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NURSESTAvo l. 31, NO. 1Inside theOperating Roomcardiac SurgeryRobotic operationssurgery in thePhilippinesNFstanford hos p ital & c l in i c sORDSp r ing 2011
FEATURES2The Evening ShiftRosemary Welde, RN, MBAPublisherNancy J. Lee, Rn, MsnEditor-in-ChiefSuzanne Taylor, RN, MS4Cardiac Surgery “On the Road”Sharon Butler, RN, BSN, MSN6Circulating for a Patient with ObstructiveSleep ApneaJoan Kline, RN, BSN, CNOREditorial BoardMark Andrews, RN, MASonya Feng, RN, MSNDana Gonzales, RNMary Lou Jackson, MSN, RNEllen LehmanNinette Pierce, RNGeoff PridhamSherry RossVickey Weir, RN, BSN, MPAGraphic DesignArtefact DesignPhotographySteve Gladfelter, Visual Art Services,Stanford University Medical Center8Hand-Off Guide for Perioperative NursesKim Axelrod, RN, CNOR; Jezrel B Badoy, RN, BSN, CNOR; KarenHafenrichter, RN, CNOR9Sharing their Wealth of KnowledgeMary Lou Jackson, MSN, RN, CNOR10The Miracle of MicrosurgeryAnnamarie Varo, RN, CNOR12Too Much PressureDana Gonzales, RN, and Ray Pickett, RN14RoboticsAnne Ganzon, RN, and Irma (Jo) Perry, RN16Soothing SoundsJEZREL B. BADOY, RN, BSN, CNOROn the cover: E. Albino, RN, BSN17A Culture of CommunicationIsobel Fox, RN, BSN, CCRN, Beth Sachro-Bonet, RN, BSN, CCRN, KimBollinger RN, MSN, CCRN, Nancy Clark, RN, CCRN, & Julie Shinn, RN,MA, CCRNStanford Nurse is published by theDivision of Patient Care Services.It is distributed to the Stanford nursingand medical communities, selectedindividuals, schools, organizations,and professional journals. Addresscorrespondence to: Editor, StanfordNurse, Center for Education andProfessional Development, 300 PasteurDrive, MC 5534, Stanford, CA 943055534. Stanford Nurse is indexed in theCumulative Index to Nursing & AlliedHealth Literature. 2010 by Stanford Hospital & Clinics,Division of Patient Care Services.All rights 18Crisis NursingVeronica Sherwood, RN20Medical Mission: Bringing Care to the PhilippinesRemy Wong, RN, BSN PCCN22The BMT/ICU Utilization ProjectTrisha Jenkins, RN, BSN, MPADEPARTMENTS125From the Chief Nursing OfficerIn Recognition
From the Chief Nursing Officernancy j. lee, rn, ms n, chief nursing offic er, vic e presiden t, patient c are ser vic esThis edition of Stanford Nurse focuses primarily on perioperativeservices, a specialty area little known to most other nurses.Behind the sea of blue scrubs, colorful hats, and surgical masksis a cadre of highly trained professional nurses who care for ourpatients when they are at their most vulnerable.Anesthetized and intubated, these patients require vigilantobservation, constant reassessment, and proactive care.Operating Room (OR) nurses advocate on behalf of theirpatients and provide compassionate care, often without thegratification of a thank you. As many of you know, surgicalservices has a very special place in my heart.The perioperative area is in many ways a world unto itself.The Main OR alone provides for over 12,000 cases per yearin 21 surgical suites with cases lasting from 2 to 12 hours.Collaborative practice is essential with over 500 employees;nearly 100 of them are registered nurses, many holdingspecialty certification from the Association of PerioperativeNursing (AORN). What I hope you take away from thispublication is a clear demonstration of the importantS PR I N G 2 0 1 1decisions these nurses make every day in the care of ourpatients.This issue also highlights some of the incredible work doneby the crisis nurses, one of the smallest nursing groupsin the hospital, and the role of a single nurse on her firstmedical mission. The final article, a discussion of ICUutilization, explores the important role nurses play indealing with end-of-life decisions with their patients.I am proud to call myself a nurse and even more proud tobe a nurse at Stanford Hospital & Clinics.STANFORD NURSEP. 1
The Evening ShiftFacilitating the Operating Room as a Resource NurseRosemary Welde, RN, MBA, Staff & Resource Nurse, Main Operating RoomThe operating room (OR) resourcenurse on the evening shift is responsiblefor the efficient functioning of the ORrooms, ensuring patient safety, andmaintaining clinical standards anddepartment policies and procedures. Asresource nurses, we must have strongorganization and communication skillsand be able to work closely with theanesthesiologist running the schedulingboard, other physicians, healthcareprofessionals, and ancillary staff.staff with each case. Timing and continuity of care areimportant in this situation. For example, we try to matchthe staff working the longest time period in the OR roomswith the longest cases. Some nurses, surgical technologists,and surgeons request to work together and we try toaccommodate these requests. If these teams work welltogether on specialized cases, our patients receive the bestcare and the staff members have increased job satisfaction.At 1500, we are usually running approximately 18operating rooms. The resource nurse makes rounds in eachOR room once per hour for an update, assists the staff inthe room when needed, and coordinates meals and breaksthroughout the shift.A typical night in the life of the resourceScenario 1nurseThe trauma beeper goes off and reads “99,” which is thecode for a Level 1 trauma in the Emergency Department(ED). The OR secretary calls the ED to get informationon the trauma patient. The patient is to arrive in 5 minutesand the OR resource nurse goes to the ED to assess thepatient. We immediately inform anesthesia and hold aroom until we receive information about the patient’ssurgical needs. We instruct the staff to stand by in OR #8,our trauma set-up room, and await the call. The patienthas been the victim of a drive-by shooting. He is alertand oriented with stable vital signs. He has clear lungsand no apparent bleeding. He has been shot in the lowerabdomen, hip, leg, and hand. Because the patient has beenshot in the abdomen, we assume the surgeon will performan exploratory laparotomy. The trauma surgeon sees thepatient and verifies that it is a “go.” We set up quickly andget ready to accept the patient. This patient arrives in theOR, the procedure is done, and no injuries are noted inhis abdomen. He is admitted to the Trauma Intensive CareUnit postoperatively for further care.At 1300 we receive a report from the day shift resourcenurse. We then make rounds in each of the OR suitesto check the progress of the cases, identify issues, anddiscuss the next cases with physicians. Many times, thecases may start later than expected, but the resource nursecollaborates with the physicians in order to ensure thecases are turned over as efficiently as possible. We usuallyaverage approximately ten “wait list” cases – cases that arenot listed on the general OR schedule. Cases are wait listedfor a variety of reasons: because the surgeon prefers the caseto be done following their regular schedule, the patient iscurrently in the hospital and the case is semi-urgent, or thecase has been on the schedule board for more than one daybecause the OR was very busy.By 1500, the resource nurse has assigned the staff nursesand surgical technologists to the appropriate rooms. Theseassignments may be time consuming for the resourcenurse, but it is important to place the most appropriateP. 2Some evenings the OR may receive as many as two to threetrauma patients, along with many urgent cases that needto be addressed immediately. An evening shift may includeany of the following typical scenarios:STANFORD NURSESP R ING 2 0 1 1
Surgical technologists Jake Lerios, ST,and Veronica Hughes, CST, preparefor a case while Rosemary Welde, RN,MBA, the resource nurse, and NinettePierce, RN, confer about the timingand progress of the current case.Scenario 2Scenario 3The transplant fellow calls to tell us we have a livertransplant patient coming in for a donated liver and “oneas a back up.” This means that if the other facility cannotuse the liver, then Stanford will receive it. The patientrequiring the back-up liver is in-house and is ready forthe OR if we are confirmed to receive the “back-up” liver.The liver transplant run time is 1900. We inform the liveranesthesiologist on call, identify the appropriate room, andstart setting up the room for surgery. Usually, we assumeit will be about six hours after the harvested liver is crossclamped, and we plan to send for the patient at that time.Careful coordination is required between the day resourcenurse and anesthesiologist to determine where cases willgo and which cases will be bumped if we get transplants.Transplant cases can continue well into the night and, onoccasion, until morning.The hand fellow calls to ask us how the schedule looks forthe evening because a man who has severed three of hisfingers with an electric saw is on the way. His estimatedtime of arrival is in one hour. Fortunately, we will have tworooms opening up in the next thirty to forty-five minutes.We set up a room, including a separate table for the fingersso that the surgeon can start working on them as soon as thepatient is asleep. Timing is critical in attaching the fingers.The surgery is successful and the team is able to save hisfingers after six hours of surgery.S PR I N G 2 0 1 1The unique role of the operating room resource nurseon evening shift is exciting and never the same. We arethe consultants for patient problems, advisors for clinicaldilemmas, and arbitrators for clinical disputes. We serve astriage nurses for patients and staff with the common goal offocusing on what is best for our patients at all times. SNSTANFORD NURSEP. 3
Cardiac Surgery “On the Road”Sharon Butler, RN, BSN, MSNStaff Nurse, Perioperative ServicesTraditionally, surgical teams only worked in the operatingroom. Since the 1980s, however, evidence-based practicehas led specialized teams to perform surgical proceduresthroughout the hospital. Advances in imaging technologyand devices for graft insertion in the aorta and heart valvesnow make it possible to treat more cases outside thetraditional operating room.P. 4STANFORD NURSESP R ING 2 0 1 1
For example, cardiac teams now close patent ductusaterious in the Neonatal Intensive Care Unit because it isconsidered safer when this procedure is performed at thebedside. The complex cannulation process for newbornswho require extracorporeal membrane oxygenation is alsocarried out at the bedside.The team may also travel to the interventional radiologysuite, the catheterization lab, and the intensive careunits (ICU) where operating room nurses and surgicaltechnologists play a crucial role in the procedure and arevital to organizing the supplies and equipment into amanageable and portable system for the surgery.A portable operating suiteThe portable system consists of a small stainless cabinet(2.5' W 4' L 3' H) that contains all of the suppliesand often serves as the operating table for the surgicalinstruments and sterile supplies. Other equipment requiredfor road procedures are a light box on a rolling standthat gives light to headlights worn by the surgeons forvisualization of the surgical site, and an electrical surgicalunit used to coagulate blood vessels to control bleeding.Collaboration is keyWhen the surgical team travels throughout the hospital,the staff is often challenged by tight quarters surroundinga patient, which is limited even more by the surgicalequipment. The anesthesia team does not always participatein surgical procedures done in the ICU. Therefore, thenurse caring for that patient has to work with the ORnurses to maintain sedation levels to allow the patient tobe comfortable enough for the procedure to be completed.The unit staff is very supportive and always willing toaccommodate special requests, such as putting on hats tocover hair and masks during the procedure.The catheterization lab and the operating room staff beganworking as a team when the interventional radiologist andsurgeon started inserting aortic stents as treatment for aorticaneurysms. The teams work together to precisely positionthe patient so surgeons can perform groin exposure and theradiologist can see the placement of the stent. The roles ofboth nursing staffs move between “active” to “available” asthe procedure progresses. The OR staff in “active” modeprepare and drape the patient and help the surgeon withgroin preparation. When groin preparation is complete, theOR staff takes on “available” role and the catheterization labstaff takes on the “active” role to assist in the deployment ofS PR I N G 2 0 1 1the stent. After deploying the stent, the OR staff resumesan “active” role by assisting with groin closure. Uponcompletion of the procedure, both teams prepare thepatient for transfer to the ICU.Another procedure done in the catheterization lab witha larger team from the OR is the Partners Trial. Thisprocedure involves aortic valve implantation, either via thefemoral artery or through a small thoracotomy incisionand then transapically placed. If the minimally invasiveapproach is not successful, the surgical team will perform asternotomy, place the patient on cardiopulmonary bypass,and proceed with open aortic valve replacement. The ORteam has to be prepared and ready for both situations.The team from the OR consists of two staff nurses, twosurgeons, two anesthesiologists, and two perfusionists.The catheterization lab is required to have many teammembers present, including four catheterization labstaff members, two interventional radiologists, and acardiologist. Additional associates in the room include aclinical specialist from the valve company and the nursecoordinator for the trial.A new electrophysiology treatment procedure involvingboth cardiologists and surgeons will be starting soon inthe cath lab. Electrophysiology treatments are currentlydone through devices introduced via the femoral arteryand then directed into the heart. Surgeons will now add atreatment to the outside of the heart via thorascopic port.This will require video equipment to be transported to thecatheterization lab so the surgical team will be able to seethe heart and the treatment during the procedure.The combination of different disciplines required toperform procedures will continue to evolve. And althoughthe hospital is committed to remodeling patient roomsand catheterization labs to be more spacious, we arepresently faced with many challenges as we perform hybridinterventional and OR procedures. But thanks to theinvention of the wheel, our operating room assistants andanesthesia technicians, and all the support we receive inother parts of the hospital, we are able to perform surgery“on the road” with great success. SNSTANFORD NURSEP. 5
Circulating for a Patient withObstructive Sleep ApneaThe Circulating Nurse’s RoleJoan Kline, RN, BSN, CNORAn interesting patient from out of staterecently asked me what I do duringsurgery. His eyes widened with interestas I explained my role to him. When Ireflect on my role as a circulating nurse, Ioften think back to my patient in OR 12.My patient in OR 12 is scheduled for a maxillo-mandibularadvancement for obstructive sleep apnea intended to movehis jaw forward in order to enlarge the space behind histongue and soft palate, making obstruction less likely. Mypreoperative assessment is the only glimpse I get of himwith his family before he drifts off to sleep in OR 12.This is my chance to reassure him and to getan overview of who he is—one of the mostcolorful and meaningful parts of my day.As I enter the OR, my eyes scan the room forneeded equipment and furniture. Efficiencyis key. With the flip of a switch our orderliesplay a major role, gathering any missing itemsas I enter the patient’s information into EPIC,our electronic medical record system. Nowit’s time to support our scrub technologist,Jenielyn Rivas. We confirm instrumentsterility. Together we count our sponges, smallitems, and sharp items before the patient enters the room. Itally our initial count on a grease board.As the anesthesiologist, Bryan Bohman, MD, wheels thepatient into the room, I greet him and introduce him toJenielyn. I grab a couple of blankets from our warmerto further extend our greeting and place sequentialcompression devices (SCDs) on him to prevent deep veinthrombosis.P. 6Once he is hooked up to our monitors, Dr. Bohmanconducts the verbal Anesthesia Safety Checklist, the firstof two “Time Outs” before the start of surgery: “Is theanesthesia machine checked? Yes. Pulse oximeter on andworking? Yes. Difficult airway? Yes, but the fiber optic scopeis here. Is the risk of bleeding greater than 500 ml? No, butthe patient has one auto unit available.”Drs. Riley and Powell apply cocaine-soaked pledgetts tothe patient’s nasal mucosa to provide analgesia and to easethe nasal intubation. They stand by the patient to assistDr. Bohman. Once intubated and catheterized, we spinthe tabletop 180 degrees. This gives the surgeons room tostand on either side of the patient’s face during surgery.They inject 0.25% marcaine with epinephrine 1:200,000 toprovide analgesia and hemostasis.I check the patient’s positioning a final time.He is in alignment, and his head is on a foam“Shea” headrest. His bony prominences arepadded. There is a pillow under his knees totake the pressure off of his back. His safetystrap is on. I position his arms on padded armboards by his sides in such a way to preventpressure on his ulnar nerves. His arms are notresting on his arterial line or his IV tubing. Iplace a grounding pad on his thigh to take thecurrent back to the cautery machine duringsurgery and get ready to prep his face while the surgeonsscrub their hands in the hallway.The surgeons place sterile blue towels around the patient’sface and drapes that extend over his head and cover his entirebody. Like an airline pilot reviewing a final safety checklistbefore take off, the entire team stops to verify the followingbefore the incision during our verbal “Time Out”:STANFORD NURSESP R ING 2 0 1 1
Necessary Introductions: There is a visiting doctorobserving, wearing his Stanford badge, and I introducehim to the rest of the team. Correct Patient and Procedure: “This is Jim XYZ. He ishere for a maxillo-mandibular advancement by Drs. Rileyand Powell.” Correct Position: “He is supine.” Correct Operative Site: “The correct site is draped.” Consent: “The consent is complete, accurate, andsigned.” Images and Implants: “The patient’s photos and x-rays areup, and the correct implants (plates and screws) are onthe field.”it and remind the orderly to check the bed, making surethat it moves easily into the sitting position—somethingimperative for post-op airway management. I call out topre-op to make the next patient ready.Upon closing the wounds at the end of surgery, Jenielynand I do the first count which is correct. After the second,then final correct count, I conduct the team debriefing thatall team members discuss: Name of Procedure and Wound Class: “Maxillomandibular advancement, clean-contaminated.” Counts: “Both counts are correct.” Specimens: “There are no specimens.” Allergies: “The patient has no known allergies.” Equipment/Instrument Problems: “None.” Prophylactic Antibiotic: “Kefzol, 1 gram given at 0745.” Key Concerns for Recovery or Management of Patient:“None.” DVT Prophylaxis: “SCDs are on and running.” Aseptic Technique: “Our integrators and indicators werechecked.” Any Critical or Unusual Steps Anticipated: “No.” Procedure Duration: “Four hours.” Anticipated Blood Loss: “500ml. One auto unit wasconfirmed with the blood bank.” Any Patient Specific Concerns: “His wife and son lefttheir cell phone number on the pink slip in the chart.”I plug in the suction, cautery, and the surgeons’ headlights.I confirm the settings on the cautery and plug in thenitrogen and electrical power equipment. Jenielyn and Iconfirm the labels and expiration dates of the cold salineand local anesthetic that I transfer to her back table. Sheclearly initials and labels both of them. Now that thesurgery is underway, I catch up on my documentation.I give North ICU a 15 minute warning and take a roomassignment. I check the patient’s arm for his ID band. Ialso complete the implant sheet and secure his x-rays andphotos. I stand next to the patient to assist Dr. Bohmanas needed during extubation. Dr. Riley applies a nasaldecongestant to the patient’s nose to reduce swelling andprevent bleeding.The patient is sitting up in his bed after extubation, awakebut very drowsy. He breathes easily with oxygen by mask at6L/minute. The surgeons and anesthesiologist accompanyhim to North ICU. As I sit down to finish my charting, Ifeel a sense of satisfaction after a very smooth surgery. SNI then check the instruments and supplies for our nextpatient’s surgery, a tonsillectomy and genioglossusadvancement. The personnel in the core supportthe technologists and nurses by providing us withinstrumentation and sterile supplies. We couldn’t do ourjob without them.As I open additional sponges and needles throughout thesurgery, I update the original count on our board. Thesurgery lasts about four hours. About an hour before theend of the surgery, Dr. Bohman hands the 45 minute noticeto me to send to North ICU. I send a bed slip along withS PR I N G 2 0 1 1STANFORD NURSEP. 7
Hand-off Guidefor Perioperative NursesKim Axelrod, RN, CNOR; Jezrel B. Badoy, RN, BSN, CNOR;Karen Hafenrichter, RN, CNOREffective communication between caregivers is vital for patient safety. This isespecially critical during “hand-off” situations, such as shift changes, when vitalpieces of information could be left out or even misunderstood and wronglyinterpreted. Such a mistake has the potential of costing the patient’s life.Several articles and studies have focused on improvinghand-off communication. However, it is rare to find a guidefor intraoperative nurses during shift changes. It is duringthis period that nurses need to be extremely alert sincethe patient’s status and acuity could change in an instant.In addition, factors such as positioning and availabilityof equipment and prosthesis need to be considered. Nothaving the necessary supplies could lead to aborting theprocedure.Recognizing this need, the Nursing Practice Council of theMain Operating Room (MOR) initiated the formulationof a hand-off guide for nurses during the operative period.Fine-tuned over several weeks, the final guide was presentedto the operating room staff in the form of a PowerPointP. 8presentation. In addition to explaining the importanceof hand-off procedures and how they are emphasized byJCAHO, nurses were also taught techniques on how toprovide effective hand-offs.Shared governance in this Magnet institution hasprovided the staff autonomy to initiate best practices.A staff-developed guide for effective hand-offs duringthe intraoperative period has great potential to improvepatient care and outcomes. Several months afterimplementation, nursing staff confirmed that the guidesignificantly made change-of-shift reports more accurateand complete. The guide assisted in facilitating a smoothtransition of effective nursing care. SNSTANFORD NURSESP R ING 2 0 1 1
Sharing their Wealth of Knowledgeexperienced Stanford OR Nurses as EducatorsMary Lou Jackson, MSN, RN, CNOR, OR EducatorMany years ago in a hospital far away,an OR nurse named Sharon taught mehow to scrub my hands, put on a sterilegown, pass instruments, and scrub andcirculate in simple cases.This eventually led me to a career in more complex cases inmany specialties including cardiovascular. It has been mygoal throughout my career as an OR nurse and educatorto be that same gentle and nurturing guide while payingstrict attention to critical details that ultimately affectpatient outcomes. Although I have only beena Stanford OR educator for three years, therehave been ample opportunities to recognizethat same wonderful teaching spirit in StanfordOR nurses with whom I have the privilege towork every day.Continual education is critical in all areas ofthe hospital if nurses are to effectively care fortheir patients. Education is highly valued andappreciated at Stanford. When nurses join theOR team, education and competence are thepredominant themes while completing theirOR region and surgical specialty orientation. Since everynurse brings different knowledge and skills, orientation iscustomized to meet each nurse’s needs. Sheryl Michelson,RN, MS, BC, Manager of Perioperative Education, and Iwork diligently to teach in the OR region; however, ORnurses learn the most from each other, just as I learnedfrom Sharon. Whether it is the initial welcome of anorientee while sharing a cup of coffee, teaching how toassess a patient preoperatively, or setting up a complexsurgical room, the nurse as a teacher in the OR is extremelyimportant for the satisfaction and success of the nurselearner.S PR I N G 2 0 1 1One teaching method the Main OR (MOR) staff membersutilize to meet the need for knowledge and skills isscheduled education sessions, which provide an opportunityfor nurses to share their expertise. One MOR nurse, KimAxelrod, recently gave a slide presentation on radiationsafety in surgery as part of her safety improvement endeavorinvolving lead aprons for staff protection. For the MORnurses unable to attend a scheduled session, informationand education is acquired from a weekly multi-pagebulletin written by Jonathan Fuller, RN, which he postsand distributes through email.Colorful posters are a creative teaching method used in theMOR to present educational information and competencyrequirements. The convenience of havinga poster near the control desk allows staffon all shifts to review the latest policyupdates. Considering the complexity andmyriad details of perioperative patient care,it is important to have references for futureaccess. The MOR is rich with resources thatnurses have created, from binders about livertransplants and eye surgeries, to photos anddiagrams on robot laparoscopies, to a generalMOR pocket reference booklet.The energy and enthusiasm of our nurses to help eachother learn and strive for excellence is inspirational. Toteach another while having the responsibility of patient caretakes confidence, energy, compassion, and a lot of patience.Nurses teaching nurses in any capacity is a gift given tohelp others gain knowledge, skills, and competence. Specialaccolades are due to the nurses who remember what it waslike when they were once rookies and then create a holisticand individualized learning environment that fostersgrowth and satisfaction. Thank you to all the nurses whoshare their expertise! SNSTANFORD NURSEP. 9
The Miracle of MicrosurgeryMicrovascular Free Flaps in Head and Neck ReconstructionAnnamarie Varo, RN, CNOR, Assistant patient care ManagerPlastic surgeons use microsurgery torestore the form and function of thehuman body that may be disfigured dueto trauma, cancer, or surgery.Microsurgery is a techniquein which surgeons use anoperating room microscopeto repair blood vessels andnerves that are otherwise toosmall to operate on. It is usedto transfer or “transplant” tissuefrom one part of the body (the donorsite) to another (the recipient site) for thepurpose of reconstruction.When part of the jawbone has been removed due to acancerous tumor, the most important application ofosseocutaneous free flaps is the reconstruction of themandible. Common donor sites are the iliac crest, thefibula, and the scapula. While the tumor surgeon isworking in the head and neck region to remove the tumor,a second surgical team can work on harvesting the fibula.The unit of tissue that is transferred, called the “flap,”maintains its own blood supply. Often two surgical teamsare able to work simultaneously, which helps expeditethe operation and shorten the overall operative time.Two nursing teams are generally required to help keepthe instruments separate, since one site is contaminatedwith tumor cells and the other site is not. Because thefibula bone requires special instrumentation, such asbone clamps, power tools, plates, and screws, experiencednursing teams familiar with the equipment of each surgicalteam are vital to performing a smooth operation and toP. 10minimizing the risk of complications. Patient safety is aprime concern, and therefore close coordination betweensurgical teams, nursing teams, and anesthesiologists isrequired. The ability to restore normal configuration of thejaw line and occlusion of the teeth is criticallyimportant to the patient’s outcome aftersurgery. Misalignment in the jaw can lead toan inability to properly chew food, swallow,or even speak. Plastic surgeons must have theskill and ability to shape a fibula bone into ajaw, as well as reconnect the blood vessels torestore adequate circulation to the tissues.Preoperative proceduresBecause these cases are long and difficult,usually 10-16 hours, each team member isvital to the outcome and success of the patient. The nursingteam consists of two circulators (nurses who are non-sterileteam members) and two scrub persons, who can be nursesor surgical technologists (sterile team members). The roleof the circulator is to be the patient’s advocate. The patientsare in an unfamiliar environment, away from everyone andeverything they know, so it is the nurse’s responsibility tomake sure the patients and their environment remain safe.During preparation, one circulator and both scrubs proceedto the operating room suite after morning report. This teamwill ensure all equipment, instruments, and supplies arepresent to start the case. They prepare the operating room(OR) suite, making it ready to receive the patient and beginthe procedure. The nurses are responsible for confirmingthat all equipment needed for the procedure is in the roomand in working order; they check the surgical bed to makesure it operates correctly and all components are visible;and they assist the two scrubs to open sterile items andinstruments and retrieve anything missing. Th
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