The instrumentalist

He stands to the right of the surgeon. He knows all the surgical instruments and exactly when each one is needed. At the end of an operation, pincers, scissors, cups – everything’s immaculate, just as it was at the beginning of the procedure.

Judging by the name, you could imagine that an instrument nurse is merely someone who follows orders. “But it’s not exactly like that. To instrument is to actively participate in the surgery. Often the surgeon doesn’t have to say a thing because, before he says it, the instrumentalist has already put what he needs in his hand”, explains José Mimoso.

Simple? “A surgeon knows the instruments of his specialty. The instrument nurse – because he works in all specialties – has to know all the instruments, as well as the steps and procedures of each one”, he explains.

Instruments are place in a standard format that has to do with sequence – the rhythm of the surgery. Nonetheless, there’s a personal signature in the way each instrumentalist prepares his or her table – according to personal preference. “I can pick up a particular piece without looking. That’s why one arranges things in a specific order”.

In a simple operation – like removing an appendix, or fixing a hernia – a minimum of 30 instruments is needed.

For a major operation, the assortment could include as many as 100. The more complicated the type of surgery, the more instruments needed.

Some come in pieces following sterilisation and have to be assembled immediately before the procedure, with minute precision. “They’re not all from the same manufacturer, so they don’t all assemble in the same way”.

“Orthopedic surgeries are the ones that involve technology – and the instruments are correspondingly more complicated, with more difficult procedures. In knee or hip replacements, there are all sorts of pieces that have to be assembled and then handed over in very specific positions”, Mimoso explains.

“Often we have to be taught – when, for example, the firms that make the replacement parts bring their technicians and instruments and talk us through it all”, he tells, because “right now, there doesn’t exist – nor are there plans for – a speciality in the surgical ward. Contrary to other countries, we don’t have what’s called perioperative nursing in Portugal”.

The day before our interview, Mimoso was the instrument nurse for a right hemicolectomy (the removal of part of the large intestine via laparoscopy – a technique of visualisation using a video camera), as part of general surgery. It was the second time one of these procedures had been undertaken at “Centro Hospitalar do Barlavento Algarvio”.

But, sometimes high-tech surgery doesn’t work. Certain instruments “have to be connected to machines – and when we test them, they don’t work”. In a situation of elevated concentration – with no margin for error, and often when people are working against the clock, “problems like this generate stress and things can get difficult”.

“What we do in terms of surgery is very well studied on paper – but it’s one thing to see in two dimensions, quite another to see “up front”, in reality. Sometimes, there are blood vessels where you least expect them!” Unexpected hemorrhages occur, and there aren’t always the instruments ready to deal with all eventualities. It’s on these occasions that the instrumentalist is in the front line.

“I’m not going to say that we invent – but there are many scenarios where we have to improvise – particularly when there’s an unforeseen problem to resolve immediately”, he said. “I worked a long time with a South African doctor who used to say that he liked the Portuguese very much – for their capacity for improvisation” he smiles.

Indeed, Mimoso is known for his calm and nerves of steel in face of adversity and the unexpected. “Even though I may often feel anxious, I never let it show. It wouldn’t help anyone”, he says.

Perhaps this is why he most enjoys his turns on the casualty ward. “They’re teams that are ready to work on any emergency in any speciality. For me, it’s fascinating work. On programmed surgeries, we know the day before what to expect – and that can get monotonous. But casualty’s a far greater challenge”.

Of all the pain and human suffering that he’s seen, there’s one episode that truly affected him. “There was a lady with a pulmonary and coagulation problem who came into the maternity unit apparently fine. Suddenly, she had blood coming from her mouth. She was rushed into surgery and we were able to deliver the child by Caesarian section and reanimate – because its heart had stopped – but the woman died. It was horrible. We know that when it comes to reanimation, we can try for half an hour – if that doesn’t work, there’s no point trying any longer. What’s for sure is that we always try. We keep trying,” he recalls with sadness.

Does he feel he has the lives of patients in his hands? “I do. I always have the feeling that I’m contributing to the saving of a life”. Over his 30 years, “I have never seen anyone deliberately act negligently. I think everyone gives their all – it’s just that sometimes the situations are so complicated that procedures don’t work”.

“There’s a saying that I heard an eye specialist use once, and which I say now at the end of every surgery – “Get to work now, God, because I’ve done my bit”, he smiles.

In 1974, Mimoso didn’t agree with the civic service that in those days one had to do to get into university. “I came to the conclusion that nursing was what most fulfilled me because I’d be working closely with patients”.