre gear people always mix us up. 'Perhaps we should swap jobs today' we joke, I wonder if anyone would notice. 

Note 2: Cell salvage is a method by which they collect all the 'gubbins' being sucked out of the patient and filter out the red cells from the blood then reconstitute them with fluids in order to give blood back to the patient - they're own blood. It saves the donated supplies and, during back deformity surgery, where the blood loss is high, it is almost a necessity.

Feeling bored, at 8:45 am I go to the loo again because if there is one thing that will ensure the surgeon arrives it's if I disappear off to the loo, no matter how long I've been waiting. 8:50 am I arrive back from the loo and of course nearly everyone is waiting, assembled in a circle for the WHO and they all look at me. "Ah, here you are at last" says the surgeon - "lets start."

But one of the theatre staff has gone to get something so we wait for them, and so other assembled members of the team start to drift off to 'get on' with something else and so the surgeon goes to make a phone call and when he comes back the ODA has gone to ring the ward, "Are we all here now?" says the surgeon - it's like herding cats! - and when we're all there we begin.

It always makes me laugh a little inside because the purpose of the WHO is to check that all the team are present and for each person to introduce themselves, saying their name and their 'job'. But everyone always mumbles these words or says them so fast or under their breath that I still, later on have to ask people what their name is (sometimes they have fancy hats with their name & profession on or I just casually strain to look at their badge, if I've already asked their name three times and forgotten it). The team is made up of people from all over the globe with all-sorts of accents and exotic names. It makes it really fun. Today we have two 'Blessings' one male one female from different parts of Africa. We also have Polish, Portuguese, Indian, Nepalese, two guys from the Philippines, English, Welsh and South African today - one of the few pleasures of the job, always good banter and humour.

The next purpose of the WHO is to glean information about the patient and to discuss this and establish the course of the surgery and whether all the necessary equipment is ready and present. We discover that the 'bloods' have not been cross matched for this patient but this can be sorted later, during the op, and the surgeon complains to his fellow that it is his job to book X-ray - why hasn't this been done? The fellow looks a bit sheepish. There is a panic about the equipment or metal work, as there is uncertainty about a particular tray of instruments that may or may not be available - the rep goes red, then white, then phones a colleague - it was supposed to be ordered in last week - a member of the theatre staff goes back up to the other theatres to check again - so we can't yet start but can get preparing, plus we still don't know about the bed. The surgeon sets a 'cut off' time of 10:30 am for the confirmation of the bed. Since the back ops are long they can't start too late or there will be complaints from the theatre staff manager. You're supposed to book an 'overrun' if surgery goes on after 6 pm so they can ensure the correctly trained staff will be around. Of course its not possible to know exactly how long the surgery will take, or anything else in the process.

Note 3: Surgical time estimates, based on the surgeon are only one part of the picture. These of course are extremely optimistic! If the surgeon says it will take four hours it can easily mean 6. This is not just due to the surgeons ego to be fair. All patients anatomy is slightly variable, particularly in deformity cases. Then you have to add on the time before the surgery - getting the patient to the anaesthetic room, then the anaesthetic time (preparing the patient with all the necessary lines for vascular access and anaesthetic drug administration etc. etc.) There is the time to sew up at the end, then time for the patient to recover in the 'recovery' ward before being taken to ITU. All this can add a further 2-3 hours at least.

I push my equipment into my 'cubby' hole in the cold corner and have a hunt for a chair. We have one especially assigned for our department but it has a habit of wondering off and I find it in theatre 12. The person returns from the other theatres (that's the one the other end of the half mile corridor) and has not been able to find the tray in question. The surgeon is informed and after some swearing, a discussion takes place with the rep about alternative trays and what may or may not be in them. Fortunately an alternative is found - cancellation dodged again - then at 9.15 we hear that we have a bed so can go ahead, at which point the patient can be 'sent for' from the ward and the trays need to be checked for 'holes'. The trays of instruments are wrapped in paper after being sterilised and stored on racks. It used to be sterile material but this got too expensive & so replaced with paper. If this gets ripped or torn when the trays are handled (or man-handled...they are extremely heavy, full of metal instruments) or if there's even a tiny hole in the two layers of paper the sterility of the set is compromised and has to be put back through a 3 to 4 hour sterilisation process again in TSSU (Theatre Sterile Services Unit). This fortunately still takes place 'in house' here. Many hospitals have the extra time wasting step of having to send all their equipment off to another site to be sterilised.

I think I may have just enough time to nip back up the corridor for a coffee and spare consumables and I rush this, only to return and find the patient has still not arrived in the anaesthetic room. There has been a certain amount of dithering on the ward plus the patient hasn't had a shower - which is important to avoid infection. I do wordle and the quick crossword, go to the loo twice more.

10 am the patient arrives in the anaesthetic room and there are no 'holes' so once the parents have said their goodbyes, they can be put to sleep and all the other magic that happens in the anaesthetic room occurs which takes until 11 am. 

Note 4: so at this point you're probably wondering what the hell I'm doing there, as you've probably realised I'm not just a 'talented' writer or journalist, there to critique the procedure - he he. I am there to perform 'spinal cord monitoring', which means in the anaesthetic room I place my needles and pads (electrodes) on the patient and these are used to monitor the patients sensory and motor signals that pass up and down their spinal cord. I use electricity to stimulate the nerves and motor cortex to give signals I can monitor on a computer and if the signals change I can warn the surgeon that the spinal cord may be being compromised and the surgeon can act. This is to help prevent any neurological deficits after surgery or, at worse case, paralysis. - Fancy huh. 

There are probably a lot of things that happen during surgery that the general public don't know about. I remember having a conversation with one of my friends, a highly intelligent lady, who was under the impression that the anaesthetist simple gave the drugs to the patient to put them to sleep then 'went' off for a coffee (she used more colourful language!). People used to wonder why they had a sore throat after lengthy surgery such as this - not realising that they will need a breathing tube inserted , attached to a ventilator to keep them alive during surgery. I am sure they tell them this these days. Also, since these operations are long the patient needs a catheter so they don't pee all over the operating table. This particular anaesthetist, unusually, hasn't been trained to do a female catheter and it transpires there's no one else on the team, other than the surgeon, who is qualified (or done the appropriate training course to do so). The anaesthetist argues that it shouldn't be him who does it really as the patient is female so the convention has become that the catheter is done by a female (and of course if the patient has requested this it will be honoured & there is always another female present.) No request in this case, it's just the whim (and religion) of this anaesthetist so he roles his eyes and exclaims, "who the hell's going do it then, shall I cancel the case?". They find a female who is qualified and we can continue.

The patient is positioned on the operating table - prone (face down) - all hands on deck in a frenzy to get everything secured, plugged in, and inserted. A tiny red light on the panel behind the anaesthetic room lights up and beeps in a high pitched tone. "Whats that noise?" the fellow asks. Oh it's an electrical fault that nobody has been able to trace to a cause. Its been like that for at least two years. I press the cancel alarm button, as I'm closest to it, which gives at least 3 minutes relief. "Why isn't the table working?" It won't go up and down, "has nobody checked it?" and it is established that it was checked but someone has unplugged it from the mains in the mean time. This also has an intermittent fault and in order for it to be controlled via the remote control the lead must be unplugged and plunged back in two or three times. Before the operation can finally begin, another WHO check is done, commencing with a check that we have the correct patient - or at least what's on the wrist band matches the op notes. The diathermy and suction don't appear to be operating - more eye rolling from the surgeon - put it up to 7 and can we have music. The team scramble round for a speaker - "what do you want to listen to?" With this surgeon it's usually 80's music but no Phil Collins, Maria Carey (too screechy) and definitely no 'Right said Fred'. I was once accused of abuse when I put on 'I'm too sexy' whilst he was closing one day - extremely sour looks received.

'Knife to skin' finally occurs at 12 pm. We are informed by the anaesthetist that she's been told, half way through the case, that the bed is no longer available as its been taken by an earlier emergency patient. "So what are we supposed to do now?" jokes the surgeon. We have no choice but to carry on. Something will have to be sorted later.

Surgery progresses relatively smoothly. The scrub nurse - the one handing the surgeons the correct instruments - is fairly new to this particular type of operation and the metal work involved and so is a little slow. There is huffing and puffing from the surgeon and the rep helps them, advising them on what to pick up and pointing to it with their laser pen to speed things up. 

One of my signals drops below the warning level, so I inform them - i.e shout to the surgeon - and they freeze. Various checks are made (everything can affect my signals so everything needs to be checked) I won't bore you with all these complex checks but lets say they are technical, physiological, anaesthetic and then surgical checks to establish a possible cause. Of course we may never know, but there is high tension as this happens and it takes yet more time. Fortunately, in this case, the signal improves and is 'within baseline limits' which means it is acceptable and the nerve pathways are functional so they can carry on.  

There is much hammering and tugging - orthopaedic surgery can be pretty brutal. There is quite a bit of blood loss as a result and the surgeon asks the anaesthetist, "are we ok?" meaning is the patient still 'fit' enough to continue, which they are and then he wants the microscope brought in to do some closer work. 

Note 5: The microscope is a large one on wheels which the surgeon can position and look through the eye pieces in order to see what he is doing better. We call this the 'time machine' because once this piece of equipment is in use, time seems to slow down for the rest of the theatre, but within the realms of the surgical field time will speed up, which is directly proportional to the 'stress' of the surgeon. 

Then they need a few X-rays, so the radiographer is called. If we are lucky we will get one that has done X-ray for spine ops before because the surgeons use a particular language which is another time waster if these commands have to be translated. For example, 'move North' means move the X-ray machine towards the patients head - nothing to do with the North the compass might be pointing to in this particular theatre. 

Eventually the surgery is finished to the surgeon's satisfaction and at this point he leaves to go and eat, drink, pee and talk to the parents, leaving the fellow to close up (sews up), which often he does so slowly that despite feeling like the op is nearly over, it can easily be another hour or so, with the sewing and dressing. 

I finish up and write my report, and remove all my electrodes, which are mostly disposable, and other things are removed ina rush to get the bed or trolley in, get the patient supine (back on their back) and the anaesthetist can continue to wake the patient and remove the breathing tube.

We often liken surgery to a flight. There are all the necessary safety checks then the take off is getting the patient positioned and opening them up. Once 'up in the air' the flight is maintained (the surgical operation) until coming into land, during closing and landing with the patient awakening. They will need a lot of pain killing medication, since this type of back surgery is said to be the most painful.