Joana Santos, Senior Theatre Nurse at The London Clinic
To most patients, we’re almost completely invisible. When a patient is called for their operation, they’re anaesthetised before they get to us. When they wake up, they are already in recovery, unaware of everything that has happened.
This invisibility can sometimes feel a bit strange, but it doesn’t make us any less important: many patients come here to have surgery of some sort, so the theatre is really at the heart of the hospital. Some of the surgeries are very simple, like a hernia repair, but some are pretty complex, like major laparoscopic surgeries or those involving robots. It still feels odd, passing instruments to a machine. Of course, the surgeon still controls the robot—they’ve not replaced them yet, and they’ve not replaced us either! But using robots minimises the chance of infection because no one is touching the patient, and a big part of our job is to eliminate infection risk wherever and however we can. In fact, the very first thing you learn as a theatre nurse is how to scrub up—that is, to wash yourself and put your gown on without contaminating anything, and to remain sterile throughout the whole procedure. Scrubbing up is the first thing I do when I arrive at work for my shift, after checking the schedule for the day.
The whole process has become routine for me now, but it took some getting used to at first. It sounds simple, but there’s a real technique to washing your hands, nails, fingers and forearms in a surgical way, and it takes a lot of training. Then there’s the fact that you have to remember throughout the surgery that you can’t, for example, scratch your nose with your sterile gloves. It’s like pulling out in a car without indicating or checking your mirrors—you simply don’t do it. Likewise, needing the loo or feeling hungry during a long operation—you learn not to, because it means leaving the theatre and then scrubbing up again when you return. I’ve found that porridge is the only breakfast that sees me through the morning.
After scrubbing up, we set the trolley. We’ll have our basic materials and tools—swabs, gauze and so on—but we’ll also have the instruments for the specific surgery on a triple-wrapped tray. The outer wrap will not be sterile, the inner wrap is sterile, and the middle one acts as an insurance layer. This means we can transport the instruments without ever compromising what’s inside. Only once the patient is in the theatre, anesthetised on the table, do we open these trays: the first layer is opened by an ‘unscrubbed’ nurse outside the theatre, then a theatre nurse proceeds to open the second and third layers to access the instruments and pass them to the surgeon as and when they’re needed.
As theatre nurses, our first concern is to look after the consultant—to ensure he or she arrives at the surgery to find the right tools in the right places. The consultants who come to our hospital practice all over London and are often internationally renowned. They have a right to expect the best and we do everything we can to make sure they get it. Consultants are extremely focussed and being able to communicate with them efficiently in theatre is an important skill.
Each consultant works in a different way according to where they trained— a surgeon from The Royal Marsden, for example, will work in a different way to a surgeon from St Thomas’—and you have to spend time getting to know them. After a while it comes naturally; you know what they need. A lot of them return to the hospital so we end up building a very trusting relationship.
One consultant in particular is very funny—time flies when we’re working with him. People are surprised to hear it, but it is very rare to go into a theatre and it all be quiet and sombre. It is a respectful environment, of course, but we do chat about normal things. Some surgeries can last for as long as six hours, so it is important that you stay mentally lively—and humour can be a big part of that. With as many as six people working in a confined space—anaesthetists, radiographers, specialists, other theatre nurses—it is also essential that we all get along well.
The variety of surgeries we assist with is enormous. I think I must have seen just about every organ in the body by now. I don’t consider any surgery too challenging—we’re very highly trained— but some are certainly pretty complex: for example, even the most experienced theatre nurse would find it hard to scrub up for ENT if they had not done it before, as the instruments are very different to those you would use for general surgery.
Another rather complex operation which we do here is the deep inferior epigastric perforator—the DIEP—for women who have had a mastectomy. It is a long procedure: a bit of plastic surgery, a bit of microsurgery and a bit of reconstructive surgery all in one. In it, we take a piece of skin and fat from the tummy and put it on the breast. It is probably the best we could hope for in terms of breast reconstruction.
Throughout any surgery we follow protocols, non-stop. These are designed for best practice. In that respect, sometimes very different operations can feel exactly the same. When it comes to closing up, for example, the most important rule is that what went in must come out: every swab, every sharp, everything. If you could hear us finishing up, all you will hear is endless counting as we sew up. We count, and we count again, and every number is checked up on a board. We are very, very vigilant. Once the patient is in the recovery room, we set things up for next patient. We are aiming for a turnaround time of 20 minutes. Then we scrub up and start all over again with the next one. Each shift lasts about seven hours, but if an operation takes longer, you stay longer of course. I love what I do. It’s funny: when I was doing my nursing course I always said I didn’t want to be a theatre nurse. Now I can’t imagine doing anything else.