Roles in Patient Care

If you have spent any time in the operating room at all, then you know that optimal patient care relies on a number of different people working together as team. It wasn’t until I had spent a few weeks working in the hospital that I began to see how each person fits in and what that meant to me as an anesthesia provider.  

Early on in your education, especially in the first few weeks, it can be difficult to tell what role each person assumes and what their responsibilities are. Reading this sheet will help to prepare you for (most) all the interactions you will have on a regular basis. Understanding what everyone’s role is, in relation to you and the patient, can make things run more smoothly and ultimately keep the patient safe. Understand that you will meet many other people working in the hospital that are not covered in this document, this is just a beginner’s guide. 

Pre-op Holding Nurse:

Keep in mind how important your interactions are in the preoperative holding area. This is often where patients and their family members have first contact with the perioperative staff members, and first impressions can be lasting. The preop holding nurse is usually the first person to greet the patient. It is this nurse’s duty to get the patient changed into a gown, provide information about the surgery, deliver emotional support, and maintain a baseline hemodynamic status. In addition to this, these nurses must ensure that all preoperative data has been accumulated. This includes taking vitals, drawing labs, retrieving medication lists, gathering consents, and sometimes starting IV’s.

You will often meet these nurses when you first come to meet and preop the patient prior to surgery. Keep in mind that they are very busy in the mornings and they may not have completely all of their duties by the time you arrive. That being said, their duties do not automatically disappear because you have arrived and also need to speak with the patient. It is important to be respectful and work together. Ask if they are finished before heading in, and if not, ask if you can listen in and ask the patient questions while they do what they need to.

     

Circulating Nurse:

This is the nurse that you will be in contact with the most during your days in the OR. Essentially, they are another advocate for patient care and safety during the entire perioperative period. Usually, you will meet this nurse when you go to speak with the patient just before heading to the OR. They also have preoperative questions to ask and will confirm that all consents and needed paperwork are in order. Once ready, this nurse will take the patient to the OR with you. Once there, they will help get the patient on to the OR table and offer you assistance with induction. They are also the ones who prep the patient, help position, insert the foley, and provide the surgeon with any needed equipment that the scrub tech might not have direct access to. Keeping everything in order, the circulating nurse is responsible for making sure that everything runs smoothly, paperwork is completed, and the patient is safe. After surgery, you will transport the patient to PACU as a team and each give a separate report to the PACU nurses. In general, these nurses will be very familiar with where everything is in the OR. Don’t be afraid to ask for their help.

     

Attending Surgeon:

Sometimes referred to as the “captain of the ship.” He or she is the one that has brought the patient to be operated on and will manage the patient postoperatively and after discharge. Being the ones that are performing the surgery, they usually have the most influential voice in the OR and call most of the shots. The staff surgeon will many times be in and out of the room, only directing residents. Other times, they will be more hands on for the duration of the case. It is important to pay attention to the moves that and emotions that the surgeon expresses during the surgery. Even if they aren’t great at communicating, you can be clued in to what is going on just by observing.  

In all of your interactions with the surgeon, just keep in mind that the ultimate goal is patient safety. There may be times in which something the surgeon is doing or requests does not correlate with this. In these instances it is important to respectfully communicate your concerns with them. If you feel your voice is not being heard, don’t hesitate to contact your instructor or attending.

 

Surgical Resident or PA:

Just as in any medical specialty, part of the educational path for MD’s and DO’s includes a residency training program. Surgery is no exception. Following medical school, they must go through years of training in which they work directly under the supervision of an attending surgeon. This means that they will often start cases, finish cases, and work alongside the surgeon during the bulk of the procedure. In private institutions where residents do not work, you may see a PA in their place to help speed up the daily routine and allow the attending to run multiple rooms at once.

 

Early on in your education it may be difficult to distinguish which members of the surgical team are staff and which are residents or PA’s. Generally, the resident of PA will start the case and the attending will arrive once things have gotten started. Additionally, it will usually be the resident or PA closing the surgical site at the end of the case.

Scrub Tech:

Also referred to as surgical technicians, these healthcare professionals are an important part of the surgical care team. Their educational training is focused in the knowledge and skills associated with sterile and aseptic techniques. It is their job to have knowledge of hundreds of surgical procedures. This ensures that they can anticipate the surgeon’s next move and provide them with the tools and equipment that they need.

You will usually first see this person in the OR. They will generally be wearing sterile gown and gloves and working with the table of surgical instruments. It is important, especially early on, to be conscious of anything in the OR that is considered sterile, including people, the instrument table, and the surgical field. You do not want to get to close to or touch these areas and cause contamination. The scrub tech can be helpful in reminding you what areas are considered sterile and can often provide insight in to how much irrigation has been used during surgery to help you calculate patient blood loss.  

Attending Anesthesiologist:

These are the physicians that make our job possible. As it is stated in our title, we are to assist them. On most days, the anesthesiologist will be supervising two to three rooms. This means that they are in charge of the anesthetic care of multiple patients/surgeries at once while AA’s and residents handle the direct management. To make their job easier, it is important that we, as AA’s and students, do our best to gather and relay as much information about the patient prior to surgery beginning. Once in the room, they will lead induction and designate any perioperative management plans. Once the surgery is underway, you will see that it is crucial to inform your attending on how things have progressed. In many institutions, they would also like to be there for extubation. Part of our job is being adaptable to different anesthesiologist’s styles. It may take time to pick them up but can pay off on the long run.

   

Anesthesia Tech:

Learn to love the anesthesia techs because they will become one of your greatest resources as an anesthesia provider. It is their job to ensure that the anesthesia carts and machines are properly functioning and have all the necessary supplies at the beginning of the day and in between cases. They handle everything from syringes to arterial line and hot fluid line setups. When cases are over, they help to turn over the rooms and restock equipment that was used. Anesthesia techs also handle any special equipment you may need. For example, they are the ones you can call if you need to perform a fiber optic intubation. Many will even stay in the room while you are operating this equipment in an effort to help troubleshoot any issues. In addition, they set up the necessary equipment to deliver anesthesia in outside of OR locations such as MRI and CT.

It is possible that you will see one of the techs in the morning when you are setting up the room. They usually make rounds in the morning to ensure that the rooms are ready to go for the morning cases. You will also see them in between cases. Be sure to keep the phone number and location to the tech room handy because you will often need to get in touch with them to request certain things. Keep in mind that the techs are covering many OR’s at once. Try to anticipate any equipment you may need and call as early on as possible. This will give them enough time to get it to the room by the time you actually need it.

PACU Nurse:

As you may already be well aware, PACU stands for Post Anesthesia Care Unit. This is the area you will usually take patients directly after surgery (unless they need to go to ICU). The patient will stay in this area for a period of time to recover before heading back to their room or before going to stage II (the next step before heading home). PACU nurses are the nurses that take care of patients in this area. They are responsible for ensuring that the patient has adequate pain control, is not nauseous, is comfortable, receives any needed medications, and remains hemodynamically stable. Their job is made much easier by a job well done by the anesthesia team in the OR.

   

You will first meet this nurse as you are rolling your patient in to the PACU. Once the patient is hooked up to monitors, connected to oxygen, and charting is completed, you will need to give a report to this nurse. The circulating nurse will also give the PACU nurse a report. Do not be afraid to repeat certain information that you feel is important. I cannot stress the importance of giving an adequate report to these nurses. They need to quickly be made familiar with the patient’s medical history, allergies, medications, IV access, Ins and outs of fluids, medications, and any intraoperative events of significance. The direct patient care is now in their hands. 

Just remember that you are just one member of a very large team. Learning to work and communicate everyone you work with will make your life easier and will lead to better outcomes for patients.