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The Angels a Patient Never Sees

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Duke Health News 919-660-1306

Behind her are anesthesiologists and surgical assistants. They are watching her comfort the patient while the anesthetizing drugs begin to take effect. An amnesia-producing drug is being administered along with the anesthesia to ensure the patient will have no recollection of the surgery. The same drug will, of course, render the patient with no memory of the angel holding her hand.

"It's one of the biggest drawbacks, I think," says Marilyn Guigar, a perioperative RN at Duke. "They don't remember us because of the drugs they are given. But I take pride in knowing that I was there for them when they were at their most vulnerable."

Because patients seldom remember the nurses who were present before and during their surgery, OR nurses rarely receive recognition for contributing to their care. Few OR nurses wear the gold stars awarded by patients for outstanding health care service at Duke.

"An OR nurse is probably one of the most misunderstood of positions here at the hospital," says Yvette West, OR general surgery manager at Duke. "Some nurses from other floors have no clue what we do, and sometimes even the surgeons and anesthesiologists don't realize all our responsibilities."

What goes on beyond the steel doors on the third floor of the hospital? It is a place few people will ever see, unless they are a patient or one of the 200 member OR staff.

"Sometimes we feel closed off from the rest of the hospital because we work behind these huge doors," Guigar says. "No one gets to see us in here, so what we do is a bit of a mystery to them. A lot of people think all we do is hand the surgeon instruments, but it goes far beyond that."

The surgical team consists of the attending and assisting surgeons, an anesthesiologist or certified registered nurse anesthetist and two OR nurses ‚ a circulator and a scrub.

Circulators are registered nurses who move about the room and are responsible for coordinating the operating room and ensuring the patient's comfort. RNs are trained in the "total patient care" concept, have the ability to perform patient assessments and understand how to prioritize and plan patient care. The circulator is required to have these skills because ultimately they can be held legally responsible for any problems that arise in the OR.

Scrub nurses are responsible for handling all sterile equipment and supplies used during surgery. They "scrub" prior to surgery just as the surgeons do, and are the only people in the OR that can hand off the appropriate tools to the surgeon. Although the position does not require the RN license, it does require extensive knowledge of all instrumentation in the room. Due to rapid technological advances in surgery ‚ especially those involving lasers and laparoscopy ‚ OR nurses must constantly master new equipment.

Together, scrubs and circulators are responsible for maintaining a sterile environment in a room that can draw a crowd of observers in addition to the surgical team. They are also responsible for keeping an accurate count of every surgical instrument supplied for a procedure everything from sponges and clamps to retractors and needles are counted and recounted before and after surgery to make sure nothing gets left behind, inside the patient.

While the surgeons, scrub nurse and anesthesiologists are each focused on their part of the surgery, the circulator needs to ensure the patient maintains a safe position and is protected from the possibility of injury. The efficiency of the procedure often hinges on their preparation.

"Making sure the equipment and surgical instruments are ready to go maximizes the efficiency of the procedure," Guigar says. "The shorter the surgery, the less chance of complications for the patient. We all work together as a team, bottom line, because it's best for the patient."

Duke's OR nurses see anywhere from 75 to 90 cases a day between them. The day begins with checking the schedule board and heading off to the appropriate operating room to set up for surgery. There are instruments to set up and count. There are patients to interview. There is an entire room that needs to be accounted for. Days in the OR can be grueling.

"The work is extremely physical," says Shaun Bingham-Dindial, a perioperative RN at Duke. "The best part is being able to focus all your attention on that one patient. You have to put yourself in their shoes and think about how you would want to be treated. I like to think we're like their guardian angels."

Within the walls of the OR it can become surprisingly easy to lose sight of the patient. Hidden beneath blue surgical sheets, the exposed portion of their body painted mustard-yellow with antimicrobial soaps and solutions to keep it sterile. The only skin showing is the area the doctor needs to see. Their faces, hidden behind a drape, are visible only to those monitoring their vital signs. Hidden, the person as a whole becomes almost secondary to that part of the body being operated upon.

Although it may seem impersonal, it is a necessity, according to West. Each patient who comes to the OR has a story to tell ‚ and they have families and friends who are counting on the OR staff to heal their loved one.

"Health care providers have to depersonalize somewhat. I have had cases come to the OR that have given me the biggest lump in my throat, but you've got to do your job. If you grieved for them right there, you'd be incapacitated."

The trick, she says, is learning to balance the need for depersonalization with the need to be compassionate.

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