11/13/24, 7\:28 PM Guide | Theatre etiquette

Theatre etiquette

Table of contents

Introduction

Medical students and foundation doctors are notorious for not knowing how to behave in the operating theatre. This is almost
invariably because nobody ever bothers to tell you how it all works, what to expect and what to do with yourself; instead, they
just expect you to somehow instinctively intuit the rules governing what is a very complex working environment. This means
most students and junior doctors get very little out of their often limited theatre exposure, and as a result are deeply uninspired
by the whole surgical thing, which I
To rescue you from potential awkwardness and embarrassment, I've put together a list of simple things I wish I had known
when I was a student. Most of these are things that I got shouted at for not doing/not knowing and therefore learned about the
hard way, my aim is to save you from having to go through this. It's very easy to feel like little more than an inconvenience in
theatre, but the informative tips below will hopefully help you learn lots, and you might even enjoy yourself!

Before the operation

Arrive on time; aiming to be about 15 minutes early is best. This is a simple point, but arriving late will make a bad
impression and the team may disappear o
without you. It is generally a
good idea to be well-rested and not hungover.
Before going to theatre, the registrar or consultant will go and see the patients to take them through the consent form and
mark them for the operation if necessary. It is best to go with them if you can. It will make a good impression on the team, and it
also means that you will get to meet the patient while they're actually awake and see their "patient journey
" through. Pay
attention to the consent process, as you will learn the answers to some common intra-operative interrogation questions,
including what the procedure involves and any common or serious complications.
After all the patients have been seen and consented, it's time to go and get changed. If you are going to be separated from
your team at the changing room door, make sure you know which theatre you need to go to when you get to the other side! If
you can't get into the changing rooms, go to the main desk, explain who you are and where you're going, and a nice person
should let you in.

Theatre attire

Here are a few key points about theatre attire...
Scrub colours
On entering the changing room you will probably be confronted by a veritable rainbow of di
example, my hospital has greens for general wear in theatre, dark blues for theatre sisters, light blues for general wear outside
of theatre, orange for healthcare assistants, pink for obstetrics and gynaecology, and grey for ITU doctors. The colours used
will vary between di
use royal blue, raspberry or turquoise scrubs), so check the local policy with someone if you're not sure which ones you're
meant to wear.
Scrub sizes
There should be a coloured band around the collar of the scrub tops and the waistband of the scrub trousers to indicate what
size they are. In my hospital, yellow is small, brown is medium, blue is large, white is extra-large, pink is XXL and red is XXXL.
Again, this may vary depending on which scrub company your hospital uses. There is often a helpful hand-made size guide
that one of the nurses has stuck to the wall somewhere - check the toilets if you can't
Shoes
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There should be a selection of rather unfashionable clog-like rubber theatre shoes available for you to put on. Don't take any
with people's names or initials written on, as you will be in trouble if they have to come looking for them! If there aren't any
spare shoes, don't be scared to ask somebody at the front desk to see if they can
don't wear your own shoes into theatre, for several reasons. Firstly, tramping mucky trainers into theatre is obviously not good
for infection control. Secondly, theatre shoes are speci
zapped by the diathermy. Finally, and perhaps most importantly, wearing theatre clogs protects your own shoes from
getting covered in horrible theatre mess. As a fourth-year medical student, I once had to squodge 2 miles home in trainers
drenched with stinky amniotic
experience, you'll never want to do it again!
There may also be wellies in the changing rooms. Don't wear these - they're for the urologists. I'll leave it to you to
why.
Hats
You will need to wear a hat to cover your hair. Confusingly, these also come in an array of colours for di
which may or may not match their corresponding scrub colours in any way. Medical sta
sometimes students are asked to wear a di
somewhere! There are two types\: stretchy elastic-backed ones, and ones that tie in a knot at the back of your head. Make sure
all stray bits of hair are tucked underneath your hat, otherwise, you run the risk of the theatre sister being less than impressed
with you. If you have a beard, there should be special hats for you with a funny extra bit to cover the beard area.
Jewellery
The general rules for jewellery are the same in theatre as they are on the wards. You must be "bare below the elbows"
with the
exception of a plain wedding band if you're married - apparently, the holy and sacred nature of wedding vows prevents
these rings from spreading any infections. If you're wearing earrings, I would either take them o
as they have been known to occasionally fall o
you wear to work. Necklaces are usually
over a year now and it's never been a problem.
Magic gowns
For infection control purposes, you are not supposed to leave the theatre area wearing your greens. If you need to pop out for
whatever reason, there is usually a stash of green gowns near the doors which will act to cover your scrubs and magically
prevent you from acquiring any transmissible bacteria during your time away from theatre. These are also extremely comfy to
wear and allow you to swoop dramatically around the hospital like some kind of cape-wearing surgical superhero. You'll see
most people wear them like a dressing gown with the opening at the front, but you're actually supposed to wear them like a
theatre gown with the opening at the back and the strings tied securely. Some hospitals may require you to actually get
changed to leave theatre, so check the local policy if you're not sure.
It can be di
still can't get a locker! Your clothes and shoes will usually be
little pile under a bench or on a windowsill; avoid the tops of the lockers as things tend to get very dusty up there. However, you
will want somewhere safe to keep your bag and other valuables. Most theatres will have lockers available for visitors, but you
will often be on a tight schedule and it can take a while to
theatre and ask the nurse in charge if it's OK to leave it in a corner out of the way. This has never been a problem as long as I
have asked
Each operating theatre will consist of several di
get scrubbed up, an anaesthetic room where clever people put patients to sleep, a little storeroom with basic equipment like
sutures and staplers, and the theatre itself. This means you will be confronted with several potential entrances when you arrive.
Just remember that you should never open any doors that go directly into the theatre during an operation, as this could let in
airborne contaminants that might land in the patient. For simplicity, I always use the scrub room door whether or not an
operation is taking place.
When you get inside your theatre, introduce yourself to everyone, explaining who you are and your grade or role. This will
encourage people to look after you and might get you cups of tea and/or cake if available (anaesthetists tend to be awesome
at baking). Make sure your name badge is clearly visible. Whatever you do, don't cower silently in the corner looking like a
lemon. The nurses and ODPs might seem stressed and scary, but in actual fact, they are lovely hard-working people who will
welcome anyone who seems keen and friendly.
This may seem obvious, but don't use your phone in the operating theatre. Put it on silent and leave it in your bag - there will
always be chances to check it in the co
This may seem even more obvious, but for God's sake don't even think of taking photographs!
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Theatre lists should start with a "team brief"
where everyone (e.g. surgeons, anaesthetists, nurses, ODPs, surgical practitioners,
medical students, company reps) introduces themselves and their role. The team, led by the surgeon and anaesthetist, then
discuss the cases for the day, including the order of the list, the positioning, drugs and equipment that are required, and any
speci
, so if
anyone walks in and asks "shall we hug?" or "have we huddled yet?" this is what they mean!
After the team brief, the
nurses and ODPs get the necessary equipment ready, and the designated scrub nurse for the operation gets scrubbed to open
and prepare the instrument trays. Meanwhile, the anaesthetists and their assistants crack on with putting the patient to sleep. If
you're anaesthetically inclined, you could always ask to go in and watch this. The surgeons may loiter in theatre or go for a
co
ALWAYS have a bite to eat and something to drink before the
surgeons go for a co
for long periods, and operations often take longer than expected for various reasons. Hunger and hypoglycaemia mean shaky
hands, slowed re
standing, heavy scrub gowns, gloves, masks and hot bright lighting can mean you also get overheated and dehydrated very
quickly. Fainting is a genuine risk, and often happens to the last person you would expect (e.g. the six-foot-something rugby
players) so make sure you look after yourself. If you end up going the whole list without peeing, you aren't drinking enough!
Speaking of peeing, it's always sensible to go to the loo before starting a long operation.

Preparing for the operation

Preparing the patient

Once the patient is asleep and the anaesthetist has established all the necessary intra-operative monitoring, they are brought
into the theatre. If a catheter is required, the nurses or surgeon will usually do this - if you've had some experience of
catheterisation you could o
It takes several people to move the patient from their bed to the operating table with the anaesthetist giving instructions and
controlling the airway, IV access and other attached monitoring. This is something you can help with which will make a very
good impression. The process usually requires the use of a PatSlide, which is basically a plastic board used to slide the patient
across from the bed to the table.
Here is a charmingly 80s video from Ross Mannion on YouTube illustrating how this is done (nowadays we usually need two
people on either side as our patients are getting heavier).
Once the patient has successfully reached the operating table, the patient is positioned for surgery. There are many di
positions which provide access to di
removed to accommodate these. The patient needs to be securely strapped to the table so they don't fall o
and should have adequate padding provided to minimise the risk of pressure sores or nerve injuries. The surgeons usually help
with this but they might go to scrub while the rest of the team do it. It is good practice to ask the anaesthetist's permission
before positioning the patient and to maintain the patient's dignity as much as possible by minimising exposure.
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Lithotomy position

Scrubbing, gloving and gowning

As a medical student or supernumerary member of the team, it is good practice to wait to be invited to scrub in. If you appear
to have been forgotten about, you can always ask permission to scrub in and assist - the worst that can happen is that they will
say no, but most surgeons will appreciate the initiative and the ones who don't are less likely to be keen on teaching anyway.
Check out our scrubbing, gloving and gowning guide for more details.
If you can't scrub in due to there being too many people/an unenthusiastic surgeon, you can either stand on a step to
watch or go hang out with the anaesthetist instead. Anaesthetists are a friendly breed of ca
teach you about all sorts of clever things that surgeons don't have a clue about, such as breathing tubes, millimoles, sodium,
ECGs and Poiseuille's law.
Here is a totally awesome video by Celine Lakra on YouTube, wherein a lady with possibly the nicest voice ever shows you how
to scrub, glove and gown properly.
Some key points that I would add to this are\:
There are three main di
and triclosan (SkinSan). I always use Iodine, as I
every last bit of skin whilst you're scrubbing. Whichever one you pick, stick to it, as mixing the solutions can lead to a really
nasty dermatitis.
Your
three-minute scrub, provided you have not done anything in between procedures that could grossly contaminate your
hands (e.g. going to the toilet or eating lunch).
Don't ever rush scrubbing in or cut corners - theatre sta
telling o
If you accidentally touch anything non-sterile at any point, you have to start all over again!
Always wear a visor mask to protect your eyes - you will be absolutely kicking yourself if you end up getting an eye-splash! I
speak from experience\: when scrubbing for an emergency C-section once I couldn't
was too scared to ask, so I went without and got a faceful of blood.
Most hospitals now promote double-gloving for surgical procedures, as it provides increased protection against needlestick
injuries and blood-borne virus transmission. You can either put on two pairs of normal gloves (I would recommend one of
your size and then one of the next size up) or there may be "indicator" gloves available with a green or blue under glove and
a normal white top glove, so you can easily spot if your glove has been torn or pierced. A lot of consultants opt not to
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double-glove purely because it makes it much more di
shouldn't impair your function to any signi

WHO Surgical Safety Checklist

The WHO Surgical Safety Checklist was introduced in 2008 and has since revolutionised patient safety and the whole culture
of surgical practice across the world. It was designed to make sure surgeons operate on the right bit of the right patient with
valid consent, as well as to reduce common preventable causes of operative morbidity and mortality such as badly
administered anaesthetics, allergic reactions, bleeding and infection. To summarise, the checklist is completed at three key
points\:
"SIGN IN"
- before the patient is put to sleep in the anaesthetic room, the anaesthetist con
the procedure they have been consented +/- marked for, as well as checking for any allergies or airway issues and making
sure all their equipment is working.
"TIME OUT" (also known as the "knife check") - before the operation starts, the whole team stops what they are doing
to con
bleeding risk, antibiotic requirements and VTE prophylaxis.
"SIGN OUT"
- before the patient leaves the theatre, the nursing sta
specimens are correctly labelled and any issues around the patient's post-operative recovery have been addressed.
The team brief at the start of the day is also part of the process. If you want to learn more about it and why it's so important,
read "The Checklist Manifesto" by Atul Gawande.

Prepping, draping and the sterile

After the knife check, the patient is prepped and draped. This involves cleaning the skin with an antiseptic solution such as
iodine or chlorhexidine, which is applied and left on to dry. Hairy patients often need to be shaved before the skin is prepped. If
monopolar diathermy will be used, the diathermy pad is placed on an area of healthy skin. A warming device like a Bair
Hugger™ might also be placed over the patient. Next, adhesive surgical drapes are applied to outline the surgical
abdomen or leg) and cover up the rest of the patient and the operating table.
Whilst waiting for the patient to be prepped and draped, stand with your hands clasped in front of you at chest or waist
height to stop yourself from touching anything dirty. You will notice that most surgeons will actually stand with their arms
folded, which seems to be a generally accepted alternative but carries a potential risk of contaminating yourself on the "dirty
"
back of your gown.
Always ask the consultant where they would like you to stand, they might want their assistant opposite them or next to them
depending on the procedure.
Once the patient is draped, you can approach the table. It is important to be aware of the sterile
allowed to touch. Things you can touch include the front of your gown above your waist, the prepped surgical
area and any instruments the scrub nurses give you. Things you can't touch include everything outside of this area. The most
common mistake medical students make is to forget that their mask isn't sterile and scratch their nose! Another common
pitfall is the surgical lights, which sometimes have sterile handles on them and sometimes don't - always check before
touching them.
Before making their
.

During the operation

Your role as an assistant

Speak clearly to other members of the team - don't whisper or mumble as nobody will be able to hear you through your mask.
Being an assistant is easy. If you do exactly what you are asked to do and nothing else, it is very di
responsibilities are likely to include\:
Holding retractors - swap hands at regular intervals to prevent fatigue and cramps
Cutting stitches and ties - always ask how long they want you to leave the ends, and whatever you do, don't cut the knot!
"Following" suture lines to keep the tension - this is the same principle as putting your
tight, but instead you pull upwards in the direction indicated by the surgeon
Using suction (be gentle) and maybe the diathermy (be careful)
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Holding the camera during laparoscopic cases - try to stay as steady as you can, and keep the surgeon's instruments in the
centre of the screen so they can see what they're doing
If you are asked to do something you don't hear, don't understand or don't know how to do, don't just guess. Ask the surgeon
to explain exactly what they need.
No matter how con
scrub nurses' tables or trays. Depending on which nurse you are scrubbed with, this could lead to anything from a polite word
in your ear to a slap on the wrist or even being told to descrub. This rule is part of general theatre etiquette but is also of
paramount importance because the nurses need to keep track of all the instruments for their
nothing gets left inside the patient. In most cases, if you need anything from a tray, even if it's just a mop that's easily within your
reach, it is good practice to ask the scrub nurse to pass it to you rather than grabbing it yourself.
If you accidentally touch anything non-sterile at any point, you will need to change your gloves, gown or possibly completely
rescrub. Be honest if this happens, as the patient will be at increased risk of infection if you become desterilised and then go on
to contaminate other things with your dirty gloves, such as surgical instruments or their internal organs. Sometimes you won't
even realise you've done it and the ever-vigilant scrub nurse will point it out to you - if this happens, apologise, thank them for
pointing it out and go sort yourself out without touching anything in the sterile
try not to get it on your hands if you can help it.
If you drop something or something falls o
up! Apologise and say clearly
"mop on the
up. This is very important to make sure nothing goes missing for the count.

Sharps

Doing operations on people generally requires the occasional use of sharp objects such as scalpel blades, needles and
scissors. Sharps safety is therefore absolutely paramount in theatre. Here are some tips\:
scalpels and hollow needles are usually passed in a plastic kidney dish rather than directly hand-to-hand
suture needles are handed over readily mounted on a needle holder and should never be touched with your hands - use a
pair of forceps to pick them up and adjust their position if necessary
when hand-tying knots, suture needles should always be "parked"
with their point facing towards the needle holder, to stop
you from stabbing yourself or somebody else while you tie
when passing sharps back to the scrub nurse, always park the needle and clearly say
"needle back to you
" or "sharp back to
you
" to ensure they take extra care
other things you might hurt yourself on include the diathermy, which can be sharp and/or burn through gloves,
orthopaedic instruments and stapling devices - one of my registrars once got his
don't underestimate them!
If you are unfortunate enough to get a needlestick injury - which can still happen despite everyone's best e
something about it immediately. You will need to descrub and manage it like any other needlestick by encouraging
bleeding, washing it thoroughly and applying an antiseptic +/- a dressing. The same goes for eye-splashes. The
will help you if you're not sure what to do. You will need to contact occupational health so they can co-ordinate risk assessing
the patient and consenting them for blood-borne virus testing - never do this yourself. Occupational health will also take your
blood for storage and arrange for you to be followed up and tested again in 6-12 weeks. Despite it being a genuinely
massive annoyance, it is very important that you attend occupational health follow-up as it's your health at stake, and also your
indemnity and payment protection insurance often won't cover you if you don't follow the process through properly.

General intraoperative survival tips

Fatigue
Long operations are very tiring, both physically and mentally, especially if you're not used to it. If you're on a placement where
you'll be in theatre a lot, one really important thing is to concentrate on your posture so you don't get a sore neck or back - this
is both surprisingly painful and surprisingly incapacitating. Most surgeons train themselves to stand with a straight back and
bend only their neck to look downwards at the patient, as this minimises the risk of strains - try to copy how they're standing
the next time you're in theatre. Don't slouch or bend your lower back too much as this will get sore very quickly and you will
rapidly start to get distracted,
going dead. If you end up being asked to hold something in a ridiculously uncomfortable position, speak up and say so, as
otherwise, you might drop things and more importantly might injure yourself or the patient.
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If and when you start to get tired, it can be extremely tempting to take the weight o
part of the operating table. Please remember that there is a patient somewhere underneath all of those drapes, and they've
already got enough problems without you squishing them.
If you're completely knackered and your hands aren't currently needed for an essential part of the operation, ask the nurses for
a stool and have a little sit down at the side of the room for a few minutes. The nurses can also bring you a lovely cold drink
with a straw (I personally recommend the ubiquitous NHS lemon squash) and will even manoeuvre the straw under your mask
for you if you ask them very nicely.
Fainting
Working in surgery is a visceral experience, in a lot of respects! Bleeding, whether from tiny venous oozers or massive arterial
spurters, is inevitable, so don't freak out when this happens. Depending on the operation, you may also end up getting up
close and personal with necrotic tissue, pus, poo or wee, which will obviously be unpleasant and smelly at times. The easiest
way to cope with this in theatre is to concentrate on breathing through your mouth and be very glad that you're wearing a
mask. It is worth noting that if you want to succeed in any branch of medicine, not just surgery, bleeding and bad smells
are something you just have to deal with. If you swoon at the sight of blood you probably need to consider a di
If you start to feel unwell or like you might faint, DON'T ignore it and hope it will go away. In most cases it will pass and you'll
be
fainting onto a member of the team and hurting them, or c) worst of all, fainting into an open body cavity and potentially
seriously harming the patient. The nurses are well versed in how to handle nausea and dizzy spells, and it may be that all you
need is a quick sit down for a couple of minutes and some sips of cold water. However, they may take you away somewhere for
a little lie-down and some toast and tea. Don't feel too embarrassed if this happens - it has happened to all of us at some point,
and the team will look much more favourably upon the assistant who acts honestly and sensibly than the one who tries to
power through and then ends up faceplanting into the patient's intestines.
Other distractions
If you need to go to the toilet, you'll need to weigh up your options and make a tactical decision. Most of the time you'll be able
to manage until the end of the operation. However, continuing to assist whilst being distracted by a massively over
might have implications for patient safety depending on the length and complexity of the procedure. If you're really really
desperate, it's better to descrub and relieve your discomfort, regardless of the potential eye-rolling/sighing/mockery your
request might invite from the theatre team.
Some bits of some operations are boring. This is unfortunately unavoidable, and even surgical trainees will sometimes get
bored in the middle of a long fa
important instructions or be slow to react when something unexpected occurs. Try thinking through the anatomy and blood
supply of the area being operated on or the pathophysiology of the underlying disease process, or asking the surgeon about
these. Don't start thinking about what to have for lunch or your upcoming epic night out on Friday, or you'll end up
irreversibly daydreaming and you will get caught out!
https\:/ /youtu.be/T4xEhU3h4AA
There may be music playing in the operating theatre. If this is the case, bad karaoke is highly likely to occur and you may be
expected to participate.
You will quickly learn that there are good times and bad times to ask questions. Most consultants appreciate students being
interested in what's going on and are more than happy to teach. However, if you want to ask something, the best time to do it
probably isn't when something big is bleeding, or when they are dissecting around something important or suturing up
something very small. Don't feel bad if you are ignored or rebu
concentrate.

Counts and closing up

When the surgeon has
hole(s) that they have made. Before this can happen, the nurses need to perform their
ensure that everything is accounted for and nothing has been left inside the patient. This can take a little while, as the two
people doing the count have to see every single instrument, even if it's still in use. Try not to disturb the nurses while they're
doing this as you might make them lose count! When they're
,
and the surgeon will verbally acknowledge this.
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Once they know there's nothing left inside, the surgeon can safely close the wound. This is often done in several layers with
several disuture materials. For example, a midline laparotomy closure often uses a big continuous size 1 PDS for mass
closure of the fascial layers, usually followed by some interrupted 2/0 Vicryl to the subcutaneous fat to bring the skin edges
together, then either subcuticular 3/0 Monocryl or skin clips to the skin itself. You will be expected to help by
retracting, cutting knots and following the suture line. If you've practised suturing before and ask nicely, you might be
allowed to suture the skin under supervision, which is very satisfying! If you've never used sutures before, don't try to blag it,
just say so - the surgeon may talk you through a couple of stitches or show you how to do it so you can have a go next time,
which is much better than giving it a go by yourself and making an embarrassing dog's dinner of things (see our suturing guides
for more details).
When all wounds are closed and the operation is
dressings are applied - these are usually OpSite dressings which come in various sizes, often endearingly referred to as
"baby
"
,
"toddler"
,
"teenager"
,
"adult" etc. The nurses often do this, but when I was a student I used to enjoy doing it as it meant I
could tell myself that I had at least contributed something useful!
At the end of the operation, the nurses perform another "
missing since the
. They again have to verbally acknowledge
this. If an item cannot be found, the theatre is searched meticulously for it, and it usually turns up on the
drape or a shoe or something. If it still can't be found, the patient needs an X-ray before they leave the theatre - this shows up
pretty much all metallic instruments apart from microscopic suture needles, and can also show mops, packs and pledgets,
which have an X-ray detectable stripe.

After the operation

When the operation is
into a ball before placing it in either the green laundry bin (for reusable gowns) or the orange clinical waste bin (for disposable
gowns). Next, check your gloves for holes, remove them by turning them inside out to prevent blood from
and place them in the orange clinical waste bin. Check your hands for any bloodstains or cuts that could indicate a torn glove
or needlestick injury. Finally, remove your mask and place it in the orange bin too. Then go and wash your hands thoroughly for
a minute or so - this is important for infection control and is also nice and refreshing if you've been stewing away in hot sweaty
scrubs for a while.
The patient is moved back onto a bed using the Patslide. Again, it is common courtesy to o
are very unwell, they usually stay in the theatre until they have woken up enough to be extubated safely, and are then taken
round to the recovery area for a period of monitoring before they go back to the ward.
The surgeons will then prepare and label any microbiology/histopathology samples, write the operation note and sign o
the WHO checklist and
Ask for feedback on anything you did well or could have done better, especially if you tied some knots or did some suturing. It
is useful to discuss any learning points and interesting aspects of the case to help you to understand what was done and why.
Thank the team for having you and say goodbye before leaving.
If you're on a placement for a few weeks, try and follow patients up after their operation. Go and have a chat with them on the
ward to see how they're doing, and follow up the results of any histopathology or microbiology from samples taken in theatre.
This will give you a better understanding of normal post-operative recovery and common surgical conditions.

Logbooks

Keep a logbook of operations you go to, especially if you think you might be interested in a surgical career. Remember that
your list needs to be con
or use an online logbook - the best one is the Intercollegiate Surgical eLogbook by the Royal College of Surgeons which is
used by all UK surgical trainees. You need two unique identi
date of birth. It is very satisfying to keep a log of procedures you've seen, assisted with and performed under supervision -
even little things like stitching up a wound count! You can also log more ward-based "medical" procedures such as
catheterisation, arterial line and central venous line insertion, pleural/ascitic taps and lumbar punctures - again, I really wish I
had known this as an F1! You can print out logbook summaries to put in your CV or portfolio, which will make you seem very
switched on and professional in undergraduate times of need, for example, if you are applying for a competitive summer
Source\: geekymedics.com
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