It has been a rough four weeks for humor.

Last time I wrote, I was finishing up my OB/GYN rotation – may it forever stay in my past – and beginning surgery. My first two weeks on surgery were in anesthesia, which has scant moments of humor. Now I’m rotating through the trauma service, which is essentially The ICU For People Who Get Hit By Volvos. So that, plus needing time to sleep, equals no posts in a month.

Also, I am pretty sure if I started cracking jokes about ICU care I’d be karma-sealing my fate to suffer some horrible demise, such as being drawn and quartered Braveheart-style, at the hands of an irate patient. Or hospital administrator. Same thing.

Now that I’ve spent a few weeks on surgery, I wanted to talk about the operating room itself. As a patient, you see the OR only for a few minutes before anesthesia gives you enough medication to knock out a horse and you go to sleep. But when the lights are off inside, the people fixing you operate inside a rigid hierarchy that is both important and tremendously humiliating, because your med student sits at the bottom.

(…get it? Eh? “Operate inside a rigid hierarchy?” Operating in the operating roo- okay fine I’ll stop.)

Your local hospital PR firm would like you to think the OR hierarchy looks like this:

[By the way, for once these images are actually my own (out of necessity, not creative drive). If you google “Operating Room Hierarchy,” you’d be amazed at how slim the pickings are. It’s like they don’t want you to know.]

A few things to notice here:

– The medical student is extremely far away and using binoculars
– Everyone is working together in perfect synergy
– Everyone is centered around the patient
– The organizational chart is “flat”
– Everyone is expertly trained

Except for the patient-centered bit, which really is true, the rest of this is wholly inaccurate and just plain wrong. Instead, here is my approximation of the OR organizational chart:

Note the far more structured flow of power. In case terms like “first assistant” and “nurse in charge of Pandora station” are foreign to you as they were to me, here is a brief glossary from a student’s perspective. Keep in mind this is, as always, in sardonic fun. I do not expect my resident to get electrified in the OR.

Chief Surgeon: Also known as the Attending. In charge of everything in the OR, including but not limited to music selection, instrument selection, personality selection, patient selection, and room temperature selection. This last item is more important than you realize when you first start your surgery rotation. If s/he notices your presence, it is a good day. As demonstrated in the chart, is capable of ruining the life of the Resident Surgeon via initation of the time-honored ritual known as Shit Rolls Downhill (SRD).

“Fellow:” The Fellow is an almost-attending who has completed residency and is learning the finer points of a subspecialty.

Resident Surgeon: The basic unit of the operating room. Does most of the operating along with the Fellow, and is your best bet for learning something during the procedure. May hate your existence if they are having a bad day, which is closely tied to the personality of the Attending and how much sleep they got the previous night. May pimp you in the presence of Attending to demonstrate their superior knowledge base. If nice, will let you stitch something unimportant. If not nice (or under pressure from Attending), can and will participate in the SRD Ritual.

“First Assistant:” A nebulous term that may variably refer to a well-trained scrub tech, an ambitious upper-level medical student, or a specially-trained nurse who has gone to school specifically for surgical assisting. Is often present in larger surgeries and can be your best friend by helping you learn to suture. Can also be your worst enemy by taking any hope of actually assisting in the procedure away from you. Gets paid per procedure, not by the hour, so they may become irritated if you take too long to perform a task, which will be always. Typically enjoys participating in Shit Rolls Downhill.

Circulator Nurse: Nurse who does not dress in sterile cartoon costume (see image) so she can touch non-sterile objects in operating room. Acts as Chief Procurement Officer when a piece of equipment necessary is missing from the OR. Often likes medical students because the presence of a student bumps them up on the totem pole. Is in charge of making sure operation proceeds on the correct body part. Is usually one of the happier people in the room, potentially due to not having to wear sterile cartoon costume.

Scrub Tech: Nurse with three primary responsibilities: maintain sterility of the operating field, pass instruments to the surgeons, and/or eject medical student from OR when they screw up, which will be often. You may attempt to risk-manage the likelihood of being ejected from the OR by being overly nice to the Scrub Tech, but success with this procedure is variable. Maximize chance of success by acquiring own sterile equipment from supply closet pre-operation. Never touch their instrument tray without their express permission as this is a sure pathway to ejection.

During procedures, will occasionally volunteer their dislike for med students, or you specifically, in front of you. Thoroughly enjoys participating in the Downhill Ritual, but are sometimes concomitantly the nicest people in the OR. This juxtaposition remains a mystery.

Scrub Nurse: In large/long procedures, will swap out with or assist Scrub Tech in shoveling feces downhill on to medical student and/or passing instruments to the surgeons.

Nurse In Charge of Pandora Station: Usually shares roles with Circulator Nurse. Typically plays favorite music during anesthesia and prep of patient before Chief Surgeon enters the room. Can be a challenging experience at 6:10AM when favorite music is instrumental Celtic.

Medical Student: Low man/woman/child on the OR totem pole. Final recipient of all material in the Downhill Ritual. Seeks to balance treacherous tightrope between asking enough questions to appear interested while avoiding irritation of any of the above entities. Desires to learn technical skill and is thus well-prepared to receive the answer of “no.” Is in the process of developing industrial-strength immune system and coping skills. Must carefully speak no evil of anyone in the OR. Primary responsibility is to make the Resident look good by mechanisms currently unclear.

The operating room is a blast, actually. You get to work with your hands, play with fun toys, help people in sometimes-dramatic fashion, and you still come to work in pajamas. It’s just a blast with an institutionalized, sometimes unintentionally funny hierarchy.