This essay will examine my role of a Surgical first assistant providing assistance during surgery for one patient and explore the legal, professional and ethical issues of the role. My case study focuses on a patient undergoing hip replacement since orthopaedic is my field of specialty. The case study was about a 9 stone lady in her late sixties, a smoker with osteoarthritis and suffer from bouts of depression. As a nurse who will be expanding my role in assisting the surgeon during surgery, I have to follow the code which sets out common standards of conduct and behaviour for those registered (NMC, 2015). This means that as I take on additional role like SFA I have a duty to uphold the NMC code within the limits of my competency. The case has caught my interest due to the patient’s mental state and skin integrity.
I have considered her skin integrity in conjunction with tissue viability, concerns that may arise post-surgery. I have an ethical responsibility to look after her mental state since she has a history of depression. I hope to explain my professional role with regards to intraoperative assisting and helping the patient cope with anxiety. For confidentiality purposes the patient will be referred as Ms. J and the surgeon as Mr. B (NMC, 2015).
PREOPERATIVE
Inform consent was done for Ms. J by introducing and explaining my role in theatre as a Surgical assistant to the Surgeon Mr. B.
Preoperatively a team brief was called in the anaesthetic room for all to attend, each of us introducing our role and designation in the surgical team. I introduce my role as a trainee SFA so other team member can give additional support in my new role. This was done to avoid overlapping of duties and avoid confusion among team members designated to do a specific task (Barnum, Salzman, et. al. 2017). To promote patient safety with regards to situation awareness the team brief allowed me to identify my scope of practice as a trainee SFA by recognising my role and prior experience of assisting in joint replacement (PCC, 2012). Accompanying the anaesthetic practitioner in the theatre lounge I introduced myself as a trainee SFA explaining that I was only assisting Mr. Bee and not performing any surgical intervention (PCC, 2012). It was my legal and ethical responsibility to acquire Ms. Jane’s verbal approval first before anything else was done regarding her care, witnessed by the Anaesthetic practitioner Ms. Jane’s approval has assured me to proceed in providing assistance for her care. I must not touch or treat Ms. Jane without permission doing so could be considered as an assault even if my intentions were justified (Beauchamp, Childress, 2009).
In the anaesthetic room I participated with the anaesthetic practitioner in checking the consent with the right surgical pentel marking during the sign-in phase (WHO, 2009). I have to respect Ms. Jane’s autonomy, her right to make informed decision about her health hence I have to balance my decision on beneficence to act in her best interest and non-maleficence an obligation to avoid harm towards her surgery (Beauchamp, Childress, 2009). My ethical responsibility was to confirm her willingness, her understanding and affirmation about the surgery being disclosed and the assurance that I have the required competence to be her Surgical first Assistant. Based on her pressure area assessment form Ms. Jane’s skin was highlighted to have skin redness around her hip as physically seen near the pentel site marking made by the surgeon. Using the adapted waterlow scoring I gathered a score of 13 suggesting Ms. Jane’s skin was at risk of irritation and bruising.
This prompted me to inform Mr. Bee of the possibility of skin infection and was therefore my professional duty to prevent such harm to happen (NMC, 2015). Mr. Bee hence recommended the use of gel pads and pressure relieving mattresses (NICE CG 179, 2014). And the use of gel padded dressing for her surgical wound after skin closure. After the anaesthetic provider has indicated to Mr. Bee it was safe to do our part. I participated in positioning Ms. Jane on the operating table by holding her still while Mr. Bee applies all the patient stops around her hip to prevent her from moving and falling (PCC, 2018). I have the responsibility to minimise the risk of surgical site infection (SSI) in pre prepping the skin prior to her surgery which was part of my training as SFA (PCC, 2018). To facilitate this stage, I have been conscious of the anaesthetic surrounding while pre prepping her exposed hip and leg ensuring sterility of the initial drape under her leg and hip which was later covered by another sterile drape.
INTRAOPERATIVE
Ms. Jane was brought into theatre where I participated in positioning the operating table at the centre of the laminar flow with the operating lights correctly aligned for better visualization and the patient supports were padded with gamgee placed between skin creases to ensure her skin integrity was maintained as well as allowing better access for both the anaesthetic team and the surgical team (Rothrock, 2014). This was one of my responsibility as SFA (PCC, 2018). With the patient’s position securely established and pressure areas well padded from skin friction on the operating table I have done my professional responsibility towards my patient’s skin integrity (NICE CG179, 2014).
A “Time Out” was performed to ensure Ms. Jane’s safety by doing so I can confirm with my fellow team members that we have the right patient with the right site surgery (WHO, 2008). In the final prepping stage of the surgical site, alcoholic chlorhexidine was used to reduce the risk of SSI (NICE guideline, 2019) preferred by most orthopaedic surgeons including Mr. Bee. As an SFA my role was to lift the leg ensuring that I have to external rotate the limb to lock the knee in full extension during prepping (Rothrock, 2014). If this was not done correctly the knee flexes and collapses down on the operating table making the site unsterile. My prime objective as a trainee SFA was ensuring sterility at all times (PCC, 2012). Once the skin was prepped, we allowed the solution to dry up to ensure its efficiency and patient safety this was my professional responsibility (NMC, 2015).
In draping the surgical site of the hip, I have to follow the directions of Mr. Bees’ preferred way of draping as his SFA I have to work under his direct supervision and must remain with Mr. Bee until the surgery was completed as part of my SFA role and professional accountability as a nurse(PCC, 2018 ; NMC, 2015). Following the draping steps of the surgeon a lot of activity in setting up and passing off tubes and cords including suction diathermy and irrigation (pulse lavage) occur before the surgeon makes his first incision (Rothrock, 2014). These instruments were secured with a towel clip to prevent it from desterilizing. Once the incision was made, as SFA we usually provide a clear field with the use of a retractor positioned by the surgeon which stated that all retractors must be positioned by the surgeon alone (PCC,2012). I may only move or reposition the retractors under direct instructions from Mr. Bee to prevent any nerve damage that could result thru improper use if done without supervision (PCC, 2012; NMC, 2015). It is important to understand that my actions as an SFA could have some ramification if I don’t have the right knowledge or the right training as provided by my current SFA course (Quick, J and Hall, S 2014).
Furthermore, as an SFA I must have demonstrable skills and knowledge on a higher level and have successfully completed my training provided in a university (PCC,2012). On my NMC code of conduct I have the legal and ethical responsibility to maintain my knowledge and skills to ensure safe and effective practice and be accountable for all actions and maintain my duty of care to all my patients. A posterior approach on Ms. Jane’s hip replacement was made to provide adequate exposure (Rothrock, 2014). As the surgery progress and the femoral head has been dislocated from the hip joint it becomes loose and floppy and may roll off the operating table in order to prevent this from happening, I stand close to the table ensuring better control of the leg movement. Once the bones have been exposed, I have the tasked to use suction and diathermy upon the instruction of Mr. Bee. Once inside the hip the surgeon will request “to buzz the forceps” which means placing the diathermy tip against the forceps that holds the patient tissue (whalan c, 2006).
Guided and instructed by the surgeon it is my professional responsibility to carefully touch the tip of the surgeon’s forceps if bleeding was seen inside the acetabular area (PCC, 2012). Most orthopaedic surgeons use pulse lavage a special irrigation system of saline wash (Whalan, C. 2006). Surgeons use this in conjunction with the use of a suction to keep the operative field clear of blood and bone debris (Whalan c, 2006; PCC, 2012). Using suction as directed by the surgeon must be done with caution in a way that will not cause injury to the surrounding structure. As a trainee SFA I need to know each step that will be encountered during the surgical procedure. I have to anticipate and think in advance on each step to help the surgery move smoothly. As per instruction by Mr. Bee he emphases to hold the limb rock steady as he prepares the femoral canal ready from prosthesis insertion (PCC, 2012). This resulted in better orientation by the surgeon to insert the prosthesis properly. If not done according to the surgeon’s direction it could result in a poorly fitting hip prone to dislocation (Whalan C, 2006). At any stage of the surgery it is was important that if I suspect a breached in the sterile field, I must immediately identify this to Mr. Bee to change our gloves or drapes (NMC, 2015). It is better to change several times than to risk any chance of infection into the joint replacement. It was more crucial to be aware of sterility when I am instructed to manipulate the hip for a better fit with strict guidance by the surgeon (PCC, 2012).
POSTOPERATIVE
The muscles and other soft tissue that were cut were repaired and the skin incision stapled back together as preferred by the surgeon. Maintaining sterility at this stage was crucial it will determine a better outcome for her skin that was at risk for irritation and bruising. The use of a gel padded dressing as advised by the surgeon will minimise that risk of skin SSI and offers a better barrier with optimum healing, applying the dressing was part of my remit as a trainee SFA. The WHO “sign out” was read aloud before any team member left the room, confirming that the surgery was completed as planned and recorded additional instructions for follow up (WHO, 2009). I am committed to provide patient dignity ensuring that Ms. Jane was well covered, and excess blood was wipe off from the operative site before transferring her onto her own bed, following hospital policy for safe patient transfer (NMC, 2015). It was my professional responsibility that all staff post-surgery adheres to our hospital policy of safe transfer from the operating table to the patient’s bed (NSPA, 2009). Ensuring the use of a pat slide and the use of a sliding sheet with at least five theatre practitioners including myself to safely transfer Ms. Jane. Immediately after surgery particularly, new joints like hip replacement.
They are vulnerable to dislocation if not handled carefully (Rothrock, 2014). Once the patient was safely move onto her bed as an SFA trainee I must ensure that a wedge was in place between the patient’s leg to prevent dislocating the hip when transporting her to the recovery room. Together with the scrub nurse it was my legal and professional responsibility to escort the patient in the recovery area where a comprehensive handover was carried out following hospital policy. During the handover it is ethical to listen carefully what the scrub nurse mentioned and add information that might have been missed like skin integrity, possible allergies or local infiltrations given in the end and advise the recovery nurse where to reach the surgeon or myself for any written clarifications. Enhancing the communication link between the scrub and recovery nurse was my duty of care to all patients who undergo all kinds of surgery (NMC, 2015). As a member of the surgical team, I have the legal duty to check that all patient’s records, nursing documentation and theatre register were correctly documented. And my participation as a trainee SFA was accurately noted in the registry theatre book. A debrief was done at the end of the list to consider good points of the operating process and teamwork, review issues that occurred and what more can be done to make the list run efficiently next time.
CONCLUSION
My case study has examined my role in every phases of the perioperative care as an SFA in the case of Ms. Jane who has undergone total hip replacement. As an SFA my role was not only to provide competent and knowledgeable assistance to Mr. Bee under direct supervision whilst not performing any surgical intervention, but to enhance communication among surgical team members. This includes preparing for the surgical procedure, explaining and obtaining consent from the patient in my participation of the surgery, assisting for the procedure and immediate post-operative follow up. I ensured that her skin integrity was recorded promptly and accurately on the tissue viability form for referral post-surgery. My role in the surgical team was not merely assisting the surgeon intraoperatively.
I have been accountable in my actions as an SFA, communicating my visual observation as well as verbal information shared by the patient. I have a professional and ethical role to identify and correct situations that could put the patient at risk as well as keeping my knowledge up to date with continuing education. I was able to gain insight into the role and responsibilities of an SFA by understanding the steps during surgery and the rationale for it. To be an SFA I am aware of my limitations and not be pressured by circumstances or even by colleagues in this case to perform something that will cut corners preoperatively, intraoperatively and postoperatively. Assuming the SFA role I am acquiring greater responsibility and therefore greater legal accountability by providing skilled assistance under supervision of a surgeon but do not intervene surgically. I come to conclude that patient safety is paramount and to ensure this, the importance of undertaking an SFA module like this beforehand must be emphasised.
References:
- NMC Nursing and Midwifery council 2015 The NMC code https://www.nmc.org.uk/standards/code
- NPSA National Patient Safety Agency 2010 Five steps to Safer Surgery http://www.nrls.npsa.nhs.uk
- PCC 2018 Perioperative care collaboration Position Statement: Surgical First Assistant www.afpp.org.uk
- Quick, J and Hall, S. 2014 The surgical first assistant are you compliant? Journal of perioperative practice GDRP: Guide to general data regulation protection (2018) www.gov.uk
- Rothrock, J.C. 2014 Alexander’s care of the Patient in Surgery 14th edition
- Whalan, C Assisting at surgical operation: A practical guide, Cambridge press 2006
- Adapted Waterlow pressure area risk assessment chart http://www.judy-waterlow.co.uk/index.htm
- Pressure Ulcers – Prevention and management CG 179 NICE guidelines 2014
- Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th edition 2001
- WHO: guidelines for safer surgery 2009 surgical checklist
- Barnum, Trevor and Salzman, David (2017) Orientation to the operating room www.mededportal.org