Your Elective Orthopaedic Surgery Experience

Thank you for choosing the Brigham and Women’s Hospital and entrusting our surgeons and staff to care for your orthopedic needs. This pamphlet is intended to provide you with more information about your elective surgical experience in the operating room and your surgical team members. Specifics about your individual surgery and the risks and benefits of surgical intervention should be directed to your individual surgeon.

Your Surgical Team

At the Brigham and Women’s Hospital we know surgery is an important and life-changing experience. For each surgery, a team of surgeons, anesthesiologists, nurses, technicians, and other staff work together to provide the safest and most effective care possible. As you may know, Brigham and Women’s Hospital is an academic teaching hospital and some of those involved in your care are in training and are supervised by attending staff.

• Attending Surgeon: Your surgeon is the leader of your surgical team. You have chosen your surgeon to perform your operation and your surgeon has planned and prepared to perform a safe and effective surgery. They are the primary decision-maker for almost every aspect of your care during and after surgery. However, every surgery requires many sets of hands to perform safely, and your surgeon relies on assistants to help retract tissues, and perform certain parts of the surgery as they designate.
• Fellows: Fellows are fully licensed surgeons who have already completed their surgical residency and are legally authorized to provide independent care and perform various orthopaedic procedures. Fellows spend 1-2 years after residency to sharpen their surgical skills in a specialty area from an attending surgeon(s) prior to becoming an attending themselves. They often teach residents and carry out scholarly research along with their clinical duties. At Brigham and Women’s Hospital, clinical fellows will often be a second surgeon listed on your surgical consent form in order to assist the attending surgeon. However, the activities of the fellows will always be under the supervision of your primary surgeon.
• Residents: Residents are also licensed physicians who have completed medical school and are now training to become orthopaedic surgeons. Residency lasts for 5 years and residents at every stage of training participate in the operating rooms, always under the supervision of the attending surgeon. At a teaching hospital such as Brigham and Women’s Hospital we take great pride in attracting the very best medical students in order to train the next generation of surgeons. However, we also believe that your safety is of paramount importance therefore, we will always prioritize your safety over any educational efforts.
• Physicians Assistants/Nurse Practitioners: Our physician assistants (PA) and nurse practitioners (NP) are essential members to not only your surgical team, but also to the team responsible for the continuity of your care at Brigham and Women’s Hospital. You have probably already met your surgeon’s PA or NP in the outpatient clinical setting and know how important they are to the function of your surgeon’s team. Their importance extends to the operating room, and they will occasionally be asked to assist your surgeon during your operative case. Like fellows and residents, the PA or NP assists the surgeon in whatever capacity they are needed, and are always under the guidance and direction of the surgeon.
• Anesthesiology: Your anesthesiology team is responsible for keeping you comfortably and safely asleep during your surgery. They will review your anesthesia options with you on the day of surgery. Your anesthesiologist also works with fellows, residents and advanced practice nurses, called CRNAs, to provide your care during surgery.
• Nurses and Technicians: You will also be meeting your operating room nurses and technicians on the day of surgery. They help with many aspects of the surgery, including making sure the rooms are properly set up, the appropriate equipment and instruments are gathered and ready to use, and helping the surgeons and anesthesiologists with varied aspects of the case.

Operating Room Flow

For many patients, the operating room is an unknown place, and surgery can provoke at lot of anxiety. To help explain what your experience will be like, we have provided a general outline of your transition through your operating room. Your specific experience may be slightly different than what is stated below, but this is to provide a general walk-through of your day. You may feel that certain aspects of your day are repetitive and unnecessary, but these repetitions are to ensure your safety.

• Once you are checked in at the hospital and brought down to the surgical area, you will be given an identification bracelet and asked to change into a hospital gown. This gown is to ensure that none of your personal clothes are damaged and that your surgical team will have adequate access to the part of the body they will be operating on. You will then be asked to get onto a hospital bed or gurney.
• You will meet your pre-operative nurse who will again verify your identity and your brief health history. They will confirm your planned surgery and make sure that all your pre-operative care and medications are safe and correct before administering them. They also verify that all the pre-operative checklists for the various teams are completed. These checklist are for your safety and though they may seem redundant, they are to help those caring for you ensure the safest care possible.
• A member of your surgical team will then meet with you to verify the procedure to be done and to ensure all necessary paperwork is completed. This may be your Surgeon, a Fellow or Resident, or a Physician Assistant/Nurse Practitioner. After verifying your consent for surgery, they will make a mark on your skin over the planned operative site to verify the part of your body to be operated on. Please ask any questions you may have remaining about your surgery to this person prior to proceeding to the operating room.
• Next, members of the anesthesia team will meet with you and discuss your specific anesthesia plan for surgery. Please discuss any questions or concerns you may have about your anesthetic during this time, including issues with pain, nausea, and anxiety. This anesthesia team will work hard to ensure you have a safe and pleasant experience in the operating room.
• Once your operating room is ready, you will then be brought back to the operating room on your stretcher. You may receive medication to help with anxiety at this point.
• In the operating room you will once again be asked to verify who you are and what procedure you are having done to once again ensure your safety. The teams will then discuss your surgical care and once this is completed, your anesthetic will begin. This anesthetic will differ from patient to patient based on your discussions with the anesthesiologist prior to the procedure and therefore will not be discussed in detail in this document.
• After your surgery, your anesthesiologist will awaken you and you will be carefully transferred back to your hospital bed or gurney. You will then be taken to the recovery room or post-anesthesia care unit (PACU). There you will meet your post-anesthesia nurse and care team who will work with you on transitioning from your anesthesia to being safely awake. They will work hard to manage your pain and meet other care needs.
• Once it is safe enough for you to do so, you will either be transitioned to your hospital room if your surgery requires a hospital stay or you will be discharged if your procedure is an outpatient procedure. If you are staying with us in the hospital, you will meet your floor nursing staff who will have discussed your surgery and post op course with your PACU nurse and will be up to date on your care.
• The attending surgeon will always speak to your significant other or any family member(s) that will be waiting about the outcome of the surgery as well as any specifics about the care after the procedure.

Our Policy on Overlapping Second Operating Rooms

While it takes an entire team to provide the safe care you expect and deserve, you have a special relationship with the surgeon whom you trust to perform your surgery safely and skillfully. Here at Brigham and Women’s we take that relationship, and the trust it implies, extremely seriously. While fellows and residents will participate in your operation, they do so only at the discretion of your surgeon. During your surgery, you are the sole focus of your surgeon and your surgical team.

However, as you may have gathered from previous paragraphs, your actual time in surgery may occupy a relatively smaller portion of your overall time spent in the Brigham and Women’s operating suite. There is a significant amount of time built into the schedule for the cleaning, setting-up and turnover of each operating room between surgical cases. In order to provide surgical services as optimally as possible (to maximize the amount of time that our surgeons are actually performing the surgery as well as minimizing the delays that patients often experience), we may at times utilize a second operating room and team in order to allow the surgeons to move quickly from one operation to another. This does NOT mean that your surgeon is performing two surgeries at once.

Hospital policy allows for a surgeon’s schedule to overlap in two rooms as long as they are present for all critical parts of the surgery. Your surgeon will determine the critical parts of your case, taking into account the particular clinical circumstances. More routine portions of the case, such as positioning and preparing the surgical field for surgery, or closing the wound at the conclusion of the case, may be delegated to other members of the team who are highly qualified to perform those duties.

If your surgeon or the operative team is aware that overlap between operating rooms may occur or is planned, they will disclose that to you in the pre-operative area or even during your clinic visit respectively. In such instances, a designated second surgeon will also be assigned to your surgery. This second surgeon’s name will also be disclosed to you on your surgical consent form.

If at any time during the process you have questions or feel uncomfortable with what you are being told then you have the right to stop and ask those questions, and they should be answered to your satisfaction prior to proceeding.

Frequently Asked Questions

Q: Do I get to choose my type of anesthesia?

A: The type of anesthetic an individual patient receives is based on many factors. Each of these factors, including your own preference as the patient are taken into account when you meet with your anesthesia team the before surgery and together, you and your anesthesia team will determine the safest and best anesthetic for you based on the procedure you are about to have.

Q: Do Residents perform portions of my surgical procedure?

A: Brigham and Women’s Hospital is an academic teaching hospital tasked with training residents to perform orthopaedic surgery. The attending surgeon allows the participation of residents in your care as they see fit and according to their experience and ability. The amount of participation may vary depending on the type of procedure and complexity and should be discussed with your surgeon individually if you have concerns. However, your safety is our greatest concern, so your best surgical outcome will be prioritized over any educational mission we may have.

Q: What roles do the Fellows have in my surgery?

A: Fellows are not involved in every operation, but many of the attendings do indeed work with fellows. The fellows are fully licensed to practice orthopaedic surgery and can legally perform many orthopaedic procedures independently. However, at the Brigham and Women’s Hospital, during elective surgery, they are still under the supervision of your attending surgeon so if they are involved in your case, they will assist in your surgical procedure. (Your primary surgeon will be present during all of the critical portions of the operation.) The fellow may also be listed as a second surgeon on your consent form when the possibility of overlapping operating rooms exist (in order to add an extra layer of safety during the non-critical part of the operation.)

Q: I have pain tolerance issues and am concerned about my pain management for surgery. How do I ensure this is adequately addressed?

A: Each individual patient decides on surgery for a number of reasons and has varying amounts of pain preoperatively. These pain concerns should be mentioned not only to your Surgeon and surgical team, but also to your anesthesia team on the day of surgery so that your pain management can be addressed in the safest and most effective way possible.

Q: Will my attending surgeon always be available for my care during surgery especially when there are overlapping operating rooms?

A: The attending surgeon will always be present and overseeing all the critical parts of your surgery. In the instance when the attending has overlapping operating rooms during the non-critical parts (see above policy), there will always be a designated second surgeon available as well to ensure your absolute safety. This second surgeon will be disclosed to you prior to your surgery.