Tuesday, June 21, 2016

Why Are Operating Rooms Always on the Top Floor of Old Hospitals?

Old hospitals were the source of many mysterious questions; What is that funny smell?.. How tight should a scultetus binder be applied?..How many hospital beds can you fit into a 600 square foot room?..Where is that blood curdling scream coming from?.. and finally, Why are the operating rooms always on the top floor of a hospital building?

In virtually any mid 20th century hospital patients were always being sent UP to surgery. The first time I heard that a patient was coming down to the operating room, I thought that either the ambient nitrous oxide in the room or sleep deprivation was getting the best of me. When I googled the question about operating rooms always being on the top floor of old hospitals very little came up. I just love obscure or overlooked questions that I can answer with my vast accumulation of foolishness so here I go again.

Cook County Hospital, Chicago, Illinois. Operating Rooms
on the top, morgue in the basement. Just like it should be.

I think that the notion of placing the OR on the top floor came about as an idea to isolate the area from the septic environment found on hospital wards. Nasty conditions like advanced syphilis, TB, pneumonia, and every contagious disease known to man was ever present in the hospital.  Setting up the OR and isolating it from general hospital traffic was a good idea. A sort of institutional inertia was set into motion and all hospitals adopted the notion of the top floor is where to place the OR.

There were other benefits to this top floor set up. Surgeons quickly learned that being on the top added another valuable tool to their pre-op evaluation armamentarium. The general surgery floor at our hospital was on the 6th floor directly below the OR. It was common hospital knowledge that the stairwell leading up to the OR was the perfect arena for pulmonary function testing. Instruct your patient that all he has to do to prove his lung capacity is to climb the flight of steps from the 6th floor to the 7th floor OR. Anesthesia residents would even write orders to hold the pre-op med until pulmonary function tests were completed. We all knew what that meant. It was not unusual to see a cachectic little old man wheezing and expectorating green mucous gobs while attempting his ascent. A resident holding his IV bottle and offering encouragement by pushing from behind was not unusual. I always remembered to watch out for slick, green spots when running up the operating room  stairs for an emergency call.

A couple of the older operating rooms actually had large skylights for natural lighting. Overhead lights had been added later in a modernization move, but those light rays beaming in were really a boon to surgery. Everyone really liked the naturally lit rooms and this was another good reason to locate the ORs on the top. After a heavy Chicago snow storm one of the first things to be cleared were the rooftop skylights.

Operating rooms on the top offered the opportunity to vent anesthetic agents which had the propensity to rise skyward when released. Today, I suspect all anesthesia is administered by a closed rebreathing circuit. In my time, it was not unusual to have an open system where exhaled gases from the patient were vented right out an open window via a clever device known as a "blow hose." Had the operating rooms been located on a lower floor of the hospital, the vented anesthetic agents could have anesthetized a captive audience, the patients on the wards. Whenever maintenance workers discovered deceased avian creatures on the roof we all suspected that it was the anesthetics.

The penthouse location of the operating rooms afforded some fantastic views of Chicago. We had several beautiful, huge, white ceramic scrub sinks located in an alcove with a splendid view of Lake Michigan. (If you would like to read what I think about  those rotten, no good, modern stainless steel scrub sinks, please see my scrub sinks post.)  Those new-fangled metal sinks look like they would be more suitable as livestock feeders and look out of place in a dignified OR. I despise them!  Ooops sorry about getting off topic.  It was a delight to watch the sailboats on the lake while scrubbing up for a difficult case. From time to time, surgeons would take a break from a case to refocus and gaze out the windows for a second or two.  Everyone appreciated the view from the top.

As a youngster, I always dashed up the stairs to reach the operating room suites. A bit of aerobic exercise served to clear the mind and the alternative was unpleasant. There was one old manually operated elevator to the surgical suites and it was manned by a cranky (that's putting it nicely) old man named Tony. He had an obvious, crippling orthopedic problem which he blamed on the entire medical world.  He must have had a series of orthopedic surgeries with a suboptimal outcome. When transporting attendings, he always kept his mouth zippered, but with nurses or residents he let the venom fly. He would begin by accelerating the elevator car up like a rocket and aggressively slamming on the brakes at the last minute leaving a gap to climb up to the 7th floor operating rooms. Upon arrival he would announce "butcher shop..everybody out."  I tried to avoid this at all cost. I suspect someone gave him the job out of kindness or because they felt sorry for his plight.

The other nice thing about being on the top floor was the relative peace and silence. Despite the posting of QUIET..HOSPITAL ZONE signs, the din of city traffic could always be heard on the lower hospital floors. I remember when James Taylor sang that old Drifters song "Up On the Roof." The lyrics "On the roof it's peaceful as can be. And the world below can't bother me."  It sounded to me he must have been singing about the location of the operating rooms.

Another feature of top floor operating rooms was a hybrid climate control system. Insects could not fly very well above about the 3rd floor so in the Spring and Summer we could open our windows. Winter meant that it was time to fire up the radiators and if they put out too much heat we could always open the windows. Whippersapperns think hybrid operating rooms are a new thing, but we had them back in the good old days of big open surgeries.

When our old penthouse operating rooms were finally retired, the area was redone at great expense to house the offices of our esteemed hospital director. What a great testimony to the value of the top floor location. Our brand new operating rooms were smack dab in the middle of a brand new building. Something always seemed like it was missing.


  1. Somebody (?) once told it was for fire safety, in the days of flammable anesthetics. An explosion or fire at the top put fewer people in danger.
    As for openable windows--I'd love to have the option. Even with my hospital's brand-new heating/AC system, I have to dress opposite the seasons, as it's too warm in the winter and freezing in the summer.

  2. Olddoc that is very interesting. I have been thinking about a post regarding flammable anesthetics which were on the way out when I was a youngster. We did have one room for using cyclopropane. It was reserved for teaching purposes and the residents had to do a certain number of cases with a flammable agent. Opening windows was nice, but they did have limited cooling ability during Chicago Summers.

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  4. You should be smart enough to latch on to any instructions given by doctors or nurse managers. Speaking and understanding several languages could prove to be a big boon and so is a good knowledge about sign language. Very often, doctors are so busy that they may not know of all developments in a patient's condition. online cna classes ca

    1. Like I told Dr. Slambow on many...many occasions, "I never said that I was smart...no way, no how!"

  5. I love you ! I was a nurse at Queens General in 1964 you are very funny love the elevator guy!!

  6. The tradition of placing operating theatres on the top floor stemmed from practical considerations like isolating surgery from contagious diseases prevalent in hospitals. Beyond infection control, top-floor ORs offered benefits like natural light, better views, and effective ventilation. The elevated location also minimized disruption from city noise, fostering a quieter environment conducive to focused surgery. While modern healthcare infrastructure may have shifted, the legacy of these high-rise ORs highlights their unique advantages in hospital design. The placement of Operation Theater OT Table within these top-floor setups underscores the holistic approach to surgical environments, ensuring optimal conditions for patient care and surgical procedures.