Operating Room Hierarchy Question


Oops. Apparently the question itself didn’t post…here it is in it’s entirety!

I’m curious about the hierarchy of the personnel during surgery. Is the actual surgeon pretty much thinking, as Alec Baldwin said in “Malice,” “I AM God.”? Is he at the top of the pecking order? Or, for example, if the surgeon is clearly and unwittingly making a medical blunder, would, say, the anesthesiologist or surgical assistant speak up and say, “Uh, Doc? You SURE you wanna be cutting THERE?”

I guess I’m just asking if a surgical team is a TRUE team…or if there is a strict pecking order that is NEVER violated…


Personally, if I were going to slice into someone’s body and mess around with what’s inside, I’d sure as hell want to feel as Godlike as possible.

That said, I think the growth in malpractice suits has made the OR team more willing to speak up if someone thinks the surgeon is going astray. It probably won’t be the anesthesiologist, who is busy looking at vital signs and gas mixes and all that, but certainly an assistant would point something out.

True story. When Mrs. Kunilou had her knee replacement, the pre-op team very carefully marked the correct knee to be replaced, and as they were about to give her the pre-op sedative, they again asked her which knee to cut. She said that while she was glad they took that precaution, it didn’t exactly fill her with confidence.

There is the tradition that the surgeon is the head of the operating room. There is also the tradition of someone scrubbing out to go get someone or something to save the patient. Thank all manner of Dieties for THAT tradition.

A couple of years ago, my cancer hospital paid the Big Bucks to hire the leading liver surgeon in Europe. He had been THE go-to guy for liver tumors, etc. His last surgery before going home to bring back his familiy (and to do a proceedure on a Head of State) was mine. He and my original oncologist had argued loud and long over the nature of the larger-than-a-saucer, almost dinner plate sized tumor on my liver.

Neither one would listen to me when I suggested it MIGHT be that rare cancer that they’d found during my first surgery. Nobody even LOOKED at the info about it.

Day of surgery. I’m on the gurney, they knock me out…cut in, and my body goes absolutely haywire. BP is non existent, whole body is bright red and shaking, all the scary stuff that can happen is happening ALL AT ONCE. Surgeon is clueless. Assistant surgeon is clueless. Anesthesiologist is clueless. Circulating nurse screams “It’s a F*&$ING CARCINOID CRISIS, GET OCTREOTIDE!!”

She’d seen one before. There was no octreotide in the room beyond one small vial. They stripped the entire area of it, dumping it in as fast as they could, and sending any and every available body to fetch more.

During the rest of the 9 total hours of surgery (should have been about 7) every person in the room deferred to her judgement, and the judgement of a dermatology nurse that they brought in because she is also a carcinoid patient. Octreotide is expensive. They gave me LOTS of it. (See also Sandostatin. I have carcinoid, not acromegaly.)

I found out about all this a year later when I read my chart. BUT, if the surgeon had been the kind some of them are, I would have died on the table while he tried to figure it out.

From my experience, in teaching hospitals. Usually the person doing the cutting is an attending or a fourth or fifth year surgery resident. Things are very hierarchical, moreso than other medical fields (although all of medicine is quite regimented). I can’t imagine anything but the most extreme circumstance where criticism is directed at anyone other than a direct peer (attending to attending) or a junior (attending to resident, fifth to fourth year, etc.). The exception are scrub nurses. A scrub nurse (the person giving out the instruments and keeping track of sponges and sutures and the like) can call anyone out for breaking protocol – usually this means touching something unsterile and “breaking scrub.” This is a hassle – the person must step away and rescrub for surgery or at least reglove up.

The anesthesiologist is on the other side of the field, behind a curtain which delimits the sterile scrub zone. Anesthesiologists are similarly regimented and have little to do with the surgical protocol, except in bad situations where they are called upon to push blood or fluids. They are not scrubbed, they are not trained in surgery, and the rarely have a good view into the incision so it is often difficult for them to tell what is going on. Besides, they are constantly monitoring pressures, color, heart rate, and breathing so they have their own things to worry about.

Near simulpost with thatDDperson.
Like I said, extreme circumstances. Working in some of the same Houston hospitals, I have to say that most surgery, even trauma surgery, is pretty sedate and mundane. Things develop much slower than ER. 95% of the time, nothing goes wrong. But when the shit hits the fan, every living person is recruited into action. The team leader usually leads. But if that person is shown incompetent, then most medical people are headstrong enough to step into that position, even if a few egos are being trodden.

It would make a good debate as to whether this is the best system. Discussion is often stifled; one doesn’t ask too many question or it seems like one is looking to criticize or distract the surgeon. The system seems to work most of the time, and I can’t imagine a person ever being criticized when it leads to a positive outcome for the patient.

Bet ya can guess which cancer hospital, huh?

Funny thing is, this Doc is now specializing in carcinoid liver surgeries. He’s totally enthralled with the challenge that they present. And he requests that nurse as often as possible.

Um, yep. Walk or drive past it every day of my frickin life. My window looks out at it. I am in the other axis of hospitals (Baylor/Methodist/VA/Ben Taub), so the only reason I ever go there is to visit labs of our collaborators and for scientific symposia.

Anyway, glad to hear you made it out of there OK. Carcinoid is a bitch but at least it wasn’t hepatocellular carcinoma or a primary biliary cancer… Hope you are keeping well.

Ehh, new liver mets, but that’s what carcinoid is all about.

Since I was a bilateral ovarian primary (9 years ago) they keep a close eye on me. Being the only one (bilateral) that they can find, and ovarian being a rare primary, they always want to know what i’m up to next.

I keep tellin’ em i’m up to about 5’6" and they keep not laughing…