Pace.
Fast pace. The speed at which a surgeon performs various manipulations is not always related to the quality and thoroughness of their execution, so the total duration of similar operations for a surgeon who operates very quickly, but fussily and insufficiently carefully, may turn out to be significantly longer than for a surgeon who operates slowly, but saving total time due to only the necessary actions, the thoroughness of their implementation, excluding annoying failures, the completeness of each stage of the operation.
Regardless of the technique and total duration intervention, the high pace of the surgeon’s work places increased demands on the assistant, who must have time to help with each individual manipulation (ligation of a vessel, tying a ligature, drying, etc.) at each stage of the operation. Here the assistant should strive not to delay the surgeon and at the same time do his job with all care. A fast-paced operation requires the assistant to have good technical training.
Average pace most favorable for quality assistance. With coordinated work and good surgical technique of the entire team, the pace “by itself” can imperceptibly increase.
Slow pace. The surgeon's slowness, as a characteristic of his personality, can also affect the pace of the operation. A slow pace may be necessary in some cases. dangerous situations. An outwardly slow pace may, as mentioned, be the result of a surgeon who generally operates very quickly, preferring to “hurry slowly.” This style usually characterizes very high craftsmanship.
Assisting such a surgeon can sometimes be very difficult, since with the meager completeness and simplicity of each of his surgical actions, any technical negligence or lack of composure of the assistant, precisely because of excesses, inevitably leads to a delay in the entire operation.
If the surgeon generally operates slowly, then the assistant should strive not to get ahead of him, which will only be a hindrance, however, he can and should promptly prepare the conditions for the surgeon to begin each subsequent stage of the operation, thereby reducing its overall duration. By assisting a slow-moving surgeon, the assistant can carefully practice his surgical technique.
Methodology. We understand by methodology accuracy, thoroughness and pedantry in the implementation of each surgical manipulation and fabric handling. As a result, it is the technique that best characterizes the surgical technique itself. In this regard, we will evaluate the level of the methodology in total as high, medium and low.
High level. The difficulties of assisting a surgeon with a high methodological level and high skill are mentioned above. This technique inevitably places its own demands on the assistant, forcing him to rise to the level of the surgeon. At the same time, the careful, thorough and pedantic execution of each surgical technique facilitates the task of the assistant in that the surgeon, as it were, “puts into his hands” what he this moment have to do. Here the assistant should strive to maintain the strict simplicity of each manipulation and not complicate it with any “liberties” of his style.
Average level. This level somewhat expands the assistant’s responsibilities, giving him more freedom of action and greater independence of choice, although this kind of independence is not a blessing, since it is not determined by necessity. best example surgical technique. In principle, the lower the operator's technique, the higher the assistant's technique should be.
Low level. Assisting such a surgeon is especially difficult, both technically and psychologically. The assistant must be extremely collected and attentive. Its task is to prevent all dangers associated with insufficient surgical skill. However, negative examples sometimes turn out to be useful for educational purposes.
Autonomy. By this term we understand the degree of independence of the surgeon from the quality of assistance, from the training and technical level of the assistant. In this regard, we will consider such variants of this characteristic of the surgeon’s style as complete, partial and insufficient autonomy.
Full autonomy. With this style of work, the surgeon does everything himself. He applies hemostatic clamps himself, ties ligatures and sutures himself, and drains the surgical field himself. Any active actions of the assistant and even attempts to actively help him interfere and sometimes cause a negative reaction. It is difficult to assist such a surgeon, if only because during the operation the assistant is forced to be almost motionless and does not feel the need. It seems that a completely autonomous surgeon can operate on “anyone.” The assistant's task comes down to holding mirrors and organs, providing the surgeon with proper surgical field.
Partial autonomy. The surgeon instructs the assistant to perform minor manipulations, which, in fact, is what assisting consists of. The given standard rules of assistance for standard situations are aimed specifically at such an operator.
Lack of autonomy. In this case, the surgeon significantly depends on the help of an assistant, since he is not used to doing everything himself. Such a “spoiled” surgeon is formed through long-term collaboration with highly qualified assistants, either he does not yet feel complete independence, or, being very experienced, he deliberately chose this style of work to train assistants. Regardless of the reasons, it is difficult to assist such a surgeon, since the quality of assistance is very demanding in all cases. high requirements. If insufficient autonomy depends on the surgeon’s insufficient qualifications, then the operation can turn into a collective one, without a clear distribution of responsibilities between team members, which is very bad, since this disrupts the operation plan and may cause problems. dangerous complications.
Knowing the peculiarities of assisting with the different working styles of different surgeons will help the assistant become a reliable assistant to each of them. At the same time, borrowing from everyone that good thing that will be more suitable for him in accordance with his individual characteristics, he will be able to derive considerable benefit from this.
5.2. CHOOSING AN ASSISTANT
What has been said here will largely relate to the operator, although it also concerns the problem of assistance. Naturally, every surgeon strives to choose an assistant who best suits his style of work and experience in a given operation. However, this possibility is not always available. The assistant also prefers a certain surgeon, but this
often also cannot be satisfied. Let's dwell on different situations, determining the composition of the surgical team and the general style of its work.
Assisting a surgeon more experienced than the assistant. This situation is the most common. In this case, the surgeon manages the work on the basis of unity of command, and the assistant must adapt as much as possible to the surgeon’s working style. Such assistance should also be considered as one of the the most important ways learning by example. However, the surgeon must also take into account the capabilities of the assistant, his technique and temperament and try not to put the assistant in an overly difficult position, even at the expense of slightly increasing the duration of the operation. If the assistant's experience is clearly insufficient, the surgeon can slightly reduce the pace and increase autonomy.
Assisting a surgeon of equal experience. Unfortunately, this is where annoying situations can arise. It is this kind of assistant who is inclined to critically evaluate the surgeon’s work, considering it from the standpoint of his experience and style. It is in such a situation that it is difficult for the assistant to refrain from giving unsolicited advice and excessive activity that interferes with the surgeon. And it is here that the assistant must strictly observe surgical discipline, adhere to the operator’s work style, and be active only in necessary cases and do not turn the operation into a “collective intervention” without a strict division of roles.
The position of the surgeon is also not simple. On the one hand, he has the right to count on the correct assistance of his colleague, on the other hand, he cannot completely ignore either fair criticism or sensible advice assistant, although this limits his autonomy to some extent. In addition, he must have inner confidence that difficult situation will receive necessary help.
The coordinated work of such a team is possible optimally if all its members comply with surgical discipline, the rules of medical deontology and the norms of human behavior determined by education.
Assisting a less experienced surgeon. This distribution of roles in the surgical team is carried out solely for educational purposes, so the maximum load and responsibility falls on the assistant. The degree of operator autonomy here may be somewhat limited, but the operator inevitably performs all manipulations exactly as he knows how - in his own style. This does not exclude the correction and improvement of his style in the process of work on the advice and demonstration of the execution of individual techniques by an assistant. The operator is obliged to follow all instructions of the assistant and listen to his advice.
The tasks of the assistant in such a situation are as follows:
- do not fetter the operator’s initiative, do not deprive him of his independence, do not “put pressure” on him with your authority and position, do not humiliate the operator’s dignity even with fair comments, but make them in a correct form;
- create the appearance of complete independence and autonomy for the operator, do not impose an unusual pace of work on him, but constantly and delicately adjust his methodology if necessary;
- be quite active in helping, leaving the key points of intervention to the operator;
- if necessary, take the initiative into your own hands - strive to do this unnoticed by the operator and other team members;
- if necessary, perform the most dangerous stages of the operation in whole or in part yourself, without changing your position;
- if necessary, impose on the operator best plan operations - to do this in such a way that, firstly, no other alternative arises, and secondly, so that the operator accepts this plan as his own decision; To do this, an experienced assistant “substitutes” for the surgeon exactly that zone of surgical action and in such a position that the further sequence of the surgeon’s manipulations becomes completely obvious to him;
- if complications arise due to the surgeon’s inexperience, do not blame him for this;
- if complications arise and your own intervention is necessary, do so immediately;
- if necessary, give advice - first ask what the operator is going to do himself, maybe there will be no need for advice;
- if the operator’s plan does not seem to be the best to the assistant, but, nevertheless, the operation will not cause harm to the patient, do not interfere with the operator in carrying out his plan;
- as the operator’s experience increases, reduce the level of supervision;
- at the end of the operation, objectively analyze all operator errors; the smart one will take it for granted.
This is the method of assisting a junior surgeon, which seems to me the most rational. However, there are other methods.
"Petty custody"- constantly remind the operator of what he must do, “hold the operator’s hand” in the literal and figurative sense, constantly seize the initiative from him when performing key moments of the operation and thereby actually perform the operation himself, without leaving him with even a misleading impression of some independent operation. If such an assistant’s behavior is dictated by necessity, then such an operator is simply not prepared to begin independent work.
Method of "throwing into water" is the other extreme. The assistant takes a completely passive position and provides the operator with the opportunity to “float” independently from any position until he requests help himself. This technique certainly has positive sides, but it may turn out to be unsafe and can only be approved in relation to an operator who has significant experience, approaching the experience of an assistant, since in this case we are talking not only about the training of the surgeon, but, mainly, about the high-quality performance of the operation, which can be significantly better with the proper activity of an experienced assistant.
To a certain extent, what has been said applies to a very specific area - medical pedagogy.
5.3. ASSISTANTS WITHOUT SURGICAL TRAINING
Since assistants of this category will most likely not read this book, everything said here is addressed only to surgeons who, due to some circumstances, are forced to operate without having any qualified assistant. Such assistants can be doctors who do not have surgical training, medical students, nursing staff and even random people.
General requirements for a surgeon forced to operate with such assistants are:
- the need for preliminary instruction of the assistant;
- training the assistant by demonstration during the operation;
- complete autonomy, the maximum methodological level available to him and such a pace that can be ensured without relying on the timely assistance of an assistant.
Doctors who do not have general surgical training. If these are representatives of the so-called narrow surgical disciplines (dentists, ophthalmologists, otolaryngologists), then they have their own specific professional habits that differ from general surgical techniques, which makes working together with them very difficult. So, for example, they are not used to working with gloves, are not used to a large surgical field, they do not have a “sense of tissue”, there is no wariness towards gauze balls, etc. Such assistants, figuratively speaking, “need an eye and an eye.” ", because, while trying to actively help, they can seriously interfere. Gynecologists, urologists, and traumatologists, as a rule, are quite “safe,” although they are not experienced enough assistants, but they are well trained in performing basic techniques.
Doctors who have no surgical training. They do not have the professional habits of narrow specialists and in this regard are less dangerous. At the same time, the lack of any surgical skills, as well as, as a rule, complete ignorance of anatomy, force one to regard such an assistant as a person without medical education, with all the ensuing consequences. The main task of the surgeon is to foresee and prevent possible violation such an assistant follows the basic rules of surgical asepsis, so even hand washing by the assistant must be strictly controlled. In addition, the surgeon must be prepared for the fact that such an assistant may fail at any time.
Senior medical students Having the same disadvantages as doctors without surgical training, they compare favorably with their better knowledge of anatomy and often a natural interest in surgery. Undergraduate students may make quite satisfactory assistants.
Nurses and paramedics, medical instructors, those who have not worked in the operating room practically do not differ as assistants from doctors without surgical training. The best assistants from among the nursing staff are operating nurses who are not part of this team, who quickly get used to this role.
Operating nurse part of the team, that is, giving the surgeon instruments, in some cases turns out to be his only assistant. Experienced operating nurses long time working with the same surgeon in small hospitals cope excellently with this dual role. At the same time, the surgeon also develops his own different style works and unconventional techniques. So, for example, he usually loads the needle with thread while the sister holds the hooks, and the sister prepares these threads in advance in sufficient quantities and places them and the instruments on her table so that they are easily accessible to the surgeon. In order to free up the hands of the operating nurse-assistant as much as possible, the surgeon learns how to remove hemostatic clamps himself when ligating blood vessels. For this purpose, “automatic” wound retractors of the Gosse type and Segal retractors, fixed to the operating table, are more widely used.
I was told about one very good surgeon who worked in a small rural hospital, who successfully performed gastric resections together with an operating nurse. At the same time, he fixed the retractor mirrors to the steam heating radiator in the operating room using a cord that was tied by a nurse.
From among the junior medical staff Operating unit nurses can also be involved in assisting. They have a proper understanding of asepsis, are accustomed to the operating room environment, and some of them have a fairly clear understanding of the character pathological process, and the course of the operation, and the technique of its implementation.
Random faces various professions, due to circumstances, may turn out to be assistants at emergency operations produced at the scene of injury or acute illness, if it is impossible to evacuate the patient to a surgical hospital. The logistics of such operations may turn out to be extremely primitive and also random and are not considered here.
If there is at least some possibility of choosing such an assistant, then I would prefer a woman who has given birth and is engaged in housekeeping for this role. She has less fear of blood than a man, she has experience in sewing and handling cloth fabrics, she is familiar with the elements of tissue preparation from the practice of cooking, she has softer hands, she is more sympathetic to the suffering of others and is often more resilient, She has less pronounced feelings of disgust towards the contents of the intestines and naked internal organs. All this, of course, does not mean that a woman is a born surgeon, but in such a situation you can count on her better adaptation and greater insurance against unpredictable fainting at the most inopportune time than an unknown man.
If there is a choice of profession, then people who are involved in some kind of manual work may be more suitable for the role of assistant. In any case, it is advisable to focus on volunteers and select from among them.
The selected assistant must be carefully instructed and, during preparation for the operation, told him what it will consist of, what he will see and what he will have to do. It is advisable to familiarize him with the tools in advance and show him on any suitable available objects how to handle them. One of the principles of such emergency training, including training in hand washing, putting on a robe, etc., is the principle of imitation - “do as I do.” During the operation, such an assistant, regardless of the quality of his work, must be periodically encouraged and praised, while simultaneously correcting all his mistakes and shortcomings, so as not to cause him psychological stupor.
In case such an assistant fails, it is advisable to have a trained backup assistant.
In the absence of an operating nurse, the surgeon undertakes all preparations for the operation and its provision.
5.4. ASSISTANCE IN DOUBLE-TEAM OPERATIONS
There are 3 types of two-team operations.
Two teams independently perform two different operations simultaneously on different areas of the body.
This method in abdominal surgery practically not used, although in principle it is possible, for example, simultaneous operations with bilateral inguinal hernias. More often, this method is appropriate for operations on organs. abdominal cavity and another area of the body, for example with polytrauma.
To ensure such operations, each team should include its own operating nurse with a separate instrument table.
The peculiarity of assisting in this case is the need to focus the assistant’s attention only on “his” operation and the complete exclusion of his natural curiosity about the progress of the case in a parallel team. Particularly important are the complete separation of tools, napkins and linen used by each team, and their separate counting. In a two-team operation, there are often inconveniences during work (crowding, etc.). Therefore, each team should strive not to interfere with each other technically and maintain the utmost restraint in its internal negotiations. The exchange of information between teams is only within the competence of the operators.
Both teams simultaneously perform different stages of the same operation on adjacent or distant areas of the body. Most often, abdominoperineal extirpation of the rectum is performed in this way. It is possible, for example, to perform synchronous plasty of the esophagus with the intra-abdominal stage performed by one team, and the intra-thoracic or cervical stage performed by another.
During synchronous operations, one of the teams is auxiliary and does not immediately start working.
All that has been said regarding simultaneously executed various operations fully applies to synchronous interventions. A feature of the latter is the need for clear coordination of the work of the teams, which is also coordinated only by operators, with whom assistants must keep up very well. For such operations, assistants must have sufficient training and experience. At the same time, one should also keep in mind the different degree of asepticity of the stages of the operation performed separately and synchronously, which imposes its own requirements on their disunity.
An independent type of synchronous operation is the implementation of some, usually final, stages by two brigades formed from among the members of the main brigade by dividing it. In this case, one operating nurse provides both teams. The auxiliary team may include, for example, only one of two assistants, who must be prepared to independently perform the stage of the operation assigned to him. This method is often used when forming output intestinal fistula and simultaneous suturing of the main incision abdominal wall(for example, during Hartmann's operation). With this option, each team is allocated separate instruments and gauze material, but the final count is carried out jointly.
Consecutive execution of stages of one operation by two different teams. In abdominal surgery, this method is practically not used, although, in principle, with very long operations and overwork of surgeons, a partial or complete change of teams is acceptable. Changing assistants is more acceptable; replacing the operator is extremely undesirable.
The basic rule for replacing an assistant or the entire team is either to transfer a free surgical field without instruments and napkins and count the material and instruments used at the time of transfer, or to transfer everything that is in the surgical field strictly by count from hand to hand.
The assistant who is newly involved in the operation is obliged to familiarize himself with the content of this stage of the operation, the topography of the organs and maintain the existing situation.
One of the common options for partially changing the composition of the team is the “mobile surgeon” method. In this case, the assistants perform the relatively simple initial and final stages of the operation, for example, opening and suturing the abdominal cavity, while performing the functions of an operator, and the surgeon performs the main stages of the operation, upon completion of which he moves to another operating table, where a team of other assistants should by this time complete the initial phase of another operation.
This organization of work significantly increases the throughput of surgical teams, but requires clear coordination of all personnel and a certain independence of assistants.
A special case of a two-team operation is the work of one of them outside the surgical field - in the preparation of transplanted organs. I do not consider this special situation.
5.5. MASTERING NEW OPERATIONS
It is necessary to distinguish between mastering operations that are new for a given brigade and mastering fundamentally new operations.
Every surgeon has a different style of work. It depends on temperament, emotional and psychological makeup, experience, mastery of surgical equipment, school, personal attitudes, age, clinical and paraclinical features of the operation, mood, fatigue and a number of other factors. Each surgeon's style of work is individual and is not always the same in different situations.
Nevertheless, it is possible to distinguish 3 main characteristics of the surgeon’s work style, the extreme variants of which impose specific requirements on the assistant’s work. These include pace, technique and autonomy. From various combinations various options These characteristics create a specific individual style of work for a surgeon. Next, we will consider 3 main options for each of the characteristics.
Pace.Fast pace. The speed at which a surgeon performs various manipulations is not always related to the quality and thoroughness of their execution, so the total duration of similar operations for a surgeon who operates very quickly, but fussily and insufficiently carefully, may turn out to be significantly longer than for a surgeon who operates slowly, but saving overall time due to only necessary actions, thoroughness of their implementation, excluding annoying failures, completeness of each stage of the operation.
Regardless of the technique and the total duration of the intervention, the high pace of the surgeon’s work places increased demands on the assistant, who must have time to help with each individual manipulation (vessel ligation, tying a ligature, drying, etc.) at each stage of the operation. Here the assistant should strive not to delay the surgeon and at the same time do his job with all care. A fast-paced operation requires the assistant to have good technical training.
Average pace most favorable for quality assistance. With coordinated work and good surgical technique of the entire team, the pace “by itself” can imperceptibly increase.
Slow pace. The surgeon's slowness, as a characteristic of his personality, can also affect the pace of the operation. A slow pace may be necessary in a number of dangerous situations. An outwardly slow pace may, as mentioned, be the result of a surgeon who generally operates very quickly, preferring to “hurry slowly.” This style usually characterizes very high craftsmanship.
Assisting such a surgeon can sometimes be very difficult, since with the meager completeness and simplicity of each of his surgical actions, any technical negligence or lack of composure of the assistant, precisely because of excesses, inevitably leads to a delay in the entire operation.
If the surgeon generally operates slowly, then the assistant should strive not to get ahead of him, which will only be a hindrance, however, he can and should promptly prepare the conditions for the surgeon to begin each subsequent stage of the operation, thereby reducing its overall duration. By assisting a slow-moving surgeon, the assistant can carefully practice his surgical technique.
Methodology. By technique we mean accuracy, thoroughness and pedantry in performing each surgical procedure and handling tissue. As a result, it is the technique that best characterizes the surgical technique itself. In this regard, we will evaluate the level of the methodology in total as high, medium and low.
High level. The difficulties of assisting a surgeon with a high methodological level and high skill are mentioned above. This technique inevitably places its own demands on the assistant, forcing him to rise to the level of the surgeon. At the same time, the careful, thorough and meticulous execution of each surgical technique facilitates the task of the assistant in that the surgeon, as it were, “puts into his hands” what he must do at the moment. Here the assistant should strive to maintain the strict simplicity of each manipulation and not complicate it with any “liberties” of his style.
Average level. This level somewhat expands the responsibilities of the assistant, giving him more freedom of action, greater independence of choice, although this kind of independence is not a blessing, since it is determined by necessity not to be the best example of surgical technique. In principle, the lower the operator's technique, the higher the assistant's technique should be.
Low level. Assisting such a surgeon is especially difficult, both technically and psychologically. The assistant must be extremely collected and attentive. Its task is to prevent all dangers associated with insufficient surgical skill. However, negative examples sometimes turn out to be useful for educational purposes.
Autonomy. By this term we understand the degree of independence of the surgeon from the quality of assistance, from the training and technical level of the assistant. In this regard, we will consider such variants of this characteristic of the surgeon’s style as complete, partial and insufficient autonomy.
Full autonomy. With this style of work, the surgeon does everything himself. He applies hemostatic clamps himself, ties ligatures and sutures himself, and drains the surgical field himself. Any active actions of the assistant and even attempts to actively help him interfere and sometimes cause a negative reaction. It is difficult to assist such a surgeon, if only because during the operation the assistant is forced to be almost motionless and does not feel the need. It seems that a completely autonomous surgeon can operate on “anyone.” The assistant's task comes down to holding the mirrors and organs, providing the surgeon with the proper surgical field.
Partial autonomy. The surgeon instructs the assistant to perform minor manipulations, which, in fact, is what assisting consists of. The given standard rules of assistance for standard situations are aimed specifically at such an operator.
Lack of autonomy. In this case, the surgeon significantly depends on the help of an assistant, since he is not used to doing everything himself. Such a “spoiled” surgeon is formed through long-term collaboration with highly qualified assistants, either he does not yet feel complete independence, or, being very experienced, he deliberately chose this style of work to train assistants. Regardless of the reasons, it is difficult to assist such a surgeon, since very high demands are placed on the quality of assistance in all cases. If insufficient autonomy depends on the surgeon’s insufficient qualifications, then the operation can turn into a collective operation, without a clear distribution of responsibilities between team members, which is very bad, since this disrupts the operation plan and dangerous complications can arise.
During any surgical intervention important role in the operating team belongs to the anesthesiologist and assistant surgeon.
Anesthesia team
During anesthesia, the anesthesiologist holds a mask and lower jaw, the anesthetist monitors the pulse. Both should be completely immersed in their work and should not pay attention to everything around them. Anesthetists who monitor their pulse should be especially strict with themselves. They must periodically report the state of the pulse to the anesthesiologist, so that, in accordance with the information received, he increases the anesthesia or, conversely, reduces the dose. If there is a significant deterioration in the pulse, it is necessary to immediately bring this to the attention of the surgeon. Usually the anesthesiologist himself monitors the pulse and throughout the entire anesthesia his fingers are on the patient’s pulse.
Nurses should also pay attention to ensuring that the patient lies comfortably on the table during anesthesia, so that the very position of the person being operated on does not have any serious consequences for him later. For example, you should not allow your arms to hang off the table during surgery, or your hands to be clasped behind your head. The consequence may be weakening of muscle strength or even loss of mobility (paralysis).
If there is a lack of staff, one person has to monitor both the mask and the pulse. If anesthesia is administered by a doctor, then one of nurses takes a place near him, taking care of the patient’s comfort during anesthesia.
Assistant surgeon
A lot of work falls to those medical workers who are, so to speak, at the surgeon’s scalpel, are his assistants. Already with the first cut, their numerous responsibilities begin. They wipe away the blood with swabs and thus clean the surgical field, allowing the surgeon to navigate the tissues, what has been done and what still needs to be done. They provide significant assistance to the surgeon when ligating numerous small vessels (when applying ligatures). At the same time, they lift the hemostatic tweezers and hold it the entire time the dressing is in progress, slightly pulling it up.
After applying the ligature, they quickly open the tweezers and remove it. The assistant holds the hooks, which are used to spread the edges of the wounds. It supports the removed parts until they are completely cut off, if necessary. After applying the sutures, the assistant sometimes has to straighten the edges of the wound with tweezers so that they are closely adjacent to one another.
Throughout the entire course of the operation, the assistants directly assisting the surgeon, giving him instruments and dressings and standing at the scalpel, should not lose sight of for a moment that they have sterile hands, which must remain so throughout the entire operation. They should, for example, under no circumstances wipe sweat or blood from their faces with their hands, run them through their hair, or handle the lids of boxes containing dressing material.
In general, they should not touch non-sterile objects with their hands. From time to time, assistants assisting the surgeon directly wash their hands in an antiseptic solution, which is located right there in a bowl near the operating table. This solution is changed frequently because it becomes dirty from blood and tissue particles that get into it when rinsing your hands.
