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Contents in Brief

Section 1: Fundamentals of Theory and Practice Section 7: Preoperative Patient Care

1 Perioperative Education, 1
2 Foundations of Perioperative Patient Care
Standards, 15
3 Legal, Regulatory, and Ethical Issues, 35
Section 2: The Perioperative Patient Care Team
4 The Perioperative Patient Care Team
and Professional Credentialing, 52
5 The Surgical First Assistant, 60
6 Administration of Perioperative Patient Care
Services, 74
Section 3: The Patient as a Unique Individual
7 The Patient: The Reason for Your Existence, 93
8 Perioperative Pediatrics, 118
9 Perioperative Geriatrics, 153
Section 4: The Perioperative Environment
10 Physical Facilities, 169
11 Ambulatory Surgery Centers and Alternative
Surgical Locations, 189
12 Care of the Perioperative Environment, 203
13 Potential Sources of Injury to the Caregiver
and the Patient, 210
21 Preoperative Preparation of the Patient, 368
22 Diagnostics, Specimens, and Oncologic
Considerations, 384
Section 8: Pharmacology and Anesthesia
23 Surgical Pharmacology, 409
24 Anesthesia: Techniques and Agents, 421
Section 9: Intraoperative Patient Care
25 Coordinated Roles of the Scrub Person
and the Circulating Nurse, 455
26 Positioning, Prepping, and Draping the Patient, 487
27 Physiologic Maintenance and Monitoring of the
Perioperative Patient, 523
Section 10: Surgical Site Management
28 Surgical Incisions, Implants, and Wound Closure, 538
29 Wound Healing and Hemostasis, 569
Section 11: Perianesthesia and Postprocedural
Patient Care
30 Postoperative Patient Care, 596
31 Potential Perioperative Complications, 602

Section 12: Surgical Specialties

Section 5: Surgical Asepsis and Sterile Technique
32 Endoscopy and Robotic-Assisted Surgery, 632
14 Surgical Microbiology and Antimicrobial
Therapy, 230 33 General Surgery, 648
15 Principles of Aseptic and Sterile Techniques, 251 34 Gynecologic and Obstetric Surgery, 680
16 Appropriate Attire, Surgical Hand Hygiene, 35 Urologic Surgery, 712
and Gowning and Gloving, 266 36 Orthopedic Surgery, 742
17 Decontamination and Disinfection, 286 37 Neurosurgery of the Brain and Peripheral Nerves, 770
18 Sterilization, 303 38 Spinal Surgery, 788
39 Ophthalmic Surgery, 806
Section 6: Surgical Instrumentation 40 Plastic and Reconstructive Surgery, 826
and Equipment 41 Otorhinolaryngologic and Head and Neck
Surgery, 851
19 Surgical Instrumentation, 328 42 Thoracic Surgery, 882
20 Specialized Surgical Equipment, 350 43 Cardiac Surgery, 899
44 Vascular Surgery, 923
45 Organ Procurement and Transplantation, 944
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 FOURTEENTH EDITION

BERRY & KOHN’S

OPERATING
ROOM
TECHNIQUE
NANCYMARIE PHILLIPS, RN, BSN, BA, MEd, RNFA, CNOR(E), PhD
Professor Emeritus
Lakeland Community College, Director Department of Perioperative Education
Perioperative Nursing, Registered Nurse First Assistants, Surgical Technology
Kirtland, Ohio

ANITA HORNACKY, BS, RN, CST, CNOR

Perioperative Educator
Surgical Pharmacology and Orthopedics
Lakeland Community College
Kirtland, Ohio
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043

BERRY AND KOHN’S OPERATING ROOM TECHNIQUE, ISBN: 978-0-323-70914-9

FOURTEENTH EDITION

Copyright © 2021 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notice

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and using any information, methods, compounds or experiments described herein. Because of rapid
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should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous editions copyrighted 2017, 2013, 2007, 2003, 2000, 1996, 1991, 1986, 1978, 1972, 1966, 1960, and 1955

Library of Congress Control Number: 2020938604

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Project Manager: Grace Onderlinde
Design Direction: Renee Duenow

Printed in Canada.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 Mary Lou Kohn

An inspiration to all perioperative nurses and caregivers

of the past, present, and future.
This page intentionally left blank
Preface to the Fourteenth Edition
This time-honored text has its roots in the operating room (OR)
orientation manual created by Mary Louise Kohn in the late
1940s while working as an OR educator at University Hospitals
of Cleveland, Ohio. Her impeccable notes were a source of
interest to many OR supervisors and educators who wanted to
standardize their teaching techniques in accordance with Mary
Louise’s orientation tool. Many observers requested copies of
her writings, and eventually the cost of providing copies became
prohibitive.
In 1951, at the request of her publisher and with the encour-
agement of her superiors, Mary Louise assembled her orientation
material into a manuscript suitable for publication. She spent
countless hours writing and revising material until the birth of
her daughter. Her dedication to her family led her to seek assis-
tance for this project from Edna Cornelia Berry, who became her
willing partner and coauthor through the first four editions.
The first edition of Introduction to Operating Room Technique
by Edna Cornelia Berry and Mary Louise Kohn was published in
1955. I was fortunate to have obtained a copy for my collection.
The first edition was dedicated to “those nurses who accept the
tension and challenge of coordinated teamwork as they minister
to the patient in the operating room.” The main emphasis was on
intraoperative care of the patient.
Berry and Kohn’s Operating Room Technique has been the
perioperative text of choice for 60 years because it emphasizes the
importance of the patient and presents the material in concise,
understandable language. The name remains “Operating Room
Technique” because that is how it has been commonly known and
identified, although the text has a comprehensive perioperative
focus. It would be a disservice to our patients to merely describe
the intraoperative phase and not include preoperative and post-
operative care.
Every new edition of this classic perioperative text has ad-
dressed changing roles, needs, and evolving technologies while
maintaining the fundamental focus that still remains valid—the
care of the surgical patient. This edition of the text identifies the
knowledge and skill needs of the caregiver and strives to incorpo-
rate components of patient care from preoperative, intraoperative,
and postoperative practice areas. A systems approach is used to
help organize patient care to minimize the risk for human error.
Berry and Kohn’s Operating Room Technique is designed to meet
the needs of educators, learners, caregivers in diverse disciplines,
and managerial personnel who care for surgical or interventional
patients in many types of environments. Knowing the “why” of
patient care is as important as knowing the “how.” Additionally, it
is important to stress that outcomes must be evaluated to support
evidence-based practice. This text is the book of choice for certifi-
cation preparation in diverse disciplines and incorporates all
elements of the core curricula specified by several accrediting and
certifying bodies.
Features of the Fourteenth Edition
• A user-friendly 12-section arrangement.
• A logical and sequential order of the subject matter.
• Incorporation of the AORN Guidelines for Perioperative Prac-
tice (2019) and AST’s Core Curriculum for Surgical Technology,
6th edition, to reflect modern perioperative practice.
• A focus on the physiologic and psychologic considerations of
perioperative patients to provide guidelines and standards for
planning and implementing safe individualized care.
• Use of the systems approach as a foundation to support solid
evidence-based practice to establish patient care procedures in
such a way that all team members can identify their roles in a
cooperative spirit of safety and efficiency.
• In-depth discussion of patients with special needs related to
age or health status considerations.
• Discussion of perioperative patient care in inpatient, ambula-
tory, and alternative sites/locations to highlight considerations
based on the setting, as well as the surgical procedure.
• Encouragement of the patient care team to identify and exam-
ine personal and professional development issues that influ-
ence the manner in which care is rendered.
• Detailed information about the fundamentals of perioperative
nursing and surgical technology roles.
• Building of knowledge in a logical sequence—from fundamental
concepts to implementation during surgical intervention—to
enable readers to apply theory to practice.
• Comprehensive coverage of a broad range of essential topics to
provide a thorough understanding of fundamental principles
and techniques and an understanding of their applications in
various surgical procedures.
• Descriptions of specific surgical procedures in each specialty
chapter to assist the learner and caregiver in planning and
delivering patient care in the perioperative environment.
• An Evolve website that has learning and teaching aids to
enhance the classroom experience and support assimilation of
knowledge. For the student, this includes tips for the scrub
person and circulating nurse, historical perspectives, body
spectrum software, student interactive questions, and an
audio glossary. For the instructor, this includes a TEACH
manual with a lesson plan, lecture outline, case studies, and
PowerPoint slides for each chapter; test bank; and collection
of all the images in the book.
New to the Fourteenth Edition
• New and revised art is provided throughout the book.
• Insightful Pros & Cons boxes throughout the text examine
the two sides of a patient care topic and provide references for
further reading.
vii
viii Preface to the Fourteenth Edition
• Updated references highlight the evidence-based practice
approach used in the book.
• Terminology and key words have been updated to reflect
modern practice.
• Each chapter has been revised to emulate current practice and
knowledge.
Organization
Section 1 describes education, learning, and professional issues.
The correlation of theory and practice is integral to the success of
patient care in the perioperative environment. Fundamental pro-
fessional and personal attributes of the caregiver are examined,
with an emphasis on objectivity in the development of the plan of
care. Legal and ethical issues are discussed.
Section 2 delineates the roles of the members of the health
care team as both direct and indirect caregivers. Nonphysician
first assistant roles and credentials are discussed in a separate
chapter. Management of the perioperative patient care areas is
described, including Magnet Status.
Section 3 provides in-depth information on patient assess-
ment and the development of an individualized plan of care,
with the patient viewed as a unique individual. Special needs are
identified by health condition and age. Geriatric and pediatric
chapters are included.
Section 4 examines the physical plant of the perioperative
environment—both hospital-based, freestanding ambulatory
facilities and alternative locations. Diagrams of conventional and
nonconventional perioperative suite designs are included with
airflow designs. Care of the perioperative environment, occupa-
tional hazards, and safety issues are examined in depth.
Section 5 explains microbiology and the importance of micro-
biologic control in the perioperative environment, with an
emphasis on standard precautions. It delineates aseptic and sterile
techniques as fundamental to intermediate aspects, such as attire,
scrubbing, gowning, and gloving. Separate chapters are provided
regarding the sterilization and disinfection of surgical instrumen-
tation and patient care supplies.
Section 6 details the primary surgical instrumentation and
equipment used during surgical procedures. The safe use of spe-
cialized surgical equipment is presented. Electricity is explained.
Section 7 discusses preoperative patient care and includes the
family/significant other in the plan of care. Diagnostic procedures
and specimen handling are described.
Section 8 covers methods of anesthetic administration and
the role of caregivers during this process. Physiologic patient
responses and related potential perioperative complications are
discussed in detail. Surgical pharmacology is included.
Section 9 describes intraoperative patient care, including posi-
tioning, prepping, and draping. The interactive roles of the circula-
tor and the scrub person are specified in Chapter 25. Economy of
motion and the properties of physics are applied. Physiologic
monitoring of the perioperative patient is described.
Section 10 focuses on the surgical site. Incisions, hemostasis, and
wound closure are discussed in detail. Wound assessment, dressing,
and healing throughout the perioperative care period are described.
Section 11 presents an expanded view of postoperative patient
care. The postanesthesia care unit is explained. Prevention of
patient complications is described. The death of a patient is
discussed, and the importance of legal evidence is stressed.
Section 12 covers the surgical specialties. Salient surgical
anatomy and procedures are described and illustrated in line
drawings for clarity.
Preface to the First Edition
The material in this text is the outgrowth of the coauthors’ experi-
ence in the operating room—one as instructor of students, the
other as head nurse with some responsibility for instructing and
guiding students. It is an adaptation of the instructor’s teaching
outline for which there have been many requests.
The aim of the book is to facilitate the nurse’s study of aseptic
technique and care of the patient in the operating room. Al-
though this text is intended primarily for the student, the authors
hope it may prove useful to the graduate nurse as well.
Because it is assumed that the student has studied pathologic
conditions necessitating surgical treatment, these conditions are
not discussed. When applicable, and as a matter of emphasis,
there is a reiteration of principles of sterile technique and safety
factors for the patient. It is hoped this will aid in fixing the prin-
ciples as patterns of thought and work.
Although operative routines vary in different hospitals, under-
lying principles are the same. Consequently, basic principles are
emphasized, and the authors have endeavored to keep the material
as general as possible. Principles must be adapted to suit the situ-
ations found in individual hospitals. Specific linen, equipment,
and procedures are mentioned merely to serve as a framework on
which to demonstrate principles or as samples for points of depar-
ture. However, the specific examples mentioned are workable
procedures that have evolved. They are kept as uncomplicated as
possible for student teaching and for use in the practical situation.
Instruments for operations are not listed and few are men-
tioned because each hospital has its instrument lists, standardized
for each case, to which students can refer.
Emphasis is placed on meeting the psychological as well as the
physical needs of the surgical patient. An endeavor is made where
possible to correlate briefly the preoperative and postoperative
care with the operative procedure, to give the student a complete
concept of patient care.
The frequent use of the imperative mood is for the purpose of
brevity, organization, and emphasis. Questions and assignments
in each chapter are to aid the student in reviewing the material, in
recalling pertinent facts, and in applying the principles to his or
her specific situation.
Obviously, if the student starts scrubbing for cases with an
older nurse after the first day or two in the operating room and if
operating-room theory is given concurrently with the practice,
much of the material in this book will have been covered by indi-
vidual instruction before class discussion.
The authors have attempted to maintain simplicity and brevity
and to present a concise outline for preliminary study. They suggest
that the student supplement this material by reference reading.
The authors wish to express their grateful appreciation and
thanks to those people who by their interest and cooperation sup-
ported them:
To Miss Edythe Angell, supervisor of the Operating Rooms at
University Hospitals of Cleveland, for helpful suggestions during
the preparation of the manuscript and for reading, critically, the
entire manuscript. We are gratefully indebted to her because we
have learned from her much of what appears in this text.
To Miss Janet McMahon, Educational Director, School of
Anesthesia, University Hospitals of Cleveland, for valuable assis-
tance in preparing Chapter 21. Also, to Dr. Edward Depp, anes-
thesiologist, Euclid-Glenville Hospital, Cleveland, who offered
suggestions on this chapter and reviewed it.
To Dr. C.C. Roe Jackson, of the faculty of Western Reserve
University School of Medicine, for constructive criticism in re-
viewing Chapter 17. To Dr. Howard D. Kohn, also of the faculty,
who has been most helpful in reading the manuscript and offering
suggestions.
To Mrs. Geraldine Mink, librarian, for her assistance; to Mrs.
Leona Peck for her patience in typing the manuscript and for her
helpful suggestions; to Miss Ruth Elmenthaler and Miss Margaret
Sanderson of the operating-room staff for their assistance in mak-
ing the photographs; and to Mrs. Anita Rogoff for drawing the
illustrations.
Edna Cornelia Berry
Mary Louise Kohn
Cleveland, Ohio
1955
ix
This page intentionally left blank
Mary Louise Kohn, AB, RN, MN
(1920-2019)
I first met Mary Louise Kohn, a leader in perioperative nursing
education and authorship, several years ago in Dallas at the As-
sociation of Operating Room Nurses (AORN) annual congress. I
moderated an educational session before a large group of specialty
nurses. When the program finished, several participants came
out of the audience to discuss the topic and ask questions. Mary
Louise, a lovely, petite lady with blonde hair and sparkling blue
eyes, introduced herself and complimented my presentation. On
October 15, 1992, I had the opportunity to interview Mary Lou-
ise. Throughout the interview, her physical presence glowed with
professionalism and dignity. The whole room seemed to reflect
her persona. She explained how the events of the era in which she
lived affected her career path.
Mary Louise came from a highly educated family. Her German
father had a Ph.D. and was a Presbyterian minister who taught
Hebrew and Greek to scholars of religion and literature. She had
several cousins who had Doctorates in various fields. Both of her
parents had passed away by the time she was 16 years old, and she
lived on a small inheritance left to her by an uncle. She graduated
in 1940 from the College of Wooster with a Bachelor of Arts in
biology and psychology. She hoped to become a doctor, but
money was tight and females were discouraged from entering
medicine. She entered nursing so she could earn a living sooner.
During W.W.II, after the bombing of Pearl Harbor on Decem-
ber 7, 1941, only 7,000 Army nurses were on active duty, but
within six months the ranks grew to 12,000. Women were rapidly
taking a larger role in the war effort and she felt that her participa-
tion in civilian nursing was critical to the success of her country.
She tried to fill in for the shortages wherever she could, especially
for the nurses who were deployed overseas. She wanted to be an
Army flight nurse, but her family discouraged her ambitions. She
was unable to fulfill that dream and talked about it in a distantly
sad way.
She received her Master of Nursing degree from the Francis
Payne Bolton School of Nursing (FPB) at Western Reserve Uni-
versity (WRU) in 1943. After graduation, she took a staff nurse
position in the operating room (OR) at University Hospitals of
Cleveland (UH). She explained that only 35 graduate nurses were
available to staff five hospitals for all three shifts.
She met the love of her life, Howard Kohn, MD, during his
internship. He joined the Army Medical Corps so Mary Louise
joined him at his duty station. They married on the army base in
1944 and lived at their own expense in a rooming house. Mary
Louise took a private duty position in the civilian sector because
it paid more money, five dollars per day.
Howard was stationed in Atlantic City at the Thomas M. England
General Hospital, which consisted of several hotels converted into
hospitals for wounded soldiers returning from the front. Mary
Louise explained that registered nurses were in demand, so she took
a position as Assistant Head Nurse on a 200 patient ward. Only
enlisted military nurses could be Head Nurses because the patients
were wounded soldiers. Her responsibility included training civilian
aides and orderlies, many of who were conscientious objectors or
deferrees of the draft. Her workday consisted of 12 hour shifts with
one hour for meals.
In 1943, Congress passed the Bolton Act sponsored by Francis
Payne Bolton, enacting the U.S. Cadet Nurse Corps, spearheaded
by Lucile Petry, to educate registered nurses for duty in the mili-
tary. All educational expenses and a small stipend were paid for a
nursing degree in return for 2 years of service in the Army Nurse
Corps if needed. The Cadet Nurse Corps attracted 169,443
women to its service. Male nurses were not actively recruited. By
1944, formal rank as a commissioned officer, usually a Second
Lieutenant (2LT) with equal privileges and pay was available to
registered nurses. The last Cadet Nurses graduated in 1948.
At the end of the European war in 1945, the number of Army
nurses was approximately 27,850. By the end of 1946, only 8,500
nurses remained in the Army Nurse Corps, none were male.
Mary Louise’s husband was discharged from the Army in 1946
and decided to specialize in ophthalmology at the Harvard Medi-
cal School, graduate program. He completed his training and re-
turned to Cleveland to practice his specialty. Mary Louise became
the OR Instructor at the University Hospitals (UH), after serving
as head nurse on the surgical floor. UH was affiliated with West-
ern Reserve University (WRU) and the Francis Payne Bolton
School of Nursing.
Mary Louise was appointed to the teaching staff of WRU and
assisted with the education of the Cadet Nurses. She was highly
organized and began to put her original handwritten teaching
notes in a retrievable format. Her educational programs and
teaching syllabus were of great interest to educators from smaller
hospitals in the United States. Many OR educators from other
hospitals requested a photocopy of her teaching syllabus so they
could standardize their own surgical programs. She found that her
teaching material was a valuable tool. The Dean of Nursing at
FPB encouraged her to publish because the volume of material
was becoming too large to photocopy free of charge. She was
approached by several publishers and accepted the offer presented
by McGraw-Hill.
In 1951, with the birth of her only daughter, Mary Louise
decreased her hours at the hospital and focused on formalizing her
written material. She eventually included a co-author, Edna Berry,
RN, AD, who was formerly affiliated with UH. Mary Louise was
family oriented and found this working arrangement with a
co-author to be a help and a hindrance. Edna, who was unmar-
ried, did not have a family so planning writing schedules around
a co-author with an infant and a husband was difficult.
The original manuscript was written by hand. Mary Louise did
not type and had to hire typists at ten dollars per page to meet
deadlines. She diligently had each chapter reviewed by a physician,
xi
xii Mary Louise Kohn, AB, RN, MN (1920-2019)
and got Edna’s agreement before sending any work to print. They
contracted artists for line drawings and illustrations and paid to
have the book professionally evaluated. There were no professional
organizations to lend guidance or standards so they drew from
their own resources for the first technique-oriented textbook for
OR nurses. The first edition was published in 1955 and contracted
for revisions every five years.
During the early sixties, The Association of Operating Room
Nurses (AORN) was founded. AORN founders contacted Mary
Louise and asked her to be part of the organization as Education
Director. She joined the organization, but explained that she
could not devote the time needed to become a founder. When
AORN created the standards and recommended practices that are
the basis of all worldwide perioperative nursing practices, they
used Berry and Kohn’s Operating Room Technique as a reference.
Edna Berry died before the sixth edition was finished. Mary
Louise took Lucy Jo Atkinson, RN, MS as co-author for its comple-
tion. Berry and Kohn’s Operating Room Technique had grown into a
well-known international OR text. It had been translated into
Spanish and Chinese and was the main text of the armed forces
surgical training programs. When Mary Louise retired her author-
ship, Lucy Jo became the solo author of the seventh edition. Mosby
purchased the publishing rights for the seventh and subsequent edi-
tions of the text from McGraw-Hill. Lucy Jo and Nancymarie
Fortunato-Phillips, PhD, MEd, BSN, RNFA, CNOR co-authored
the eighth edition and Nancymarie became the solo author for the
ninth through thirteenth editions. Nancymarie co-authored the
fourteenth edition with Anita Hornacky, RN, BS, CST, CNOR,
who will assume solo authorship with the fifteenth edition as part
of the Elsevier family of publishing.
Mary Louise lived to be 99 years old and passed away in the
spring of 2019. She met with Nancymarie and Anita several times
during the production of the thirteenth edition and gave her
opinions of the fourteenth edition before she died. Mary Louise
and her work as an educator and author was truly the cornerstone
of what perioperative nursing is today. Her experience and dedica-
tion inspired many perioperative caregivers. She was a wonderful
friend and mentor.
Acknowledgments
I want to thank so many people who have made this fourteenth
edition possible. First, I want to thank all of the reviewers of the
previous editions for their time in review and for their input. The
identified needs of this group provide the baselines for the growth
and effectiveness of this work. The reviews were very detailed and
appropriately critical.
I am so grateful to the many nurses, surgical technologists, and
readers of previous editions who wrote to me or called requesting
specialty topic coverage in this edition. We welcome feedback at
all times and can be contacted by the email address listed at the
bottom of this page.
I want to thank our ongoing students in all disciplines
(perioperative nursing, registered nurse first assistant, and surgical
technology) for asking hard questions and forcing us to step be-
yond the classroom to satisfy their learning needs. We see them as
the future of patient care and the representatives of the high stan-
dards described in this text.
I want to thank my perioperative nursing and surgical tech-
nologist colleagues for their professionalism and for making the
task of revision exciting and fresh. A special thank you to Joe
Fortunato, Jr., who created much of the art for this edition and
other authorship projects.
I want to thank Sandra Clark, Executive Content Strategist;
Danielle Frazier, Senior Content Development Specialist; and
Grace Onderlinde, Project Manager, for their support and pa-
tience during the production of this edition. Their support made
this project possible.
We want to thank Mary Lou Kohn, RN, who trusted us with
her wonderful creation. She is the epitome of the perioperative
nurse we should strive to be. We put her foremost in mind before
we commit any word to paper. We ask ourselves, “How would
Mary Lou describe this?” Or, “What would Mary Lou think
about adding this?” We do this not only out of reverence for her
trust but also because she still exemplifies the highest standards of
patient care despite being long retired. Mary Lou is a delightful
human being and forever a perioperative nurse.
Nancymarie Howard Phillips
nancymphillips@aol.com
Anita Hornacky
anitahornacky@aol.com
xiii
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Contents

Section 1: Fundamentals of Theory Section 2: The Perioperative Patient Care

and Practice Team
1 Perioperative Education, 1 4 The Perioperative Patient Care Team
The Art and Science of Surgery, 2 and Professional Credentialing, 52
Perioperative Learner, 2 Dependence of the Patient on the Qualified Team, 53
Perioperative Educator, 5 Credentialing of Qualified Caregivers, 53
Application of Theory to Practice, 9 Perioperative Patient Care Team, 53
Expected Behaviors of Perioperative Caregivers, 10 Evolve Website, 59
Realities of Clinical Practice, 12
Evolve Website, 13 5 The Surgical First Assistant, 60
First Assistant’s Knowledge and Skill Level, 61
2 Foundations of Perioperative Patient Care What Does the First Assistant Do?, 62
Standards, 15 Disciplines Associated with First-Assisting in Surgery, 69
Surgical Conscience, 16 Evolve Website, 73
Patient Rights, 16
Accountability, 16 6 Administration of Perioperative Patient Care
Standardization of Patient Care, 17 Services, 74
Recommended Practices, 20 Establishing Administrative Roles, 74
Professionalism, 25 Interdepartmental Relationships, 79
Professional Perioperative Nursing, 25 Patient Care Departments, 79
Evidence-Based Practice, 25 Patient Services Departments, 80
Nursing Process, 26 Departmental Service Divisions, 81
Standards of Perioperative Nursing Practice, 28 Coordination Through Committees, 82
Clinical Competency of the Perioperative Nurse, 31 Surgical Services Management, 86
Scope of Perioperative Nursing Practice, 32 Budgeting and Financial Responsibility, 89
Surgical Technology, 32 New Product and Equipment Evaluation, 91
Clinical Competency of the Surgical Technologist, 33 Evolve Website, 92
Continual Performance Evaluation and Improvement, 33
Evolve Website, 34
Section 3: The Patient as a Unique Individual
3 Legal, Regulatory, and Ethical Issues, 35 7 The Patient: The Reason for Your Existence, 93
Legal Issues, 35 The Patient as an Individual, 93
Liability, 36 The Patient with Individualized Needs, 96
The Joint Commission and Sentinel Events, 39 The Patient with Cancer, 103
Consent, 42 The Patient with Chronic Comorbid Disease, 110
Documentation of Perioperative Patient Care, 44 The Patient Who Is a Victim of Crime, 112
Legal Aspects of Drugs and Medical Devices, 47 End-of-Life Care, 116
Ethical Issues, 48 Death of a Patient in the Operating Room, 116
Evolve Website, 51 Evolve Website, 117

xv
xvi Contents

8 Perioperative Pediatrics, 118 Section 5: Surgical Asepsis and Sterile

Indications for Surgery, 118
Considerations in Perioperative Pediatrics, 119
Technique
Perioperative Assessment of the Pediatric Patient, 120 14 Surgical Microbiology and Antimicrobial
Preoperative Psychologic Preparation of Pediatric Therapy, 230
Patients, 127 Microorganisms: Nonpathogens versus Pathogens, 231
Pediatric Anesthesia, 128 Types of Pathogenic Microorganisms, 235
Intraoperative Pediatric Patient Care Considerations, 132 Antimicrobial Therapy, 245
Common Surgical Procedures, 134 Evolve Website, 250
Postoperative Pediatric Patient Care, 152
Evolve Website, 152 15 Principles of Aseptic and Sterile Techniques, 251
What Is the Difference between Aseptic and Sterile
9 Perioperative Geriatrics, 153 Techniques?, 252
Perspectives on Aging, 153 Transmission of Microorganisms, 253
Perioperative Assessment of the Geriatric Patient, 156 Human-Borne Sources of Contamination, 253
Intraoperative Considerations, 166 Nonhuman Factors in Contamination, 254
Postoperative Considerations, 167 Sources of Infection, 255
Evolve Website, 167 Environmental Controls, 255
Standard Precautions, 257
Section 4: The Perioperative Environment Principles of Sterile Technique, 259
No Compromise of Sterility, 265
10 Physical Facilities, 169 Evolve Website, 265
Physical Layout of the Surgical Suite, 170
Transition Zones, 171 16 Appropriate Attire, Surgical Hand Hygiene,
Peripheral Support Areas, 172 and Gowning and Gloving, 266
Operating Room, 175 Appropriate Operating Room Attire, 267
Special Procedure Rooms, 185 Surgical Hand Hygiene, 276
Construction or Renovation of the Surgical Suite, 186 Gowning and Gloving, 278
Evolve Website, 188 Evolve Website, 285

11 Ambulatory Surgery Centers and Alternative 17 Decontamination and Disinfection, 286

Surgical Locations, 189
Ambulatory Surgical Setting, 189
Alternative Sites Where Surgery Is Performed, 198
Evolve Website, 202
12 Care of the Perioperative Environment
Guidelines for Cleanliness in the Surgical
Environment, 203
Establishing the Surgical Environment, 203
Room Turnover Between Patients, 204
Daily Terminal Cleaning, 208
Evolve Website, 209
13 Potential Sources of Injury to the Caregiver
and the Patient, 210
Environmental Hazards, 210
Physical Hazards and Safeguards, 211
Chemical Hazards and Safeguards, 223
Biologic Hazards and Safeguards, 225
Risk Management, 227
Evolve Website, 228
Central Processing Department, 286
Central Service Personnel, 287
Instrument Cleaning and Decontamination, 287
Disinfection of Items Used in Patient Care, 291
Methods of Disinfection, 292
203 Disposable Products, 300
Evolve Website, 302
18 Sterilization, 303
Sterilization versus Disinfection, 304
Sterilization, 304
Assembly of Instrument Sets, 306
Packaging Instruments and Other Items for
Sterilization, 307
Thermal Sterilization, 311
Chemical Sterilization, 317
Radiation Sterilization, 323
Control Measures, 324
Custom Packs, 326
Evolve Website, 327
 Contents xvii

Section 6: Surgical Instrumentation Types of Anesthesia, 423

Alternatives to Conventional Anesthesia, 452
and Equipment Evolve Website, 453
19 Surgical Instrumentation, 328
Fabrication of Metal Instruments, 328 Section 9: Intraoperative Patient Care
Classification of Instruments, 329
Handling Instruments, 346 25 Coordinated Roles of the Scrub Person
Evolve Website, 349 and the Circulating Nurse, 455
Division of Duties, 455
20 Specialized Surgical Equipment, 350 Efficiency of the Operating Room Team, 483
Using Specialized Equipment in Surgery, 351 Evolve Website, 486
Electrosurgery, 351
Laser Surgery, 355 26 Positioning, Prepping, and Draping the
Microsurgery, 361 Patient, 487
Ultrasonosurgery, 367 Preliminary Considerations, 487
Integrated Technologies, 367 Anatomic and Physiologic Considerations, 493
Evolve Website, 367 Equipment for Positioning, 494
Surgical Positions, 500
Physical Preparation and Draping of the Surgical Site,
Section 7: Preoperative Patient Care 506
21 Preoperative Preparation of the Patient, 368 Evolve Website, 521
Hospitalized Patient, 368
Preoperative Preparation of All Patients, 368 27 Physiologic Maintenance and Monitoring of the
Transportation to the Operating Room Suite, 379 Perioperative Patient, 523
Admission to the Operating Room Suite, 379 Monitoring Physiologic Functions, 523
Evolve Website, 383 Evolve Website, 537

22 Diagnostics, Specimens, and Oncologic Section 10: Surgical Site Management

Considerations, 384
Diagnosing Pathology, 385 28 Surgical Incisions, Implants, and Wound
Specimens and Pathologic Examination, 385 Closure, 538
Radiologic Examination, 388 The Surgical Incision, 538
Magnetic Resonance Imaging, 393 Surgical Landmarks, 543
Nuclear Medicine Studies, 394 Wound Closure, 546
Ultrasonography, 395 Evolve Website, 568
Sensory Evoked Potential, 396
Plethysmography, 397 29 Wound Healing and Hemostasis, 569
Endoscopy, 397 Mechanism of Wound Healing, 570
The Patient with Cancer, 397 Types of Wounds, 571
Evolve Website, 407 Factors Influencing Wound Healing, 572
Hemostasis, 575
Wound Management, 584
Section 8: Pharmacology and Anesthesia Complications of Wound Healing, 590
23 Surgical Pharmacology, 409 Postoperative Wound Infections, 592
Pharmacology Baselines, 410 Wound Assessment, 592
Considerations in Surgical Pharmacology, 413 Basic Wound Care, 593
Surgical Drug and Pharmaceutical Sources, 415 Evolve Website, 593
Pharmacologic Forms Used in Surgery, 417
Potential Complications Caused by Pharmaceuticals Section 11: Perianesthesia and
and Herbal Medicine, 419 Postprocedural Patient Care
Evolve Website, 420
30 Postoperative Patient Care, 596
24 Anesthesia: Techniques and Agents, 421 Postanesthesia Care, 596
The Art and Science of Anesthesia, 422 Admission to the Postanesthesia Care Unit, 598
Choice of Anesthesia, 422 Discharge from the Postanesthesia Care Unit, 600
Anesthesia State, 422 Evolve Website, 601
Knowledge of Anesthetics, 423
xviii Contents

31 Potential Perioperative Complications, 602 35 Urologic Surgery, 712

Potential for Complications during and after Anatomy and Physiology of the Urinary System, 712
Surgery, 602 Special Features of Urologic Surgery, 715
Respiratory Complications, 603 Surgical Procedures of the Genitourinary System, 720
Cardiovascular Complications, 606 Male Reproductive Organs, 730
Fluid and Electrolyte Imbalances, 617 Endocrine Glands, 739
Blood Volume Complications, 619 Transsexual Surgery (Sex Reassignment), 739
Shock, 626 Postoperative Complications of Urologic Surgery, 740
Metabolic Crises, 627 Evolve Website, 741
Iatrogenic Injury, 631
Evolve Website, 631 36 Orthopedic Surgery, 742
The Art and Science of Orthopedic Surgery, 742
Section 12: Surgical Specialties Anatomy and Physiology of the Musculoskeletal
System, 743
32 Endoscopy and Robotic-Assisted Surgery, 632 Special Features of Orthopedic Surgery, 746
Eight Essential Elements of Endoscopy, 632 Extremity Procedures, 751
Knowledge and Skill for a Safe Endoscopic Fractures, 752
Environment, 640 Joint Procedures, 756
Types of Endoscopic Procedures, 640 Repair of Tendons and Ligaments, 764
Hazards of Endoscopy, 642 Cast Application, 765
Care of Endoscopes, 643 Complications after Orthopedic Surgery, 768
Considerations for Patient Safety, 644 Evolve Website, 769
Duties of the Assistant for Flexible Endoscopy, 644
Robotic-Assisted Endoscopy, 644 37 Neurosurgery of the Brain and Peripheral
Evolve Website, 647 Nerves, 770
Anatomy and Physiology of the Brain, 770
33 General Surgery, 648 Special Considerations in Neurosurgery, 772
Special Considerations for General Surgery, 648 Patient Care Considerations for Craniotomy, 775
Breast Procedures, 650 Surgical Procedures of the Cranium, 779
Abdominal Procedures, 654 Peripheral Nerve Surgery, 785
Liver Procedures, 657 Evolve Website, 787
Splenic Procedures, 659
Pancreatic Procedures, 659 38 Spinal Surgery, 788
Esophageal Procedures, 660 Anatomy and Physiology of the Spinal Cord
Gastrointestinal Surgery, 661 and Vertebral Column, 788
Intestinal Procedures, 666 Special Considerations for Spinal Surgery, 791
Colorectal Procedures, 670 Pathology of the Vertebrae and Spinal Cord, 796
Abdominal Trauma, 673 Surgical Procedures of the Spine, 800
Anorectal Procedures, 674 Evolve Website, 805
Hernia Procedures, 676
Amputation of Extremities, 677 39 Ophthalmic Surgery, 806
Evolve Website, 679 Anatomy and Physiology of the Eye, 806
Ophthalmic Surgical Patient Care, 807
34 Gynecologic and Obstetric Surgery, 680 Special Features of Ophthalmic Surgery, 809
Anatomy and Physiology of the Female Reproductive Ocular Surgical Procedures, 812
System, 681 Eye Injuries, 823
Gynecology: General Considerations, 684 Ophthalmic Lasers, 825
Diagnostic Techniques, 685 Evolve Website, 825
Vulvar Procedures, 689
Vaginal Procedures, 690 40 Plastic and Reconstructive Surgery, 826
Abdominal Procedures, 694 Special Features of Plastic and Reconstructive
Perioperative Obstetrics, 697 Surgery, 826
Complicated Birth, 701 Skin and Tissue Grafting, 829
Assisted Reproduction, 705 Head and Neck Plastic and Reconstructive
Nonobstetric Surgical Procedures and the Pregnant Procedures, 836
Patient, 707 Plastic and Reconstructive Procedures of Other Body
Evolve Website, 711 Areas, 839
Burns, 846
Evolve Website, 850
 Contents xix

41 Otorhinolaryngologic and Head and Neck Special Features of Cardiac Surgery, 902
Surgery, 851 Cardiac Surgical Procedures, 909
General Considerations in Ear, Nose, and Throat Mechanical Assist Devices, 916
Procedures, 851 Complications of Cardiac Surgery, 921
Ear, 854 Evolve Website, 922
Nose, 859
Oral Cavity and Throat, 863 44 Vascular Surgery, 923
Neck, 866 Anatomy and Physiology of the Vascular System, 923
Face and Skull, 875 Vascular Pathology, 925
Evolve Website, 881 Diagnostic Procedures, 926
Special Features of Vascular Surgery, 928
42 Thoracic Surgery, 882 Conservative Interventional Techniques, 931
Anatomy and Physiology of the Thorax, 882 Vascular Surgical Procedures, 934
Special Features of Thoracic Surgery, 885 Evolve Website, 943
Thoracic Surgical Procedures, 893
Chest Trauma, 895 45 Organ Procurement and Transplantation, 944
Intrathoracic Esophageal Procedures, 896 Types of Transplants, 944
Complications of Thoracic Surgery, 898 Tissue Transplantation, 944
Evolve Website, 898 Organ Transplantation, 947
Evolve Website, 962
43 Cardiac Surgery, 899
Anatomy of the Heart and Great Vessels, 899 Index, 963
Physiology of the Heart, 901
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Operating Room Technique
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 SE C T ION 1 Fundamentals of Theory and Practice
1
Perioperative Education
CH APT E R OUT LIN E
The Art and Science of Surgery, 2
Perioperative Learner, 2
Perioperative Educator, 5
CH APT E R OBJEC TIVES
After studying this chapter the learner will be able to:
• Compare and contrast the art and science of surgery.
• Identify three characteristics of adult learners.
• Name five educational resources available for the learner.
• Define the difference between andragogy and pedagogy.
KE Y T ERMS AN D DEF IN IT ION S
Andragogy Teaching and learning processes for mature adult
populations.
Behavior Actions or conduct indicative of a mental state or
predisposition influenced by emotions, feelings, beliefs, values,
morals, and ethics.
Disruptive behavior (bullying) Power imbalance that involves
intimidation, oppression, or aggression and results in a counter-
productive atmosphere.
Cognition Process of knowing or perceiving, such as learning
scientific principles and observing their application.
Competency Creative application of knowledge, skills, and inter-
personal abilities in fulfilling functions to provide safe, individu-
alized patient care.
Critical thinking The mental process by which an individual solves
problems.
Disease Failure of the body to counteract stimuli or stresses
adequately, resulting in a disturbance in function or structure of
any part, organ, or system of the body.
Environmental factors Water, air, soil, and food. Contamination
and exposure of any of these factors can lead to disease.
Evaluation A process by which the educator measures perfor-
mance by standardized indicators established by a school,
employer, or professional organization.
Knowledge Organized body of factual information.
Learning style Individualized methods used by the learner to under-
stand and retain new information. These may be visual, auditory,
tactile, sensory, kinesthetic, or performance-oriented behaviors.
Mentoring A nurturing, flexible relationship between a more
experienced person and a less experienced person that involves
trust, coaching, advice, guidance, and support. A sharing rela-
tionship guided by the needs of the less experienced person.
Application of Theory to Practice, 9
Expected Behaviors of Perioperative Caregivers, 10
Realities of Clinical Practice, 12
• Describe how adult learning principles apply to patient
teaching.
• Discuss the problems associated with disruptive behavior in the
perioperative environment.
Objectives Written in behavioral terms, statements that determine
the expected outcomes of a behavior or process.
Occupational hazard A workplace hazard that can cause physical,
biologic, or chemical injury, leading to disease or death.
Orientation Period during which a student or new employee
becomes acquainted with the environment, policies, and proce-
dures of a professional environment.
Pedagogy Teaching and learning processes for immature and/or
pediatric populations. A very directed style is used.
Perioperative Total surgical experience that encompasses preop-
erative, intraoperative, and postoperative phases of patient care.
Preceptor A person who observes, teaches, and evaluates a learn-
er according to a prescribed format of training or orientation.
Psychomotor Pertaining to physical demonstration of mental
processes (i.e., applying cognitive learning).
Role model A person who is admired and emulated for good
practices in the clinical environment. The relationship between
a role model and a learner can be strictly professional without
personalized mentoring.
Skill Application of knowledge into observable, measurable, and
quantifiable performance.
Surgery Branch of medicine that encompasses preoperative,
intraoperative, and postoperative care of patients. The discipline
of surgery is both an art and a science.
Surgical conscience Awareness that develops from a knowledge
base of the importance of strict adherence to principles of asep-
tic and sterile techniques.
Surgical procedure Invasive incision into body tissues or a mini-
mally invasive entrance into a body cavity for either therapeutic
or diagnostic purposes; protective reflexes or self-care abilities
are potentially compromised during such a procedure.
1
2 SE CT ION 1 Fundamentals of Theory and Practice

The main focus of this chapter is to establish the baseline or TABLE

framework for an in-depth study of perioperative patient care 1.1 Common Indications for Surgical Procedures
and support the educational process of the learner. Consideration
is given to the perioperative educator, who may not have had a Indication for
formal education in the teaching of adult learners. Both learners Surgical Procedure Example
and educators should understand that the same learning and Augmentation Breast implants
teaching principles apply to patient education. The key terms are
commonly used terms that the learner should understand as the Debulking Decreasing the size of a mass
basis for learning about and participating in the art and science Incision Open tissue or structure by sharp dissection
of surgery.
Excision Remove tissue or structure by sharp dissection

The Art and Science of Surgery Diagnostics Biopsy tissue sample

Repair Closing of a hernia
Health is both a personal and an economic asset. Optimal health is
the best physiologic and psychological condition an individual can Removal Foreign body
experience. Disease is the inability to adequately counteract physi- Reconstruction Creation of a new breast
ologic stressors that cause disruption of the body’s homeostasis.
Additional influences, such as congenital anomalies, infection, Palliation Relief of obstruction
trauma, occupational hazard, or environmental factors, interfere Aesthetics Facelift
with optimal human health and quality of life. As both a science
and an art, surgery is the branch of medicine that comprises peri- Harvest Autologous skin graft
operative patient care encompassing such activities as preoperative Procurement Donor organ
preparation, intraoperative judgment and management, and post-
operative care of patients. As a discipline, surgery combines physi- Transplant Placement of a donor organ or tissue
ologic management with an interventional aspect of treatment. The Bypass/shunt Vascular rerouting
common indications for surgical intervention include correction of
Drainage/evacuation Incision into abscess
defects, alteration of form, restoration of function, diagnosis and/or
treatment of diseases, and palliation. Table 1.1 describes some of Stabilization Repair of a fracture
the most common indications for surgery.
Parturition Cesarean section
In the 1930s the English physician Lord Berkeley George
Moynihan (1865–1936) said, “Surgery has been made safe for the Termination Abortion of a pregnancy
patient; we must now make the patient safe for surgery.” Surgical Staging Checking of cancer progression
intervention is becoming a safer method of treating physiologic
conditions. Most of the former contraindications to surgery that Extraction Removal of a tooth
were related to patient age or condition have been eliminated Exploration Invasive examination
because of better diagnostic methodologies and drug therapies.
More individuals are now considered for surgery; however, each Diversion Creation of a stoma for urine
patient and each procedure is unique. Perioperative caregivers Implantation Inserting a subsurface device
should not become complacent with routines but should always
be prepared for the unexpected. Surgery cannot be considered Replantation Reattaching a body part
completely safe all the time, and patient outcomes are not always Amputation Removing a large structure
predictable.
Stenting Using an implant as a supporting device
A surgical procedure may be invasive, minimally invasive,
minimal access, or noninvasive. An invasive or minimal access Neoconstruction Face transplant
procedure enters the body either through an opening in the tis-
sues or by a natural body orifice. Noninvasive procedures are fre-
quently diagnostic and do not enter the body. Technology has
elevated the practice of surgery to a more precise science that complexity of the procedure and the general health of the indi-
minimizes the “invasiveness” and enhances the functional aspects vidual. Procedures performed on patients who remain overnight
of the procedure. Recovery or postprocedure time decreases, and in the hospital vary according to the expertise of the surgeons, the
the patient is restored to functional capacity faster. Improvements health of the patient, and the availability of the equipment.
in perioperative patient care technology are attributed to the The purpose of this text is to provide a baseline for learning
following: the professional and technical patient care knowledge and skill
• Surgical specialization of surgeons and teams required to provide safe and efficient care for patients in the
• Sophisticated diagnostic and intraoperative imaging techniques perioperative environment.
• Minimally invasive equipment and technology
• Ongoing research and technologic advancements Perioperative Learner
Surgical procedures are performed in hospitals, in surgeons’
offices, or in freestanding surgical facilities. Many patients can The learner in the perioperative environment may be a medical,
safely have a surgical procedure as an outpatient and do not re- nursing, or surgical technology student enrolled in a formal educa-
quire an overnight stay at the facility. The types of surgical proce- tional program, or the learner may be a newly hired orientee.
dures performed on an outpatient basis are determined by the Medical students have a surgical rotation that includes participation

in surgical procedures. They learn some of the basic principles of
surgical technology and sterile technique to ensure the safety and
welfare of patients.
Some nursing schools offer basic exposure to perioperative
nursing, as a short observation period, part of the core curricu-
lum, or an elective. After graduating from nursing school the
nurse needs further education before functioning as a periopera-
tive professional.1 This education may take place in a postbasic/
postgraduate perioperative nursing course offered by a commu-
nity college or a hospital orientation program. Entry-level educa-
tion for perioperative practice prepares nurses to be generalists.
Basic perioperative nursing elective programs focus on the role of
the perioperative nurse as both generalist circulator and scrub
person. Specialization can follow a period in professional practice
in a specific service. The perioperative nurse’s role encompasses
supervision of unlicensed personnel who scrub in surgery, such as
surgical technologists, and requires knowledge of practices and
procedures performed under this title.
Surgical technology programs focus primarily on scrubbing in to
prepare and maintain the sterile surgical field and handle instru-
ments. Some surgical technology programs offer circulating experi-
ences under the supervision of a registered nurse; however, the role
of the circulator requires knowledge and skill not commonly cov-
ered in significant depth in shorter training programs. Most surgical
technology programs provide scrub experiences in many specialties.
After satisfactory completion of the program, many technologists
are capable of functioning in the scrub role as a generalist or, in
some circumstances, a specialist. Advancing technology indicates
the need for specialized competencies for all disciplines of periop-
erative patient care. Surgeons, perioperative nurses, and surgical
technologists should continually strive to learn new procedures and
technologies in a team-oriented environment.
Perioperative caregivers new to a particular practice setting
should learn the specific performance standards and expectations
of that institution. All personnel go through an orientation pro-
cess to familiarize themselves with the philosophy, goals, policies,
procedures, role expectations, and physical facilities specific to
their institution. Departmental orientation is specific to the area
in which the caregiver is employed.
Many graduates seek employment in the institutions where
they performed clinical rotations. This is usually beneficial to
the facility and the employee. Some students are hired into ap-
prenticeships before graduation, enabling them to work in the
operating room (OR) in a limited capacity in anticipation of a
permanent position. Schools that permit students to work while
still in the education process should have a policy in place to
delineate the student role from the employee role. The policy
should be made known in writing to all clinical facilities hosting
students and students performing clinical rotations where appren-
ticeships are offered. The following are considerations in develop-
ing a policy for working students:
• Students may not work for compensation during official clinical
hours.
• Students may not wear facility name or identification badges
while performing clinical rotations as an agent of the school.
• Students may not wear school name or identification badges
while performing work for compensation as an agent of the
facility.
• Students may not take time off from classroom or clinical
rotations to work for compensation.
• Students are not part of the clinical staff during clinical
rotation hours.
CHAPTER 1 Perioperative Education 3
TABLE Characteristics of the Adult Learner Compared
1.2 with the Child Learner
Adult (Andragogy) Child (Pedagogy)
Is self-directed Is task oriented
Uses activities that follow Uses activities that follow stages
transitions of maturity of development
Uses intrinsic thought processes Uses extrinsic thought processes
Uses problem-solving approach Uses trial-and-error approach
Values self-esteem Values self-esteem
• Students are to maintain patient confidentiality at all times.
• Students may be screened by the school or facility by routine
background checks and drug testing.
• Students should be subject to health screening and vaccinations
followed by titers for proof of immunity (i.e., varicella; rubeola;
diphtheria, tetanus, pertussis [DTaP]; and hepatitis B). Tubercu-
losis testing should be performed before clinical rotation.
All learners in the perioperative environment are adults and
perform better if given due respect. This concept applies whether
the caregiver is experienced or a novice. Treating an adult learner in
a pedagogic manner (pedagogy), as a child is treated, is counterpro-
ductive and becomes a barrier to learning. The learner can become
resentful and unable to separate feelings of inexperience from feel-
ings of inadequacy. Regardless of the level of learning required, the
general characteristics of the adult learner (andragogy) as com-
pared with the child learner (pedagogy) apply (Table 1.2). These
concepts also should be applied to patient education programs.
Not everyone learns at the same speed or assimilates informa-
tion in the same manner. Theoretic knowledge or a skill learned
quickly by one individual may be difficult for another. Cognition
is premised on the ability to process and retain information.
Learning styles vary among individuals and are influenced by
internal and external factors. Examples of learning-style influ-
ences are listed in Box 1.1. Learning styles were described in the
early 1990s by Howard Gardner at Harvard University. Under-
standing the differences in individual learners is the first step to
imparting knowledge and skill.2 Seven learning skills identified by
Gardner are summarized as follows with application of teaching
methods for perioperative learners:
1. Visual-spatial: Very environmentally aware. Learns well by
observation, puzzles, graphics, and modeling.
• The educator can create poster boards with images of in-
strument pictures and setups. Posters can have backgrounds
of blank sterile fields constructed of felt and cardboard
• BOX 1.1 Learning-Style Influences
• Intelligence • Social skills, including communica-
• Attentiveness tion skills
• Cultural and ethnic background • Manual dexterity
• Educational preparation • Physical senses
• Motivation to learn • Physical health
• Concentration and distractibility • Perceptual preferences and sensory
• Personality characteristics partiality (e.g., visual vs. auditory)
• Psychologic strengths or • Environment
deficiencies
4 SE CT ION 1 Fundamentals of Theory and Practice
cut-outs of instruments with Velcro backing for students to
place on the surface.
2. Bodily kinesthetic: Keen sense of motion and hands-on sense.
Communicates well by physical practice.
• The educator can provide sterile drapes and instrument trays
for students’ use in preparing sterile fields and setups. The
task can be made more challenging by timing the process and
creating competition for the best time with the highest de-
gree of accuracy. Teams competing against each other in table
setups and draping make the activity fun and exciting.
3. Musical: Learns well by listening and the use of multimedia.
Frequently learns better with music in the background.
• The educator (with the help of the students) can enumerate
specific steps to a procedure, such as donning the sterile
gown and gloves. The steps are recited to a musical beat
provided by rhythmic clapping or to an instrumental back-
ground tune. Most students recognize simple childhood
tunes and can sing or say the steps to the music. Also, mod-
ern musical instrumentals are easy to use for this purpose.
4. Interpersonal: Group dynamics and study sessions work well
for this learner.
• The educator can assign topics to groups for exploration
and development. The students present their findings to the
class in a forum setting. Some students may want to simu-
late procedures for the class.
5. Intrapersonal: Learns well through self-study and indepen-
dence. Highly self-motivated and disciplined.
• The educator can guide individual students in the creation
of personal flashcards or organization of class notes. Stu-
dents who learn best by self-study generally seek assistance
only when further explanation or clarification is needed.
6. Linguistic: Very good with language and auditory skill. Learns
effectively through lectures and explanation.
• The educator presents lectures on specific topics and uses
multimedia to reinforce the discussion. PowerPoint presenta-
tions enhance the lecture and can be printed for the students
to use in following along. Embedded video is useful, and
links to websites provide variety, such as www.youtube.com.
7. Logical-mathematical: Prefers to investigate and solve problems.
Conceptual thinking precedes detailing with these learners.
• The educator can use several testing formats to challenge
the learners. Tables set up with instruments for identifica-
tion by category or classification give students the opportu-
nity to determine how each item is used in a particular
specialty. An interesting twist to this method involves in-
tentionally omitting a particularly necessary item from the
field; the students have to reconstruct the steps of the pro-
cedure to figure out which item is missing.
Each facility should clearly define the role of the perioperative
learner of each discipline. Activities of new perioperative nurses and
surgical technology students are not the same. The perioperative
nurse is involved with more direct patient care and decision making
through physical assessment. The student surgical technologist is
concerned primarily with preparing and maintaining the sterile field.
Both disciplines of learners help prepare for, assist a qualified pre-
ceptor during, and clean up after surgical procedures, but they are
not considered members of the staff complement. Instructional staff
should observe for and guard against laziness in the preceptor group.
Some preceptors may want to sit back in the pretense of “letting the
student take over.” In essence this is not an improper approach to
precepting, but it can be abused if the preceptor continually leaves
the student to flounder or delay the progress of the procedure.
Some preceptors and surgeons may “bully” the students and
become impatient because of the students’ inexperience. Disrup-
tive behavior (bullying) is counterproductive. Students should
be taught to speak up when necessary, respect the preceptors and
surgeons, but not be afraid to ask questions.3 Most facilities have
developed a “zero tolerance” policy concerning interprofessional
relationships wherein one person causes another person to feel
intimidated or fearful. Some facilities now require a preceptor
class to address appropriate behavior, understand student learning
styles, and learn what is expected of them and how to help stu-
dents become successful.
Students should know basic standards and protocol before
entering the OR for a clinical rotation. Preceptors may have de-
veloped shortcuts with questionable technique not understood by
students who are new to the OR environment. Students should
not blindly perform tasks directed by preceptors that cause ques-
tion as to technique or safety without fully understanding what
resultant outcome is expected.4 Educators should discuss the po-
tential for these questionable events and give the student a vehicle
for professionally or assertively deferring or opting out of doing
something that is nonstandard by the level of education they have
experienced in the classroom. This process can be particularly
uncomfortable if the student does not feel supported by the edu-
cator, who is a mentor in the environment, in doing what has
been ingrained as the standard of care. Some examples of this
activity include but are not limited to the following (these exam-
ples actually happened at a clinical site):
1. Event: Preceptor insists on gowning and gloving from the primary
sterile field and instructs the student to do so as well. Student
deferral vehicle: “My clinical instructor will give me a deficiency
grade if I gown and glove from the back table. I am required to
gown and glove from a separate surface other than the main field.”
2. Event: Preceptor is impatient and goes to sit on a stool in the
corner because part of the procedure is taking a long time.
Student deferral vehicle: “My clinical instructor will give me a
deficiency grade if I sit and change the level of sterility of the
front of my gown.”
3. Event: Preceptor instructs the student to offer a towel from the
open and biologically contaminated back table to a person
who plans to enter the working sterile field. Student deferral
vehicle: “My clinical instructor will give me a deficiency grade
if I offer a towel from my working back table.”
Learners are not expected to assume responsibilities for which
they are not fully prepared, but they should be taught to politely
speak up when something is not right for the benefit of the team and
the patient. Only through continued study and experience can indi-
viduals qualify as team members in the perioperative environment.
The new perioperative nurse in a hospital orientation program,
who will be functioning in interchangeable scrub and circulating
roles, may learn the scrub role first in the learning sequence so as
to learn the art of anticipation of surgeon and patient needs during
a surgical procedure. This is the closest vantage point by which
participation enables the perioperative nurse to be familiarized
with the surgical process. An educator, preceptor, or other qualified
staff member scrubs in as support and gradually allows the new
perioperative nurse to take over more of the work in the sterile
field. One of the primary behavioral objectives is to gain knowl-
edge and skill in sterile technique. Performing the scrub role allows
repetition of tasks performed within the sterile field and better
prepares the perioperative nurse to supervise surgical technologists.
The second component of the perioperative nurse’s learning
sequence is the circulating role. A registered nurse preceptor is

assigned to teach the new nurse the coordination of the scrub and
circulating roles. Standard routines are taught under the supervi-
sion of an experienced perioperative nurse with comparable
knowledge, skill, and educational preparation. Guidance and help
from the clinical educator and other experienced staff members
help the new perioperative nurse pull it all together. Surgeons and
other staff members contribute to the learning process.
Personality traits, such as emotional maturity, social skills, and
psychologic characteristics, are continually assessed by the educator.4
A moody, easily angered, and negative person can be very difficult to
deal with as a future team member. The learner who does not possess
assertive skills for dealing with stressful events cannot function ef-
fectively in a team environment. Subjective responses to all activities
should remain on a professional level if the team is to function effi-
ciently. The perioperative nurse in training should be evaluated on a
periodic basis to assess for increased competency levels.
Perioperative Educator
Experience in the perioperative clinical setting should be planned
and supervised by an experienced perioperative nurse educator.
The term educator is used throughout this text to refer to the per-
son responsible for planning, implementing, and evaluating the
learner’s experiences in the classroom and clinical perioperative
setting. Other teaching personnel at the clinical site include peri-
operative nurse preceptors.
The educator should consider the effect on the learner who is
seeing the perioperative environment for the first time. The OR can
appear cold, large, and overwhelming. A tour of the facility before
beginning the program can help decrease the learner’s anxiety.
A structured curriculum uses behavioral objectives, written
guidelines, and relevant assignments for feedback to ensure that
learning has occurred. Learner conferences are held at regular in-
tervals to discuss procedures and progress. AORN (The Associa-
tion of periOperative Registered Nurses) offers perioperative
nursing coursework in the AORN Periop 101 and Periop 202
programs purchased by hospitals for training of new perioperative
nurses (www.aorn.org/Periop101/).
Didactic presentations should be incorporated into the teach-
ing program to provide information concerning the theory and
detail of all performed actions in the perioperative environment.
Presentations should be offered by knowledgeable presenters who
are well prepared to deliver information to the group. If Power-
Point multimedia are used, the educator should be sure to use
accurate and concise terminology when creating the slides. Hand-
outs can be printed in several formats for distribution to the
participants to use when following along with the talk or taking
notes. Overloading each slide with wordiness and silly images
causes confusion and wastes time. The key elements should be
simply worded and should not exceed six lines of text per slide.
The educator should not read exactly from the slides, but explain
while incorporating the concept the slide imparts. Font style
should be simple, and font size should be readable even at the
back of the classroom. Avoid typing words in all caps. The slide
color scheme and design can be selected from predesigned
templates or customized per presentation. Colors such as blue and
green are easier on the eyes than reds, oranges, and bright yellows.
Time between slide changes should permit questions or examples.
Positive reinforcement helps the learner build confidence and
competence. The educator should not punish a learner for making
honest errors during supervised learning. Degradation and damage to
self-esteem are barriers to learning. The learner should not be required
CHAPTER 1 Perioperative Education 5
to perform any function for which he or she has not had adequate
training or guided practice. The educator should maintain a list of
procedures in which the learner has participated and has demon-
strated increasing levels of competence. Whether the learner is in a
school-sponsored OR education program or a departmental orienta-
tion program, the duration of the program should be sufficient to
afford opportunities for adequate experience to facilitate success. The
AORN position statement on basic orientation recommends a period
of 40 hours in each specialty as part of the orientation process.
Check-off sheets can help track experiential progress during the
education process. Fig. 1.1 shows an example of a basic check-off
sheet for the evaluation of knowledge and skill in the scrub role.
Fig. 1.2 shows an example of a basic check-off sheet for evaluation
of knowledge and skill in the circulating nurse’s role. This sheet
can be modified to apply to specialties as needed. The Association
of Surgical Technologists (AST) and AORN have developed skills
checklists available through the organizations.
Behavioral Objectives
The learner takes an active role in the teaching/learning process by
helping identify behavioral objectives. Effective and organized
educational experiences are identified and based on these objec-
tives. The identified behavioral objectives are attained through
critical-thinking exercises. Skill in questioning and encourage-
ment in making discoveries allow the learner to use critical
thinking as a learning tool.
Evaluation of the learner’s progress is measured by how suc-
cessfully the learner has met the behavioral objectives. Behavioral
objectives are identified and written in behavioral terms and based
on standards of expected performance and accepted standards of
patient care. In 1956, Benjamin Bloom described the measure-
ment of cognitive learning. He detailed six levels of learning,
ranging from simple recall to advanced abstract thinking.
Bloom’s taxonomy provides a framework for structuring cogni-
tive and affective learning. Therefore the concepts to be learned
and the behavioral objectives to be met should form the founda-
tion on which all perioperative caregivers build their practice.
Each behavioral objective in Box 1.2 is measurable and is evalu-
ated by performance standards.
Elements of Effective Instruction
The organization of the instructional material and the learning expe-
rience are further enhanced by the way the program is presented.
The elements of effective instruction are summarized as follows:
• Set clear and concise behavioral objectives measurable in cog-
nitive terminology that describes knowledge, comprehension,
application, analysis, understanding, and evaluation.
• Establish a learning environment that is controlled by the educator.
• Provide variation in presenting material. Videotapes, DVDs, ani-
mated computer programs, podcasts, and photographs can be
alternated with lectures and hands-on practice. Handling instru-
ments and supplies in a classroom is less intimidating than han-
dling them in the perioperative environment for the first time.
• Encourage the exchange of questions and answers as an assess-
ment tool. Learners often ask exactly what they need to know.
The educator can determine areas of deficient knowledge.
• Reinforce learning. After a skill has been taught in a didactic
manner, provide guided practice in the clinical laboratory
before the task is actually performed in the perioperative
environment. Provide positive support for desired behaviors.
Another random document with
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cents up, and club lunches, with an ample selection of good things to
eat, for fifty or sixty cents. You may pay more for your room and
bath, but you get more for your money, with better service. We made
it a rule to go to the newest, largest hotels, and indulge in every
comfort that was afforded. Why? Not to be extravagant, nor to say
that we had stopped at such or such hotels. After you have driven
day after day, and come in stiff and tired, there is no bed too soft and
no bathroom too luxurious to overrest your mind and body.
Economize in other ways if you must, but not on good food and
comfortable lodgings.
Our third day was still a drizzle; we would no sooner have the
top down than we would have to put it up again, and often the side
curtains as well. Our objective point was the charmingly quaint town
of Bedford, and the Bedford Arms. This part of Pennsylvania was
more beautiful than what we had been through, and every mile of the
day’s run was a pleasure.
I have not spoken of our lunches, a most important item by one
o’clock. We had brought a small English hamper, fitted with the usual
porcelain dishes, cutlery, tin boxes, etc., for four people, and unless
we were positive that a good place to eat was midway on the road,
we prepared a lunch, or had the hotel put one up for us. This latter
plan proved both expensive and unsatisfactory. Usually Toodles was
sent foraging to the delicatessen shops for fresh rolls, cold meats
and sandwiches, eggs, fruit, tomatoes, and bakery dainties, and the
hotel filled our thermos-bottles with hot coffee. We carried salt and
pepper, mustard, sweet and sour pickles, or a relish, orange
marmalade, or a fruit jam, in the hamper, and beyond that we took
no staple supplies on the whole trip. We met so many people who
carried with them a whole grocery-store, even to sacks of flour, that
you would imagine there was not a place to get food from the
Atlantic to the Pacific. Often later on we would meet these same
people and find that they had thrown or given away most of their
larder. Of course, the camping parties, which are legion, are houses
on wheels! Aside from the tents, poles, bedding, and cooking
utensils, we have seen stoves, sewing-machines, crates of tinned
foods, trunks full of every conceivable incumbrance they could buy,
strapped to the back and sides and even on the top of the car, and
usually the personal luggage jammed in between the mud-guards
and hood of the engine. A traveling circus is an orderly, compact
miniature in comparison. And the people!—sitting on top of a
mountain of baggage, or under it, the picture of woe and discomfort.
That may be fun, but I fear I have not developed a capacity for such
pleasure. Have you ever seen a party of this description unpack and
strike camp after a hot, broiling, dusty day of hard travel? You will do
as we did—drive right ahead until you come to a clean hotel and a
bath.
We have been told so often that one has to develop an “open-
air” spirit to really enjoy a long motor trip! Quite true! I can’t imagine
what the fun can be of touring in a closed limousine, and yet we
have met that particularly exclusive party more than once. On the
whole, an absence of flies, ants, mosquitoes, and sand and dust in
one’s bed and food does not detract from the pleasure of the trip. It
may be all right to endure such annoyances for a few days in the
woods, to fish or hunt—but weeks and more weeks of it! We admit
our “lack,” whatever it may be termed, and enjoy clean linen, hot
tubs, and tables that have legs not belonging to ants and spiders.
In Wisconsin we met a most unique and charming couple, both
past fifty, who had lived all over the world, even in South America, a
Mr. X and wife, from Washington, D. C. They were going on the
same route as we were, and back to Washington, via southern
California, the Yosemite, New Mexico, New Orleans, and then north.
So their trip would be twice as long as ours. They loved the open,
with that two-ton-equipment enthusiasm excelling all others we had
met. From an over-stocked medicine chest, so carefully stowed
away that they bought what they wanted en route rather than unload
everything to try to find it, to a complete wardrobe for every
occasion, which was never unpacked, they had every conceivable
utensil that a well-furnished apartment could boast of. They even
bought a small puppy, as a protection at night when camping; the
poor little beast caught cold and crawled under the pile and died.
They solved the lunch problem in a unique way. If they passed a
good corn-field, they “procured” a few ears and stopped at the next
farmhouse and calmly asked the loan of the kitchen for a short time,
and cooked their corn and bought bread and milk, etc. Mrs. X
remarked: “It is all so simple! We have all these things in case we
should need them, but they are so well packed in the car it is really
too bad to disturb them; so I live in one gown, and we buy what we
need, and it is most satisfactory.” Later we learned that they had
camped out just three nights in several weeks.
But I have digressed, and left you at the Bedford Arms, one of
the most artistic, attractive inns that we found. The little touches
showed a woman’s hand. Flowers everywhere, dainty cretonnes,
willow furniture, and pretty, fine china; in appearance, courtesy, and
efficiency, the maids in the dining-room might have come from a
private dwelling. Will someone tell me why there are not more such
charming places to stop at on our much-traveled main highways.
Why must hotel men buy all the heavy, hideous furniture, the
everlasting red or green carpets and impossible wall-paper, to make
night hideous for their guests—to say nothing of the pictures on their
walls? It is a wonder one can sleep.
There is much of interest to see in Bedford—really old, artistic
houses, not spoiled by modern gewgaws, set in lovely gardens of
old-fashioned flowers, neatly trimmed hedges, and red brick walks.
There were few early Victorian eyesores to mar the general beauty
of the town. As we were walking down the main street about sunset,
we heard a great chattering and chirping, as if a thousand birds were
holding a jubilee. Looking up, we found, on a projecting balcony
running along the front of all the buildings for two blocks, hundreds of
martins discussing the League of Nations and Peace Treaty quite as
vigorously as were their senatorial friends in Washington. They were
fluttering about and making a very pretty picture. It sounded like the
bird market in Paris on a Sunday morning, which, in passing, is an
interesting sight that few tourists ever see.
It was with regret that we left the next morning for Pittsburgh.
The day was clear and cool and the best part of the Lincoln Highway
was before us; in fact, the first real thrill so far, and one of the high
spots of the trip. This was a stretch of seven and a half miles of
tarvia road on the top ridge of the Alleghany Mountains, as smooth
as marble, as straight as the bee flies, looking like a strip of satin
ribbon as far as the eye could see. On both sides were deep ravines,
well wooded, and valleys green with abundant crops, and still higher
mountains rising in a haze of blue and purple coloring, making a
picture that would never be forgotten. The top was down and we
stopped the car again and again, to drink it in, and, as one of us
remarked, “We may see more grand and rugged scenery later on,
but we shall not see anything more beautiful than this”—and it
proved true.
We had come 442 miles, from New York to Pittsburgh, over fine
roads and through beautiful country. Approaching Pittsburgh, we
came in on a boulevard overlooking the river and “valley of smoke.”
Great stacks were belching out soot and smoke, obliterating the city
and even the sky and sun. They may have a smoke ordinance, but
no one has ever heard of it. We arrived at the William Penn Hotel, in
the heart of the business center of the city, a first-class, fine hotel in
every regard. We found the prices reasonable for the excellent
service afforded, which was equal to that of any New York hotel. The
dining-room, on the top of the house, was filled with well-dressed
people, and we were glad that we had unpacked our dinner clothes,
and appeared less like the usual tourist, in suits and blouses. It was
frightfully hot during our two days’ stay. You go out to drive feeling
clean and immaculate, and come in with smuts and soot on your
face and clothes, looking like a foundry hand. The office buildings
are magnificent, and out a bit in the parks and boulevards the homes
are attractive, and many are very handsome, especially in Sewickley.
But aside from the dirty atmosphere one is impressed mostly by the
evidences of the outlay of immense wealth. An enthusiastic brother
living there took us through a number of the business blocks, and
told us of the millions each cost and the almost unbelievable amount
of business carried on. I can only describe Pittsburgh as the
proudest city we visited. Not so much of the actual wealth
represented, but of what the billions had accomplished in great
industries. We went out in the evening and stood on one of the
bridges to look over the river lined with monster furnaces. The air
was filled with sparks, jets of flame bursting through the smoke. All
you could think of was Dante’s Inferno visualized. And what of the
men who spend their lives in that lurid atmosphere, never knowing if
the sun shone, nor what clean, pure air was like in their working
hours? I shall never look at a steel structure again without giving
more credit to the men who spend their waking hours in those hells
of heat and smoke than to the men whose millions have made it
possible.
The second day, nothing daunted by the heat, we went out to the
St. Clair Country Club for lunch and golf, about a twenty-mile run
through the suburbs. This is a comparatively small and new club, but
our host told us that they were soon to have a fine club-house and
improve the links. The location is attractive, and the luncheon was
delicious. We had brought our golf bags, tennis racquets, and
bathing suits with us, much to the amusement of our friends. After
sitting in the car day in and day out, I know of no better way to
stretch your legs and arms and to exercise your stiff muscles than to
put in a few hours at either game. My husband described this course
thus: “You have to hold on to a tree with one hand and drive with the
other, the bally course is so steep.” There are many more
pretentious country clubs and golf links about Pittsburgh, but this
small one had charm and a homelike atmosphere. Our last evening
we were taken to the “New China,” the last word in Chinese
restaurants—beautiful, clean, and artistic! You have your choice of
American or Chinese dishes. As we were looking for sensations, we
ordered some marvelous dishes with impossible names. One portion
was sufficient for three hungry people. The other two portions were
untouched. I do not know what we ate, but it was delicious. Truth
compels me to state that we were all ill for three days, and decided
to patronize home cooking in the future.
We did not get away until noon the next day, as our auto top had
been torn in the garage, and the manager kept out of sight until
noon, and then, after considerable pressure had been brought to
bear, he made a cash settlement of fifteen dollars, wishing us all the
bad luck his “Mutt and Jeff” mind could conjure.
 III

OHIO AND DETOURS

We were assured that we should find good roads through Ohio to

Cleveland, where we were to take the D. & C. steamer to Detroit. If
we were to take this part of the trip again, we should certainly go to
Chicago, via Toledo and South Bend, Indiana. As we had relatives in
Detroit waiting in the heat to see us, and to depart for cooler climes,
we took the most direct route through Youngstown, Ohio, to
Cleveland. The roads were poor and the many detours were almost
impassable—over high hills, on narrow sandy roads, winding like a
letter S through the woods. One long stretch was so narrow that two
cars could not pass; so they had two roads, one going each way.
The Doctor remarked, “I wonder what would happen if a car broke
down on this detour.” Prophetic soul! He no sooner had said it than
we rounded a curve, and presto! there were six cars, puffing and
snorting, lined up back of an Overland car, which was disabled and
stuck fast in the sand. In half an hour there were ten cars back of
ours—and the sun setting over the hills, and fifty miles to
Youngstown! The owner of the car knew nothing of his engine.
Heaven save us from such motorists! But Heaven did not save us,
for we met dozens of men, headed for the wilds of somewhere, who
were as blissfully ignorant of what made the wheels go round as
their wives were.
It may have been a coincidence, but is nevertheless a fact, that
nearly every car we saw disabled, ditched, stuck in the mud or sand,
or being towed in, on the entire trip, was an Overland car. It really
became a joke. When we saw a wreck ahead of us, some one
exclaimed, “Dollars to doughnuts it is an Overland!”—and it generally
was. It used to be a common expression, “If you wished to really
know people, travel with them.” I would change it to “Motor, and grow
wise.” There were as many varieties of dispositions in that belated
crowd as there were people. Everyone got out of his car and went
ahead to the wreck, offering advice, growling, complaining, and
cursing Ohio detours. A few sat on the roadside and laughed,
chatted, or read the papers. As it was hot and dusty, we looked like
an emigrant train. My husband is an engineer with a knowledge of
cars. He suggested some simple remedy which enabled the man to
get his car to the next siding, and we all started with a whoop of joy
on the wretched road, leaving the Overland owner to spend the night
at a farmhouse near by.
Our troubles were not over. With a steep grade before us, I was
driving, going up steadily on second speed, when a real wreck
loomed up three-quarters of the way to the top of the hill. Two
drunken niggers had upset a rickety old truck loaded with furniture in
the center of the road, and their car had zigzagged across the road,
narrowly escaping a plunge down the steep embankment. You could
not pass on either side; so, with my heart in my mouth, I reversed,
backing our car into the farther side of the road, with two wheels in a
deep stony ditch, but safe from sliding down-hill on top of the cars
coming up back of us. It looked as if we were to share the fate of our
Overland friend and stay there indefinitely. We all jumped out and
tried to clear the house and lot out of our way. Those miserable
niggers just sat on top of the débris and refused to work. After
tugging at spring beds and filthy bedding, we succeeded in getting it
pushed to one side. I had had enough driving for one day, so gave
the wheel to my husband, and he started the engine. We did not
budge! The next half-hour was spent in filling up the ditch with
stones and making a bridge by covering the stones with boards.
Eventually the car started, pulling itself out of the slough of despair,
and narrowly escaped turning turtle. The Doctor, Toodles, and I all
called wildly, “Keep going! don’t stop!”—and on he climbed to the
top, while we trudged up through the dust, a quarter of a mile. All
that night I dreamt I was backing off the Alps into space.
 Oh, what a tired, dirty party it was that drove up to the Ohio Hotel
in Youngstown that night! Someone had told us that there was a
good hotel in Youngstown, but we soon came to form our own
conclusions about hotels. This was a delightful surprise. Not only
good, but wonderful, for a city of the size of Youngstown. After we
were scrubbed and sitting down to a delicious dinner in the big cool
café, a broad smile spread over the table, and the Doctor suggested,
“You know, it really might have been worse!”
The next day we had more detours; but, in the main, the state
highways, when they could be traversed, were good. The rural
scenery through Ohio was pleasing, but we had left the Lincoln
Highway and the beautiful farms of Pennsylvania.
We reached Cleveland by four, driving directly to the D. & C.
wharves. The “Eastern States” was being loaded, and the monster
“City of Detroit III,” a floating palace, was starting out for Buffalo, I
believe. Although the week-end travel is always heavy, and this was
Friday, we were most fortunate in getting staterooms, with brass
beds (not bunks), running water, and a bathroom. It may be of
interest to state that the cost of shipping the car to Detroit, a night’s
run, was only $14.50. As we did not sail until nine o’clock, and we
could not go aboard nor leave the car, we drove out the Lake Shore
drive overlooking Lake Erie, through beautiful suburbs, with
attractive homes and gardens, and then something told us it must be
time to investigate the hotels. As we had all sampled the excellent
cooking at the Statler, we dined at the fine Cleveland Hotel—modern
in all its appointments, in good taste, and unexcelled service. We
remarked the appearance of the people. There was not a smartly
gowned woman in the dining-room, and the waiters had a monopoly
of the dress suits. Being hot, and in midsummer, and a more or less
transient gathering, might have been the reason. In many large
cities, in first-class hotels, we found the tired business men in
business suits and the women in skirts and blouses. Never did
anything taste more delicious than the broiled fresh whitefish, just
out of the lake, green corn on the cob, melons, and peaches. As long
as we remained in the Great Lakes region, we reveled in the
whitefish, broiled, sauté, or baked. It is the king of fresh-water fish.
 I am beginning to realize that I am exhausting my descriptive
adjectives when it comes to hotels. Time was, not so very far distant,
when a hotel like the Cleveland was not to be found, except in
possibly half a dozen cities in this country. Now it is the rule. On all
our long trip, with the exception of three nights, we had perfectly
comfortable, clean double rooms, usually with twin beds, and private
baths with modern sanitary plumbing and an abundance of hot, not
tepid, water. We have been assured by the proprietors that the
change has been wrought by motorists who demanded better
lodgings. I think the farmer is the only member of society who still
holds a grudge against us as a class; but when he is the proud
possessor of a “Little Henry” he slides over to our side
unconsciously. A book could be written on “Motoring as an art, a
profession, a pastime, a luxury or a necessity, a money maker or a
spender, a joy or a nuisance”—and then much more!
Before leaving Cleveland I must speak of its fine municipal
buildings, its many industries, and its far-famed Euclid Avenue, once
the finest of streets, lined on both sides with massive, splendid
residences, many with grounds a block square; alas! long since
turned into boarding-houses, clubs, and places of business—the
inevitable transition from a small to a great city.
Our trip across Lake Erie was quiet and cooling. That is not
always the case, even on such big steamers as the D. & C. line
affords. I have seen that lake lashed into fury by waves that rocked
the largest boat like a cockleshell. Breakfast on the steamer was all
that could be desired. It was some time before we had the car on the
dock, ready to start to our hotel in Detroit. The ride up the river had
been interesting, past old Fort Wayne, the Great Lakes engineering
plant and dry docks, and the grain elevators; even at that early hour
(seven A. M.) the wharves were alive with the bustle of trade.
Here I pause. Detroit was my home city and that of my father
and grandfather in territorial days. My earliest recollections of it were
of broad streets, fine homes, and an atmosphere of dignified culture
and home-loving people. But now! It has outgrown recognition. It has
outgrown every semblance of its former charm. Like Cleveland, the
old homes on the principal avenues are all given over to trade, and
the streets down-town are overcrowded, noisy, and well-nigh
impassable. The Statler is a new and fine hotel. We went to the
Pontchartrain, formerly the old Russell House, which in its palmy
days, in the Messrs. Chittenden régime, was the center of the social
life of Detroit. It has passed through several hands, and is now
doubtless torn down. We found it run down and undesirable in every
way. Even then we felt more at home there and made the best of
things. We spent two and a half days, as hot as I ever experienced.
The nights were so hot that sleep was out of the question. A drive
around the Island Park, Belle Isle, cooled us off a bit. Thousands
were taking advantage of the municipal bathhouses or a swim in the
river.
If the city has been spoiled down-town, it has been equally
beautified in the outlying sections. The drive to Grosse Pointe along
Lake St. Clair has ten miles of residences unsurpassed in America.
The magnificent home of Senator Truman Newberry and dozens of
others that could be mentioned, set in acres of highly cultivated
grounds, commanding an unobstructed view of Lake St. Clair, are
worthy of a special trip to Detroit to see.
We lunched at the Country Club, but weakened when it came to
trying the celebrated golf links. It was too boiling hot! There were not
more than a dozen people at the club. Usually the place was
crowded. There are other fine clubs and links about Detroit, and the
city seems to have gone golf mad—a very healthful form of insanity!
The Detroit Athletic Club, in the business center, claims to be the
finest private city club in America. If patronage is any indication of its
excellence, this must be true. My brother, Mr. L., gave us a beautiful
dinner there, and we certainly have not seen anything to surpass it.
Our time was all too quickly spent, and the heat literally drove us out
of town. Before leaving, we paid our respects to the mayor, Mr. C.,
an old-time friend. While we were pleasantly chatting with him and
he was graciously offering us the keys of the city, my husband had a
summons served on him and the car locked for leaving it more than
an hour at the curb. He was taken to police headquarters and paid
his fine and then returned for us. As we were praising the efficiency
of the mayor, he gave us a knowing smile, and some days later
showed us his summons!
 IV

ON TO CHICAGO

I realize that I am giving a most unsatisfactory picture of the

Eastern and Middle-West cities. Our time was limited, and space
forbids my giving anything but a cursory glance, a snapshot view, of
their size and beauty. And, then, most tourists visit these places and
the reading public have an intimate knowledge of them.
We left Detroit, having been told at the Michigan Automobile
Association that we should find excellent roads. As one prominent
broker remarked, “You can drive the length of the state on
macadamized roads.” Where were they? Surely not the way we
went, the way described in the Blue Book. And let me state right here
that we have never had much faith in that publication, and now what
little we had is nihil! A few miles out of the city we struck a detour
which lasted nearly to Ann Arbor. We had left at six o’clock, and
when we reached the university city all places to dine were closed.
We did not dine. We had pot-luck supper at a Greek restaurant, and
started for Jackson to spend the night. Ann Arbor is a beautiful
place, and the university buildings and fraternity houses are second
to none of all we saw in other states. The road did not improve, and
we arrived at Jackson very late and put up at the Otsego Hotel. It
was crowded, and we were given the “sample rooms,” in which the
traveling-men displayed their goods on long tables. We had
comfortable beds and private baths, but you felt as if you were
sleeping in a department store, with the counters covered with white
cloths. Otherwise, the Otsego is a good hotel, and we were perfectly
comfortable. By the time we were through breakfast, we asked to
have a lunch put up, and were kindly but firmly told that it was nine-
thirty, and the chef had gone home and locked up everything. We
pleaded for some hot coffee and anything cooked that was left from
breakfast. But no, not a sandwich nor a roll could we buy! We met
this condition time after time. If we arrived at a hotel after eight
o’clock in the evening, we were met with the same retort—“Chef
gone and everything closed.” A dozen times and more we were
obliged to go out and forage for supper—“due to the eight-hour law,”
we were always told. As it was nearly ten o’clock, we trusted to luck
to find a lunching-place en route. Fortune certainly favored us in the
most unexpected way—not in our roads, which still were poor, but in
the shape of two little girls on the wayside. As we were passing
through a hamlet called Smithfield—before reaching Albion—we
were attracted by two dainty girls with baskets of goodies waiting for
us. Their names were Evelyn and Willetta Avery, and they proved to
be fairy godmothers. Their mother owned the neighboring farm, and
these children were spending their vacation in supplying lunches to
passers-by. Everything was done up in fresh napkins and was real
home cooking. This is what we bought from them: a quart of fresh
blueberries (which Toodles, in her joy, promptly upset in the tonneau,
and we walked on blueberries for days!), fresh cake, pie, honey,
hard-boiled eggs, tongue sandwiches, hot bread and rolls, a pat of
sweet butter, and oh! such home-made pickles, raspberry jam (a pint
glass), and a bottle of ice-cold spring water, an abundance for four
hungry grown-ups, and all for $2.10. We gave them both liberal tips
and they smiled and waved us out of sight. That was a banner
luncheon, and the best but one on the trip.
We stopped in the interesting city of Albion. The college was
founded and endowed by General Fisk, of Civil War fame, whose
only daughter, Mrs. P., is one of New York’s most beautiful and
prominent women. That afternoon about four we came to Battle
Creek, and as the Doctor’s eyes were troubling him, from the heat
and dust, we drove to the sanatorium, where he could receive
treatment. It is an immense place and beautifully kept up. We were
sitting in the car outside, watching the crowds of patients with their
friends, when a number of wagons, like popcorn wagons, came into
view, pushed about by the white-robed attendants. The wagon itself
and the four uprights were covered with white cloth and festooned
with fresh vines and flowers. In the center, hidden from view, was an
ice-cream freezer, and young girls in white, carrying flowers, were
dispensing ice-cream cones at five cents each. It was as pretty a
sight as I ever saw. The carts were wheeled through the grounds
and everyone, sick or well, indulged. It was our first introduction to
ice-cream cones, but we acquired the habit; and thereafter our
afternoon tea consisted of ice cream, generally bought at a soda-
water fountain in some small town along our road. It may be
fattening, but it is nourishing and refreshing. Even in the tiny hamlets
on the plains of Montana we found good, rich ice cream. It is
certainly an American institution and a very palatable one.
We had come ninety miles over bad roads, and it was 160 miles
to Chicago, so we decided to stop at Paw Paw for the night. We
drove through the town and inquired which was the best hotel—our
usual question—and were told that they had two, but the Dyckman
House was first-class—a typical small country hotel, with little
promise of comfort. We were shown into big, comfortable rooms with
one private bath; but were told that “supper was over.” The manager
was a typical small-town person of importance, but had a kindly eye,
and looked amenable to persuasion. The others had given up hope;
not so with me! Then and there I invented a “sob-story” that would
have melted Plymouth Rock. It became our stock in trade, and many
a supperless night we would have had without it. After praising up
the town and his hotel, and saying that we had heard of its
hospitality, and so forth; that we were strangers, and had come all
the way from New York; that we were tired and hungry, and I really
was not very well; and that the price was no consideration, etc., he
walked out to the kitchen and caught the cook with her hat on ready
to depart, gave his orders, and in twenty minutes we were doing full
justice to a perfectly good supper. After we had finished, I went out
into the summer kitchen and found a good-natured Irish woman, as
round as she was pleasing, fanning herself. I gave her a dollar,
thanked her for staying, and made a friend for life.
Even in Michigan our New York license attracted much attention.
When we came out of a hotel or store, a crowd of people had
invariably gathered about the car and were feeling the tires. The size
seemed to astonish them. The fact that we had come from New York
filled them with awe, and when, in fun, we said we were going to San
Francisco, they were speechless! “Aw, gaw on!” or “By heck!” was all
that they could exclaim.
Our last taste of Michigan roads was worse than the first. We
went by the way of Benton Harbor, with sandy detours and
uninteresting country, until we struck the strip of Indiana before
coming into South Chicago. Our troubles were over for a long time. A
breeze had come up from the lake, and we slept under blankets that
night for the first time in two weeks. We were all familiar with
Chicago, and we wished to stop out on the Lake Shore, if possible.
We drove through the city, out on the North Shore Boulevard to the
Edgewater Hotel, of which we had heard charming reports. A block
below the hotel cars were parked by the dozens. It is built directly on
the shore, with the most remarkable dining-room at the water’s edge,
like the deck of an ocean liner, filled with palms, flowers, and smartly
dressed people, many in evening clothes. The tables were all
reserved, and so were the rooms, two weeks in advance—this was
the pleasant news that awaited us! Could they take us in the next
day? “No, possibly not for a week or more.” No “sob-story” to help us
here! But the clerks were obliging and advised our going about ten
miles farther out, to the North Shore Hotel in Evanston, which we
found delightful in every way—very near the lake, quiet, furnished in
exquisite taste, and good food at reasonable prices. But even here
we found the eight-hour law in force; we could not get a bite after
eight o’clock. We went to half a dozen restaurants—all closed! In
desperation we went into what looked to be a candy store, and found
they were closing up the café! They could serve nothing but ice
cream and sodas. We asked to see the manager and told him our
plight. He was an Eastern man, a long-lost brother. He said, “As you
placed your order just before eight o’clock, of course we shall serve
you.” It was quite nine by this time. He kept his face straight, and we
tried to do the same. That dinner certainly did touch the spot! It was
the “Martha Washington Café,” and certainly immortalized the
gracious lady for all time for us. Later we went back to the
Edgewater Hotel for our mail and to dine, and we were more
charmed with it than before.
 We had come 1028 miles from New York. Our car had to be
thoroughly cleaned, oiled, and looked over; so we were without it for
two days. The street-car strike was on in full force, not a surface car
moving in the city. Consequently, we walked, rested, and saw but
little of the city. It was quite ten years since any of us had been there;
in that time Chicago had grown and been so improved that we hardly
knew it. If Pittsburgh people are proud of their city, Chicagoans are
the original “boosters.” Nature has done so much for its location. Its
system of parks and boulevards is not equaled by any city. There is
a natural, outspoken pride evinced by the people of the best class—
not ashamed of a humble beginning, but glorying in the vast
importance of the commercial and financial life. To quote from the
folder of the Yellowstone Trail, which we picked up here and followed
without any trouble to St. Paul, Minnesota, “Nothing need be said
about Chicago. Chicago is the heart of America and speaks for
herself.” Other cities may challenge this, but there is every evidence
of its truth. In time, Chicago will give New York a good race; in fact,
she is doing it now.
Our genial Doctor left us here, much to our regret. We went on, a
select party of three.
 V

THROUGH THE DAIRY COUNTRY

“A good road from Plymouth Rock to Puget Sound.” Thus reads

the Yellowstone Trail folder. If you really believe a thing, you may be
excused for stating it as a truth. The trusting soul who wrote that
alluring statement has never been over the entire trail, or I am
greatly mistaken. Credit must be given for the system of marking the
trail. At every turn, right or left, the yellow disk is in plain sight.
On leaving Chicago, we went through Lincoln Park and up the
Sheridan Road to Milwaukee. The road is a wonderful boulevard,
with beautiful homes and estates and glimpses of Lake Michigan,
past the Great Lakes Naval Training Station, now the largest in the
United States. We had heard much of Zion City. Driving down its
main street was like a funeral. The houses were closed, the buildings
seemed deserted, and the only evidences of life were two men, a
horse and wagon, and a stray dog! We found a good macadam road
to Oshkosh from Milwaukee and many such stretches through
Wisconsin. At times the road followed closely the shore of Lake
Winnebago, and then would wind through fertile dairy country.
Trainloads of butter and cheese are shipped from here each year,
and high-bred dairy cattle are raised for the market. Was it not
strange that we did not have Wisconsin cheese on the menu at any
hotel in that state? Several times we asked for it, but no cheese was
forthcoming.
The first night we put up at Fond du Lac, at Irvine Hotel. It was
fairly good, but a palace compared with what we found the next night
at Stevens Point—the Jacobs Hotel. This was our first uncomfortable
experience—a third-rate house, with no private bath, hard beds in
little tucked-up rooms, a bowl and pitcher with cold water and two
small towels the size of napkins, and the most primitive table you
could imagine. The weather had kept cool and clear, but the sandy
roads with deep ruts were awful! As it had rained in the night, the
clerk assured us next morning that four cars were stuck in the road
west of the town, and we had better not start. We asked him if there
was a good hotel at Marshfield. “Good hotel! Well, you folks just wait
till you see it! They actually have Brussels carpet on the floor of the
dining-room! Good hotel, eh? Nothin’ better this side of Chicago!”
The cars were lined up in the street waiting to start. The clouds
looked heavy and threatening, and not a ray of blue sky. Everyone
was talking to someone. The formalities are discarded on such
occasions. We fell into conversation with a charming man, Mr. H.,
from Fargo, North Dakota. Later we found that he was the ex-
governor, and his name was sufficient to get anything you wanted in
the Northwest. He and his family were touring to New York; so we
exchanged maps and experiences, and he gave us a list of towns
and hotels that proved invaluable, with the kindly remark, “If you will
show the hotel clerks this list with my name, I am sure you will be
well taken care of.” We certainly were—and more!—from there to
Yellowstone Park.
We found the Blodgett Hotel at Marshfield—with a really, truly
carpet in the dining-room—a good hotel, clean and comfortable. The
next day we had two hundred miles to go to St. Paul, and were
promised good roads. Colby, Eau Claire, and Chippewa Falls are all
attractive towns. Wisconsin boasts of six thousand lakes. It certainly
is a paradise for the huntsman and the angler—“The land with charm
for every mile.” The method of numbering the state highways is the
best we have found. You simply can’t lose your way. We,
unfortunately, had several long detours and did not reach St. Paul
until one A. M., a very sleepy trio, in a disreputable-looking car.
 VI

CLOTHES, LUGGAGE, AND THE CAR

We decided to take as little luggage as possible. In the end, we

found that we had more than ten people would need. Each of us had
a large dress-suit case, a small handbag with toilet articles, an extra
bag for soiled linen (which proved useful), two golf-bags, with
umbrellas and rubbers (which were never used), a case of tennis-
rackets and balls, a shawl-strap with a heavy rug, rain-coats and top-
coats for cold weather, the lunch-hamper, and a silk bag for hats.
The tonneau was comfortably filled, with still room for two, and even
three, people. The thermos-bottles were stowed away in the side-
pockets, easy of access. All the maps were in the right-hand front
pocket by the person sitting with the driver. We had an old rug which
was so disreputable that no one would steal it; we had been on the
point of throwing it away a dozen times, but after it came from the
cleaners we hadn’t the heart to leave it behind. That old relic proved
to be the joy of the trip. We sat on it when lunching on the roadside,
used it to protect the car from the bags and golf-clubs, and when we
had a puncture down it went under the car to avoid collecting all the
dust of the road on my husband’s clothes. We still have it, and
consider the old veteran deserves a pension for life. My advice—
take an old rug!
And our clothes: Of course, a silk or an alpaca dust-coat; linen
soon shows soil and looks mussy. This applies to the ladies. I won’t
attempt to advise men, for they will wear what best suits them. We
wore one-piece gowns of serge, and, when it was hot, voile or even
gingham. We each had a silk afternoon frock, which would shake out
and look presentable for dinner, a black evening gown for dress-up
occasions, a half-dozen crêpe de chine blouses, and a cloth suit. We
could have done without the suits. They were used but once or
twice. We all took heaps of under-linen, only to find that we could get
one-day laundry service in any good hotel, and could buy almost
anything in the cities, and even in the small towns. The color of our
linen resembled coffee at times, but, aside from that unpleasant
feature, we could keep clean and comfortable with no trouble. We
each had a sport skirt, a sweater, shoes, a pair of evening pumps, a
pair of heavy top-boots, and two pairs of Oxford ties, black and tan,
with sensible heels. In driving, I soon found the long-vamp, pointed
toe not only a nuisance, but dangerous, and used an old-fashioned,
round-toed low shoe. Hats! There every woman is a law unto herself.
We each had a good-looking hat in the hat-bag, which, after being
tied to the rug-rail, sat on, smashed by the bags, and wet a few
times, still kept our hats very presentable. Straw hats will break and
be ruined. Those made of ribbon or black satin will withstand the
weight of a ton of luggage and come out looking fairly decent. Wash
gloves proved practical, also white Shetland veils. Toodles was
swathed like an escaped harem beauty; but one good Shetland veil,
well tied and pinned in, kept my sailor hat in place comfortably, even
when the top was down and I was driving. The hat with a brim is a
necessity when the sun shines for weeks at a time. I did not wear
motor goggles, but the others did. Through all the Western states we
found the female population in khaki breeches and puttees, khaki
blouses, and hats like a sun-bonnet or a cowboy’s sombrero, and
occasionally a coat to match, which was short and of a most
unbecoming length. Often high tan boots were substituted for the
puttees. It was a sensible costume, and well adapted to the country
and life in the open that Western women lead. They all rode astride,
wisely. Often we met parties of four in a Ford just hitting the high
spots on the road.
The farther we went into the real West, the West of the movies
and the early days pictured by Bret Harte, we realized what part
these Western women had played, and were still playing, in their
unselfish, brave, industrious, vital lives, in the opening and
developing of that vast territory, and in making such a trip as ours
comfortable, safe, and even possible. I think, if I ever take the trip