Scrub

I learned to scrub concurrent with learning to circulate, back when nurses in the OR were expected to perform both roles well, even as there were scrub techs who only scrubbed. This is no longer the case, as scrub certification programs became the norm. I'm glad I had the chance when I did.

These days, when I scrub, it's often just hands or feet, as those are the less technically demanding cases. When I was taught initially, I learned general cases, urology, peripheral vascular, transplants, gyn, and a few simpler orthopedic cases, eventually a bit of arthroscopic cases. Learned ortho scrubbing in Boston, scopes, backs and trauma broken bones, but never total joint replacements. Those are very complex to scrub, and the surgeons expect the scrub to have it all memorized, just handing them what they need in the proper order. Huge set-ups, many pans of instruments.


So, when I'm scheduled to scrub, I take off my watch and ring, and check my case carts. Make sure I have everything I need for the whole day, from two to ten cases, usually more like four or five. Check the schedule for special equipment or implants, pull the extras for the specific cases, light handles, gloves - in various sizes and types - for everyone, fluid bottles, other commonly used sets for just in case, like k-wires or 70˚ scopes, different shavers, or osteotome/curette sets. Sutures as needed, depending on the case and surgeon preference. Deciding what needs to be open, what needs to be just available, and knowing what we have as a facility so as not to screw over another room, or myself later in the day.

Go to the sink, do a 5 minute scrub, dry, apply surgery scrub approved antibiotic gel, take a quick break. About 15 minutes until the first case, get mask on, open all the supplies, re-gel to specifications, self gown and glove to sterile standards, set up table in a clear and organized way, counting sharps with circulator, setting out drapes, pulling out frequently used instruments, setting up the mayo stand with cords used at the beginning, light/camera/remote/shaver, bovie, suction, drill cords.

Surgical team comes in scrubbed, I hand towels or gowns, glove them, drape or assist draping. This can be just a surgeon, maybe a fellow &/or resident, sometimes 2nd resident, occasionally med student or PA.

Then the case starts, and I hand instruments pretty much constantly throughout as they dissect and repair, as well as handle irrigation, specifically requested implants as handed to me by a rep or circulator, replace anything dropped or contaminated, protect everyone from scalpel blades and suture needles, watch for any potential contamination by anyone, hold retraction as needed, move my table to allow access, drape c-arm or mini-c-arm, move in and out as x-rays are taken and the c-arm is moved in and out of the way. Anticipate needs based on what they are doing, and mumbled plans that change as they see the actual damage, and communicate that to the circulator.

For fractures, handling the drill bits, tissue protectors, k-wires, changing out heads or chucking up different items, hand the depth gauge while getting the proper screw driver for the proper screw. When given the size, pulling it out of the screw rack (sometimes ain't easy) measuring it and confirming as I hand it over. Noting it so the circulator can document implants.

I adjust what I have up close depending on the part of the case, to avoid a pile of instruments that could pierce a glove or be dropped or simply to make it easier to hand what is needed without rummaging through.

This little bugger has cut through more doubled gloves than anything else. And everyone uses it.



And knowing all the names, and alternate names, and joke names for them all. Handing an instrument in a rapid, fluid, steady motion to the surgeon's hand in a way that they can use it properly without looking at it, and to the proper hand. Sometimes two instruments, one to each hand, at about the same moment. No, that's not even uncommon, a needle driver(there are many different kinds) and a pick up (innumerable different varieties) so they can sew.

This all becomes second nature, the variations are what takes attention.

Then closing, as I do final counts with the circulator, accounting for every sponge and sharp. As I cut suture as the resident stitches. Circ gives me dressings, which I prepare to surgeon preference. Once unsterile, I cut away drapes, make sure no instruments are discarded, remove tourniquet and bovie pad, coil cords, usually with help from the circulator or whomever comes in to assist turnover, get all the wet stuff safely in garbage bags - mostly just for arthroscopy, there is remarkably little blood. Discard my sharps properly, take my now tidied table to decontam beside sterile processing(SP), toss the laundry in the bin, garbage in the other bin, pour out suction containers, wash my hands, get another table, and go right back and do it all again.

After double checking the schedule so I have in my head what I need next, I make sure SP knows any one of a kind, or not enough of a kind, instruments or sets I need turned over. Meaning, cleaned and re-sterilized for the next case, or perhaps the one after that. Or for another room. Making sure no one has stolen the drill I knew was there first thing, but might have been needed sooner for another case. Or that the patient's hardware that they wanted has been processed for them. I may have to take specimens to be sent, or broken items brought to the SP staff's attention.

I return to the room, and hopefully the core guy and the resource staff have mostly cleaned the room, and will stay to help me open. If not, I will wipe everything down, mop, make the bed, change linen and garbage bags, adjust spotlights as needed, before opening supplies. But, hey, at least we have packs with most of what we need all in one place. When I started, we had to open everything, table cover down, every individual part of the drapes, bovie, gowns, pitcher, every scalpel blade, needle counter, suction and tip, bulb syringe. This is much faster now.

Our turnover time, from patient out to next patient in, is about ten minutes. Getting a few more minutes because the patient is still in the block room is wonderful. Although too much, all day long, because of a slow anesthesiologist, makes a big day much longer. As long as I'm open when the patient rolls in, I have time to set up.

This all sounds so much busier than when I circulate, but in terms of actual jobs and the time it takes, it's not much different, depending on specifics. And as circulator, I help with all the scrub does, and make sure they feel as cared for as I want to be when I'm scrubbed.

Some days, it's actually pretty chill, getting to joke with everyone, as the automatic responses take over.