Behind the mysterious doors of operating rooms

Growing up watching medical dramas, I was always enchanted by what went on behind closed doors when the patient was wheeled to the operating room, the revered OR. The anxious faces of the family with their noses pressed against the glass, peering down at their patient undergoing surgery and praying for the best, stirred my curiosity.

But I grew up to a totally different reality. Our hospital operating rooms do not have a family viewing room and, at best, the family is left to sit outside the operating theatres on cold benches, waiting for news of their loved ones. They rarely get to see the lead surgeon come out to give them news about the surgery. Sometimes they are sent away and asked to see their patient the next day during visiting hours.

This unfriendly process cuts across to the private sector too, shrouding surgery in a cloud of mystery for our patients. Most people are generally uncomfortable with the sight of blood and hence would not venture into an operating room willingly.

The stable patient will go back to the ward while an unstable one may spend some time in the high dependency unit (HDU). Throughout the whole process, everything done is documented in the patient’s file for posterity. The patient can then be handed over to the ward nursing team, and the family members, who cannot wait to see their patient, may finally breathe!

The mystery around surgery has led to some pretty negative outcomes that could be averted. It is not uncommon for family members to question what went wrong when a patient dies in the operating room and remain unconvinced that everything possible was done to avert the death, sometimes resulting in litigation.

Good preparation is crucial to calming the patient and family during surgery. For elective (planned) surgeries, the patient will have seen the doctor prior and understood and accepted the condition, the nature of the surgery and what it is intended to achieve. In emergencies, the situation is different. The patient may be unconscious or in intense pain and the process can be terrifying.

After admission to hospital, the surgical team does a bedside patient and diagnostic report review, affirms consensus on the planned procedure, and obtains a signed consent. Pre-operative instructions are given depending on the procedure, such as pre-op starving, ordering of blood and medical implants where needed, and prescription of intravenous fluids.

In the case of elective surgery, the anesthesia team will assess the patient’s anesthetic risk at the bedside, discuss and agree on the anesthesia method with the patient, and take consent. The patient may be offered a mild sedative to help him or her sleep better. In emergencies, the patient will most likely meet the anesthesia team in the operating room.

Prior to surgery, the nursing team has the mammoth task of going over the pre-op checklist. This process may intimidate the patient and leave one feeling violated and hence it is handled with utmost sensitivity. The patient goes through a drill that may leave one feeling like one is checking into a maximum security prison. Clothes, jewellery, glasses, dentures and prostheses are removed and replaced with the flimsy hospital gowns and theatre cap that never seem to cover the necessary areas. The bladder is emptied, the patient is labelled and tagged, and all consents are reconfirmed. All patient records, infusions, blood and blood products, medical prosthetics to be used and necessary X-rays and scans are assembled. Only then does the infamous wheeling of the patient theatre happen.

At theatre, the patient is handed over to the OR team like a very precious package. The receiving team counter-checks the checklist and confirms it before the patient crosses the sterility barrier. The double doors then close, locking out the frantic family, and the waiting begins.

Meanwhile, the patient is wheeled to the receiving area, vital signs are re-checked for the third time, and the consent is re-confirmed. Finally, the patient is ready to meet the surgeon and anesthetist before the last mile to the operating table. As the nursing team completes their preparations by counting their surgical towels, swabs and instruments, the patient is taken through a final review of allergy check and then put under anesthesia. The surgeon and the assistant(s), who are scrubbed and ready, then get the go-ahead from the anesthetist to proceed with the surgery. Just so you know, the head surgeon does take instructions from someone else too!

Depending on the procedure, the patient may be awake on regional anesthesia (common in caesarian section where mothers describe it as ‘dying’ from the waist downwards) or will be asleep with a tube down the throat delivering anesthetic gases throughout surgery in the case of  general anesthesia.

The surgeon may be responsible for the actual surgery, but the anesthetist has the responsibility of maintaining the body’s physiologic function at normal levels, hence keeping you alive, even when things don’t go as planned. And you have the nurses to thank for maintaining sterility, hence saving you from infection, managing the surgical equipment, and providing extra supplies.

The duration of the procedure is dependent on the type of surgery, the patient profile (dissecting certain areas of the body may be more difficult in a patient who has undergone previous surgery or is obese), and the available surgical instruments. Complications arising during the procedure can prolong the surgery, cause the procedure to change, or cause abandonment of the procedure altogether to avoid risk of death.

At the end of surgery, before the patient is closed up, the almost religious counting of instruments and swabs takes place in a silent operating room. Only when the scrub nurse is satisfied that her count is accurate and every tiny piece of gauze has been accounted for will she allow the surgeon to close up the incision.

When the anaesthetist brings the procedure to an end, the patient with regional anaesthesia is good to go but the one under general anaesthesia requires reversal. The gases are discontinued and reversal drugs administered to wake up the patient. Oxygen is maintained until normal breathing resumes and the tube in the throat is removed.

Thereafter, the patient is wheeled to the post-anaesthesia care unit for post-operative monitoring and completion of prescribed blood transfusion, if any. The stable patient will go back to the ward while an unstable one may spend some time in the high dependency unit (HDU). Throughout the whole process, everything done is documented in the patient’s file for posterity. The patient can then be handed over to the ward nursing team, and the family members, who cannot wait to see their patient, may finally breathe!