Whether you are having an outpatient surgery such as rotator cuff repair or a larger procedure such as total shoulder replacement, surgery is very much a team effort. Here are a few of the key players in surgery, some of whom patients will meet and others they will not.
Patient Access Representative
When a patient arrives at the hospital, a Patient Access Rep (PAR) will help him or her get registered in the computer system and will gather demographic and insurance information. If there is a co-pay required for surgery the PAR will ask if you would like to pay anything toward the co-pay at that time, though usually you may wait until after surgery if you prefer.
The pre-op nurse will ensure that a patient is checked in and prepared for surgery from a clinical perspective. This includes having the patient remove his or her street clothes and get in a hospital gown, placing an IV and starting fluids and antibiotics, cleaning the surgical site with a special soap, asking questions about health history and current medications, and inputting the preferred pharmacy for post-surgery prescriptions, which must be sent electronically.
The circulating nurse is in the operating room to assist with preparing the room and supplies for the surgery. He or she will also assist the anesthesiologist when you are going to sleep and waking up, as well as document what happens during surgery, including the relevant procedure times and what implants are used, and the surgical “time-out”, when the entire team paused to verify details about the patient and procedure to ensure safety. The circulating nurse is not sterile, so if the surgical team or anesthesia needs something from outside the sterile field or outside the operating room, the circulating nurse can go get it. This is also the nurse who updates the patient’s family or friends via telephone about progress during surgery.
The anesthesiologist or anesthetist is responsible for putting the patient to sleep and controlling their pain for the procedure, as well as making sure all of the organ systems are maintained and working properly during the surgery, from making sure there is blood flow to your brain, to making sure your toes are getting enough oxygen and your body is maintained at a safe temperature. They are in the room throughout the procedure to monitor the patient’s vitals, ensure they stay asleep, and help control any pain during the procedure. If the procedure is being done with a “block”, where a part of your body, such as your right or left arm, is numbed temporarily for pain relief during and after the surgery, the anesthesiologist does this, usually prior to the surgery.
For patients of the Oklahoma Shoulder Center, Dr. Betsy Nolan is the primary surgeon. The primary surgeon is responsible for most of the surgical procedure.
The ‘first assist’ is usually a resident surgeon or a physician assistant (PA) but may also be another attending surgeon. They play an important role in positioning of the patient. Their role in surgery is to provide support in whatever way the surgeon requests, such as holding retractors or using suction to keep the surgical field clear so the surgeon can see better. The first assist also acts as another set of eyes and ears for the surgeon. As the surgeon focuses on a particular task, it is the first assist’s job to survey everything else happening and do what’s necessary to support the surgeon. In many cases, the PA and/or resident also assists with taking care of the patient post-operatively if a stay in the hospital is necessary.
Scrub techs are another part of the surgeon’s support team. They set up all the sterile instruments for surgery, assist with retraction, handing instruments to the surgeon, helping put total joint implants together, and perform other sterile tasks as needed during the procedure.
Device Company Representative
For surgeries that will use an implant of some kind, a representative from the device company is also present. The representative will unpack the boxes to ensure everything meets the company’s specifications and be available to answer any specific questions related to the company’s implant or instruments.
Immediately following surgery patients will go to the post-anesthesia care unit, or PACU, where nurses will monitor your vital signs as your anesthetic wears off, and will ensure that your pain, nausea, and other symptoms are controlled. Once you are awake and stable in PACU, you will then either go to back to your ambulatory care unit (ACU) room and then home, if having outpatient surgery; or you will go to the Medical/Surgical Floor (usually specifically a ward for total joint replacement patients) for overnight recovery.
Post-Operative Nurses & Techs
After surgery, a team of nurses and techs will care for the patient on the floor. Nurses will administer meds and monitor pain levels, nausea, and other postoperative symptoms to ensure the patient stays comfortable while recovering. Techs assist with activities like toileting and bathing, as well as checking vital signs.
For some procedures, X-ray is required during the procedure to check, for instance, fracture alignment or hardware placement. An X-ray tech with a mobile X-ray machine called a C-arm comes into the operating room to take x-rays when requested by the surgeon. The X-ray tech may also get images in PACU or on the floor, if needed.
Physical Therapy (PT) and Occupational Therapy (OT) are both important to your recovery from surgery. PT will teach you how to do elbow/wrist/hand exercises after shoulder surgery, and OT will teach you how to do your activities of daily living (ADLs), such as bathing and dressing, with one arm. The therapists are also helpful in adjusting your sling to fit properly and comfortably when you get out of bed.
A case manager or social worker may be assigned to you for assistance in planning for your needs after you leave the hospital, which includes arranging for home health nursing/PT/OT as needed, obtaining assistive devices like walkers or shower chairs if required, or making referrals to acute rehab or a skilled nursing facility in the event the patient cannot go home after surgery (though this is rare after shoulder or elbow surgery).
Additional Support Roles
Aside from the team members directly involved in surgery and pre/post-operative care, there are additional support staff members often working behind the scenes. This category includes schedulers, medical coders, billing department staff, medical records staff, and hospital administrators, all of whom help ensure a smooth process for patients. Staff in the sterile processing department also prepare the sterile instruments for surgery. Without all these team members, we could not as successfully do what we do. While a patient will mostly see their surgeon, PA, and pre/post-op nurses, it takes the entire team to ensure a successful surgery.
By Oklahoma Shoulder Center PLLC
July 1, 2020