Snapshots from a career in Theatres
- Equipment and Facilities
Back in the late 1970s to anaesthetise patients we used anaesthetic machines that ran on medical gas cylinders attached to them as we had no supplies of piped medical gases at the Yarmouth General Hospital. As one cylinder began to run out we would turn on the second one and replace the first one with another new one. We kept the stocks of cylinders in a cupboard in the male changing room that also doubled up as the joint rest room for theatres.
The medical gases and anaesthetic vapours the patients breathed in and then out went straight into the theatre atmosphere as there was no form of extraction system to remove them from the air the staff were breathing in and out all day long. Thus everyone in theatre from the surgeons, anaesthetists, nurses and operating department assistants were being exposed to these gases and vapours every day. Little wonder I often went home with a headache and seldom if ever questioned why?
Once we moved to the JPUH in the early 1980s, all medical gases were supplied via gas pipelines for patient anaesthesia and all anaesthetic waste gases from the patients were removed from the theatre environment via a gas scavenging system that was initially passive but eventually converted to an active system. This ensured minimal exposure of the staff to anaesthetic gases and vapours, so vastly improved their standard of working conditions which continues to this day. Thankfully gone were those almost daily headaches!
Looking back again to the 1970s, at the Yarmouth General all the waste products produced in theatres from the surgical procedures had to be removed and transported from the theatres to the points of disposal by the Operating Department Assistants both during the day and at night when emergency surgery took place.
I can often remember in the middle of the night when it was dark and cold and wet having to leave the warmth of theatre to push a patient trolley fully loaded with empty gas cylinders and numerous sacks of surgical waste and empty cardboard boxes along the corridor to the lift and descend downstairs to eventually push that same trolley out towards the Accident and Emergency yard at the back of the hospital. This would have been after a busy late shift in theatre and half the night undertaking emergency surgery too. Then the sacks of waste and cardboard had to be carried down the stairs of the incinerator room and left at the bottom in a pile ready to be burnt the following day. Upon returning to the trolley the empty gas cylinders had to be placed in the large storage cupboard at the back of the Accident and Emergency Department and replacement cylinders checked out put on the trolley and taken back to theatre ready for the next day’s work. Only then could you leave for home to get a few hours’ sleep and be back at seven thirty next day for another full shift.
Once we were ensconced in our new theatres at the JPUH those days of having to transport all that theatre waste ourselves thankfully became a thing of the past. Our new theatres were and are equipped with an exit hatch and a dirty corridor where all theatre waste produced is removed from, and staff are employed to take it and place it in the relevant receptacles that are then taken from the back of theatres to the disposal areas at the rear of the hospital. Another example of progress and one that could not have come a moment too soon!
- Monitoring equipment
The equipment available to us for the monitoring of patients has advanced enormously over the years and to think back now to what we had at the start of my career seems almost unbelievable.
In the early 1980s all we had to use was a stethoscope, a blood pressure monitor and a small electrical piece of equipment called a Downs Pulsometer. This device had a peg like end that clipped to the patients finger and showed a flashing red light, in time with the patients pulse, and a screen showing the pulse rate. ECGs were only available in the cardiology department to give a paper readout not a continuous one as now. I remember the first continuous ECG machine arriving in theatres as it was brought in by a consultant anaesthetist to use one day. It was used on the first patient of the day and at the end of the case my senior colleague started to put it back into its box, the anaesthetist said 'no! I want it for all the cases', which did not go down well with my colleague.
The next advancement of equipment came with automatic blood pressure machines called the Dinamap, which at the touch of a button would give you the systolic, diastolic and mean blood pressure plus the patient’s heart rate. This could be set to give readings from continuous to thirty minute intervals. This was a large piece of equipment that was almost two feet square, sixty by sixty centimetres, and very heavy, so was kept on a large trolley.
As more advances were made more new equipment arrived such as Co2 monitoring (capnography), invasive blood pressure monitoring and continuous Central Venous Pressure monitoring and the oximeter which measured the oxygen level of the patient’s blood. All these advances have made patient care in theatre much safer and less stressful for those looking after them.
- The Sluice Room and Surgical Instruments
At the Yarmouth General in the 1970s we had very little by way of pre-laid up surgical instrument sets that had been sterilised ready for immediate use. What we did have was a big instrument cupboard containing a large selection of surgical instruments so that we could perform almost all types of surgery from General, Gynaecological, Urological and some basic Orthopaedic surgery.
On weekends if there was a quiet spell all the instruments were removed from the cupboard and we had to wash them by hand, dry them, put them back in exactly the correct place under sister’s watchful eye and them she would quiz us as to their name and function, happy days!
Every day before the operating lists began we selected the instruments needed for the various operations and these were placed in large metal mesh trays and then placed in the two autoclaves for sterilizing prior to each surgical case. Thus timing was of the essence so as not to keep the surgeon waiting. The area where the autoclaves were placed was called the Sluice Room and after the surgery was complete the instruments had to be scrubbed and cleaned by hand in two large sinks in the sluice room before being sterilized again either for further surgery or being returned back to the instrument cupboard. It was hard, relentless and dirty work and if you kept the surgeons’ waiting - thankless!
In the sluice we also cleaned and sterilised all the anaesthetic equipment, most of which was not single use in those days, such as airways, face masks and endotracheal tubes with their introducers and dirty suction jars full of sputum, wonderful!
There were some pre-laid instrument sets for immediate use but they were mostly basic orthopaedic sets used at the Gorleston Orthopaedic Hospital and other dressing sets used on the Wards. The Sterilising Department was situated at Northgate Hospital and was very much in its infancy in the 1970s.
However when we moved to the JPUH in the early 1980s, regulations regarding the sterilisation of surgical instruments changed drastically and we moved over to a complete pre-laid up instrument set system for all surgical disciplines. No autoclaves were allowed in Theatres and some staff seriously wondered how they would cope without them!
This was the brave new world of the New Theatres and the metal had to be grasped with both hands. It eventually proved its worth and saved the staff a tremendous amount of work and effort enabling them to focus on a new dawn in theatre practice. It speeded up surgical throughput and allowed, with the purchase of new instruments, a greater range of surgery to be tackled here at the Paget. A tremendous bonus for our community as it has brought in surgeons with ever increasing and greater skills to benefit all.
This new dawn has led to very new and exciting techniques over the last forty years at the Paget that are still with us today and no doubt will continue to expand and improve even more in the years to come.
- Airway Management
Delivery of the anaesthetic gasses to patients has changed dramatically over the years from reusable to single use items to improve safety to patients. The masks we used in the past were dark black rubber and quite frightening for the patients whereas now they are made of clear plastic and for children have a range of different smells. The Endotracheal tubes were made of red rubber and had to be washed and re-sterilised after use. The waste gasses breathed out by the patient are now scavenged and pumped out of the theatre so the staff do not have to breathe them in as we did in the early days. The biggest change came with the introduction of the Laryngeal Masks and Cuffed Oropharyngeal airways although the COPA did not stay in use for long as the LMA was far superior. The LMA has evolved over the years and there are many variants including the I-GEL which is used for resuscitation as it is so easy to use.
- Key Hole Surgery
Perhaps for me the greatest change I have experienced in the General Surgical Theatre at the JPUH in the past forty years is the almost overwhelming move away from open to keyhole or what we call laparoscopic surgery.
Back in the late 1970s most patients requiring surgery had it performed by the open method. This regularly involved a relatively large surgical incision. As a result many patients suffered some form of bleeding that required receiving blood or fluid products intravenously on the operating table, they then stayed in hospital for a relatively long period of time to recover and were often off work for an even longer period of time compared to patients today. The only concession then was the beginning of key hole surgery by the Gynaecologists who began performing laparoscopic sterilisations.
Fast forward to the last twenty years and while I was working in the General Theatre at the JPUH we gradually began to use key hole surgery for virtually every aspect of General Surgery. It seemed like every few months the staff had to train on and learn how to use yet another new piece of laparoscopic instrumentation but in a way it was also extremely exciting knowing that we here at the Paget were at the forefront of surgical expertise.
We now mostly repair all hernias, remove most gall bladders, remove most bowel tumours and resolve most bowel obstructions using key hole techniques. Very little is done via the open route. This has come about not only due to the instrumentation that has been developed but also the major improvement in camera optics and TV screen technology. The quality of this equipment is absolutely mind-blowing but it does not come cheap. However when weighed against the benefits, it is amazing.
Patients are in hospital for a fraction of the time they used to be compared with open surgery. These patients are back to work in the community far earlier than they used to be. The positive effect upon them is far better for their mental wellbeing so overall the benefits are immense.
With this equipment the surgeons can do things for their patients at an earlier stage in the disease process as fortunately diagnostic technology has kept pace with the surgical technology.
This means we rarely hear those dreadful words I used to hear quite regularly in the late 1970s from the general surgeons ‘Sorry this is an open and shut case’- that is the disease process has spread too far and there was nothing the surgeon could do to help the poor patient.
With the rise of key hole surgery and its embedded state in our surgical armoury it is almost as if my first twenty years in theatres on the General Surgical side have now been replaced. This is now the norm for virtually every surgical specialty. Non-invasive key hole surgery is here to stay.
How thankful we should be for these advances in surgery and that here at the JPUH we are truly at the forefront of them.
- Team Work
The way the theatre team works together now is completely different to how it was when I first started over forty years ago.
One of the biggest changes was in the early days when whatever the doctor said was done without question by any of the non-medical staff. The consultants were addressed only by their title or Sir or Miss and only spoken to if they spoke first to you. Any questions went through the senior member of staff, usually the sister. When doctors started to introduce and address staff by their first name this was difficult to get used to by the older staff that were not used to this informality, even though this was only done in the rest rooms, not in front of patients.
With the introduction of the theatre “TIME OUT” protocol staff are now encouraged to speak out if they see a potential problem and to question things as this improves safety. Titles are still used in front of patients to maintain professionalism between colleagues.