During the Operation
Once the surgeon makes the first cut, there are risks of infection, blood loss, electrical burn from the cauterization device, sponges and instruments being left inside the body, and pressure injuries resulting in skin ulceration and/or paralysis. For this operation, Bob is going to be on his back and completely paralyzed for hours. Since the anesthesia drugs suppress all the person's reflexes, there is also the risk of corneal ulceration, because the eyelids can't blink and the cornea may dry out. Other risks include fluid overload, medication reaction, blood transfusion reaction, and injury during transfer.
It is the circulating nurse's primary responsibility to guard against these occurrences in the following ways:
- Properly ground the patient's body.
- Make certain the nerve plexus areas (armpits and behind the knees) are not pressing against any parts of the operating table or equipment.
- Provide adequate padding to pressurized areas with foam rubber wedges and the like.
- Monitor and report blood loss by keeping track of amounts in suction collection bottles and weighing discarded sponges.
- Monitor sterile technique of surgeons and scrub nurses.
- Measure and record the intake of intravenous fluids.
- Measure urine output and output from any drains.
- Calculate blood loss.
- Count all sponges, instruments, and needles before start of surgery and immediately before final closure.
If you can get a chance to speak to your circulating nurse before you go under, do it. Get him or her to give you the reassurance you deserve. This nurse might just be a bit more diligent knowing that you have a working knowledge of operating room procedure. The circulating nurse is the patient's advocate in the operating room.
I worked as a circulating nurse some years ago in a Chicago hospital. This one case involved major bowel surgery, which necessitated a wide opening of the abdomen. There was profuse bleeding that resulted in the use of 204 gauze sponges. Toward the end of this five-hour case, the surgeon looked up at me and said, "I'm ready to begin abdominal closure. Did you complete the sponge count?"
"We're missing one sponge. I'm doing a recount," I replied. "Okay, we'll wait."
I recounted the bloody sponges, and the total came to 203. I searched through all the garbage bags, and there was no missing sponge. I looked up at the surgeon and said, "The missing sponge is not out here. Let's do a portable x-ray before you close."
"I am not going to delay closing any further. You keep looking around for the sponge. I'm sure you'll find it on the floor."
"The sponge is likely still inside your patient, Doctor."
"I never leave sponges! Maybe we need to question your ability to count."
"Doctor, this patient is not leaving this room without an x-ray. If we do it now, we save her the added insult of you reopening her and causing more time under anesthesia than is necessary."
"You can take the x-ray after I close because you will not find anything in the patient."
Although the surgeon was violating hospital policy, I could not stop the closure. I notified the supervisor, who in turn called the chief of surgery. By the time he responded, the surgeon had finished closing the skin. In any event, we completed the abdominal x-ray, and the sponge was lying under the large bowel in the lower right quadrant. All surgical sponges have a string woven in that shows up on x-ray. The sponge removal took an additional two hours. No surgeon is perfect, but if this one had been a little less arrogant, his patient would have been better off.