Setting Yourself Up for Success in the O.R.

Working in the O.R. (Operating Room) as a radiologic technologist can be a little intimidating sometimes.  Depending on what type of case you might be asked to provide fluoroscopy for can sometimes mean the difference between having a great day, solidifying your place as a key member among a team of medical professionals, or wanting to crawl under a rock, hoping the surgeon forgets your name and face by tomorrow.
Being tasked to go to the O.R. doesn't have to come with those feelings of uneasiness if you know how to set yourself up to succeed. Failing to plan is planning to fail and with these next steps you'll be looking forward to going to the O.R. and building a stronger rapport with the staff and surgeons so that they will be requesting you by name to assist in their surgical cases. Let's get started.

Introduce yourself to the circulator, surgical tech, vendor(s)/reps, and surgeon

Anytime I walk into the O.R. at a new facility, or I just don't recognize someone in the room, I will walk over and introduce myself to that person.  For example, say you are going to the O.R. for the first time in a new hospital you were just hired at.  If possible, walk into the room before you grab the c-arm and introduce yourself to the circulator and surgical tech.  These two individuals are almost always in the room before the case, setting up and getting ready for the patient to show up.  An example of what to say to the circulator would be "Hey, my name is Johnny. I'm the new x-ray tech.  Where would you like me to set up the c-arm so that its out of the way of everyone"? Or "I was thinking of bringing the c-arm in this way and putting it over there so that its out of the way of everyone until they need me, what do you think"?  Keep in mind that it is in your best interest to keep the circulators abreast of your intentions with the c-arm.  They are responsible for what is going on in the room during the procedure and you want them on your side if there is an issue with you or your equipment.
If you think you may need some guidance with positioning during the procedure, find the vendor/rep and become quick friends.  You should always introduce yourself to them.  They have a wealth of knowledge and experience on what the surgeon wants and needs to see to make the procedure successful.  Continuing with the previous scenario, once you have introduced yourself to the circulator and surgical tech, locate the vendor/rep.  Your introduction may sound something like this "Hey, my name is Johnny, I'm the new x-ray tech.  I'm not familiar with this case, what exactly does the doc need to see up on my monitor"?  After he/she gives you some insight, follow up with "Thanks. If you see me struggling, don't hesitate to give me some advice".  This way you will definitely have some help, or at least some recommendations on how to fix your image if you are not sure.  The last thing the rep wants is his/her surgeon upset, so they will be more than willing to help you out.
Make your presence known and if you are unfamiliar with the type of case they are doing, make this known also.  Nobody likes surprises of this type and in this setting.  Don't be afraid to walk up to the surgeon and say "Hey doc, my name is Johnny and I will be your x-ray tech today if that is ok with you.  I haven't done one of these cases before, but I will do my best to get you the picture you need."  Wait for them to respond.  99.9% of the time the response will be positive and they will briefly tell you what they want to see when you shoot your image. 

Have a voice

Don't be afraid to ask the surgeon if he/she wants that image magnified, centered, or rotated.  It is these little questions that will help you perfect your craft in cases down the road.  Make mental notes of how every surgeon likes their images orientated on the monitor.  For example, some surgeons like their lateral spine images landscape vs portrait.  If you ask how they prefer to have it you can save yourself the trouble of trying to "fix" an image to does not need it.  This also goes for when you need the anesthesiologist/CRNA to raise or lower the table in order for you to get you c-arm into the correct position.  A simple "Can I get the table up/down, please." will suffice. 

Save and Swap Your Images

You should make a habit of saving the first image you take.  It is generally an AP (Anterior/Posterior) image and is useful if the surgeon decides he wants you to send the "before and after" images, meaning before and after the hardware was put in.  This initial "scout" image will also save the original technique used for an image with presumably little to no metal (screws and instruments) introduced into the image. This can come in handy further into the case when there is a lot of hardware in the image and you may be having trouble getting a good quality image, even with the HLF (High Level Fluoro).
It should become habit to save and swap your image every time you go from AP to LAT position with the c-arm.  I may venture to say that it can become good practice to save and swap, or at the very minimum swap, your images when there is a "change" in the image.  For example, when the physician drills into a tibia to the desired depth, save that image and swap it to the right.  The surgeon will then want to insert a guide wire to that same depth.  He/she can now see side by side images of the guide wire compared to the drill depth.  The next step will be to insert the screw into the tibia using said guide wire, so save the guide wire image and move it to the right giving the surgeon another more recent image for comparison while they insert the screw to the desired depth.  Now some techs will say that it is not necessary to save the image every time you move it to the right.  Sometimes you can just swap the image to the right and be just fine.  This is true until the surgeon decides the screw that they just put in is too long/short. Now the surgeon wants to put another screw of a different length in.  It has been my experience that they like to see what the last screw length looked like compared to the new one, side by side, just in case.

Sending Images to PACS

Be sure to ask what images the surgeon would like sent to PACS.  You will notice throughout the procedure the surgeon will request that you save certain images.  Take note which ones these are and ask if they would like those sent as well.  In the past I have seen surgeons ask me to save images throughout the procedure and only want the finals sent.  Likewise, I have had surgeons ask to see what images I have saved and they picked random ones that I saved (without their request) throughout the procedure and they chose a few of those as well as the scout and final images.  My point is when in doubt, save.  You won't regret having too many images but you will regret not having that single image the surgeon is requesting you to pull back up from three pictures ago and you have to tell them "Sorry doc, I didn't save that image (because you didn't tell me to)". We want to set you up for success, so save and save often until you get a feel for what the surgeon may or may not want to see and if they are going to throw you a curveball like requesting you pull up an image you took five minutes ago that they didn't ask you to save (this has happened to me in many spine cases). When you do send your images to PACS, be sure to add the dose report/dose summary.  It is good practice.  I worked at a hospital where protocol was to annotate the fluoro time on the image.  This tells the radiologist nothing when it comes to patient dose.  There is no way to tell what the technique was and for how long.  Was the "low dose" button used?  How about the HLF button, and for how long?  Annotating only the fluoro time does little to track actual patient dose.

Breaking down the c-arm

Congratulations! You made it through your first O.R. case!  Now lets break down this c-arm and clean up.  Be sure to lower the c-arm completely down before shutting down.  Once the system is off, there is no power to lower or raise the c-arm.  Unplug the monitor from the wall first, then the c-arm from the monitor.  Wipe down the cords as you are wrapping them up on the monitor.  Be sure to wrap the cords loosely.  If you wrap them too tightly, they will get kinks in them and will cause tripping hazards for the next person who uses this c-arm.  Wrapping them loosely also gives the tech who is using the c-arm the ability to quickly remove the cords from the monitor without having to unravel the cord loop by loop.  This comes in handy if you arriving to the room at the last minute and need to set up in haste. 
Check you c-arm for blood.  There is nothing worse than seeing dried blood on a c-arm left as a gift form the last tech who used the c-arm.  Don't be that tech.

Leaving the O.R.

It is a good idea to ask the circulator or surgeon if they want you to wait until they are done closing the patient before opening the door to pull the c-arm out.  Never assume that it is ok to just open those doors and leave when they are done with your services. There will be some times when you have to leave the c-arm in the room and come back later to take it out.  Ask the circulator where the best place for the c-arm is so that it is out of everyone's way, they will still need to get the patient's bed in the room when they are done. 

Saying "Thank You"

After every case I make sure to go back to the circulator, vendor/rep, and surgeon to tell them "Thanks for the help" and I make sure to address them by name if I'm the new guy in the room.  This helps solidify their name in my head but also forces them to remember your name too.  Nobody likes that awkward feeling when someone remembers your name but you don't remember theirs.  As I am backing out of the room with the c-arm I say a "Thanks again everyone!" one last time.
Setting yourself up for success in the O.R. is a process.  If you follow this process, you will be successful.  Everyone in the O.R. during a procedure is trying to keep the surgeon happy and in a cheerful mood.  If you are the one who puts them in a bad mood, well, you won't be making very many friends in the O.R. and people will shutter at the sight of you walking through those doors into a case.  If you can manage to make some friends, and at the very least get to know some names, people in the room will be more likely to want to help you out and you suddenly have access to all of their knowledge and experience when you find yourself in a bind.

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