I am going to break this down for you. And bring you along with a normal case. For ease, I’m going to call it a lap appy, or a laparoscopic appendectomy. This is considered a bread and butter call case. By that I mean there are a lot of lap appys performed per week in my OR. At least 5. One memorable summer when we still doing sterrad for the scopes, we did 100 in a month.
The room is dark and all is still. Suddenly a beeping sound splits the quiet. A hand emerges from the covers and fumbles with the pager and presses a button to make it stop. Mindful of the other sleeper, the light is not switched on. Glasses are put on, phone is grabbed, and I take pager and phone into the office to start the cascade of the case.
Looking at the display on the pager, I answer the page. If it is a surgeon I will be logging at the same time I am calling back. If it is the nursing supervisor, I call them back.
Regardless of the number, I call them, identify myself and say, “I was paged.”
There is an appendix in the ER. The surgeon who called wants to cut skin in 30 minutes.
This is the first point of managing expectations. I am at home, I get a 30 minute response time. This is a lap appy and easy to pull. I tell surgeon that it usually takes an hour from point of contact but I will try for 45 minutes. Because I live the closest to the hospital and I’ll be there in 10 minutes.
All of this is happening as I get dressed. And put on shoes. I clip the pager to my shirt.
I grab keys and wallet, probably still talking, and unlock the car. I hang up with the surgeon and immediately call the scrub tech if I know who it is. This is because the nursing supervisor will have to make all the phone calls and the scrub tech is the last one they make.
After notifying the scrub tech, I tell them to drive carefully. Always. There have been 2 accidents on call here in NC and a close friend was killed driving home after a night shift in CA.
I am at the end of the street, and I call the nursing supervisor. I tell them that there is a lap appy and I give them the details: name, surgeon, and, most importantly, I tell them the projected time of the surgery.
I live 5 minutes from the hospital. Especially in the middle of the night with no traffic. And I arrive soon after hanging up with the nursing supervisor.
I badge in to the department, grab scrubs, and move to the locker room. I wear easily changed clothes. I have been known to wear my jammies in, especially if it is the middle of the night. I grab socks from my locker, and a hat. I get dressed.
On the way to the OR core, I grab a surgical mask and put it on.
Sometimes I run into the nursing supervisor here. Most often I do not.
I grab a department phone and log in. Concurrently, I am logging into the electronic health record. I double check I know which room and patient name I am calling for report from the ED.
I call the ED and ask for the nurse taking care of patient A, in bed 65.
Since most of the information is already in the chart I scan it while I wait. I check lab results, especially HCG (pregnancy test) if the patient is female and of child bearing age, which is 12-55 in my hospital system. I look at what medications they have been given. When I get the nurse on the phone I only have 2 questions- are they lucid, and do they have family with them.
What this boils down to is can they sign consent?
If they are not lucid, and there is no family at bedside, there are many steps I have to do to ensure proper consenting is done.
But this appy is a 45 year old male that is alert and oriented x 4 and none of that applies. But I have to be aware of it because sometimes it all applies.
After getting off the phone with the ED I go down to the basement where the instruments and supplies are kept. Long ago I memorized all the appy cards. I was not kidding when I said that this case is one of the most common.
I am still the only one in the department when I come back up, case picked and instruments acquired. This is not unusual as I live the closest.
I leave the table with the case on it in the surgical room and make sure the video tower is present and on before I leave the case to be opened by the tech while I am getting the patient.
Entering PACU, I turn on all of the lights. And get the supplies that I need for the patient: the consent for surgery, the consent for anesthesia, and the sequential stockings that will be used during surgery.
I walk down to the ER.
I wave and say hello to the nurses and techs at the desk as I pass by.
Entering ER room 65, I glance to ensure that there is a family member present. Introducing myself, I begin to unhook the patient from the IV, and monitors. I begin questions that are geared toward what I know is on the pre-surgical checklist that I will be completing when we get back to the PACU, which is where the patient is starting and finishing with OR today.
I begin with name and birthdate that I ensure matches my expectations and the armband. I ask about NPO status, implanted metal such as a total hip or knee, any screws, any allergies. i was mocked by my trainer in CA about taking more than a minute for immediate survey. This is the immediate survey. This is when I inform them that the lap appy is the most common surgery I do at night.
I assure the family member that there are surgeons and the anesthesia team to meet and they will be accompanying the patient. I will take them to the surgical waiting room after the patient has gone back.
I chat the entire way back to the PACU. I don’t want the patient to feel self conscious in the gurney, being trailed by the family member.
Entering PACU with the gurney, I invite the family member to sit while I get a warmed blanket. I caution that all the stools have wheels and please be careful.
While I was getting the blanket, I glanced into the OR and made sure that the scrub tech was opening.
After putting the blanket on the patient, the OR is about 5 degrees cooler, at least, from the ED, I pull out my phone to alert anesthesia that the patient is in PACU. I send the text after changing lacy back to PACU.
My million dollar idea is a hospital specific auto-correct. Medical words are not in the auto-correct data base. In my head, I would never have to correct my text messages and names of staff would be entered into the data base. Too much time is lost correcting texts. Feel free to use my idea. I’ve not done anything with it in three years.
I digress.
I sit on the stool next to the patient’s gurney so I can do the pre-op checklist in the computer. By this I mean put in the answers to the questions I’ve already asked. While making small talk.
I can talk about lots of different things. I can talk about my husband waking me in the middle of the night once so excited that they’d announced the most likely cause of appendicitis. I can talk about how the symptoms probably started and the likely way their day unfolded. I can college sports. I can talk regular sports. Whatever the patient needs to feel comfortable.
Usually it is the cause of appendicitis.
By this time I have put down all my answers that I’ve already gotten. And we are at the sleep apnea portion of the checklist. I usually tell them the story of the cat snoring on my back and waking me up in the middle of the night. This always gets a laugh. I ask him if he’s had a sleep study or been diagnosed with sleep apnea. I ask about snoring, and sleepiness in the middle of the day, blood pressure medications. the reason this is so important is because this can have down the road impacts for anesthesia. EVERYONE gets screened.
I write out the consent, using the order that had been put in by the MD. Or hold it for them to fill out if it has not.
Anesthesia is here by this time and the ologist is speaking to the patient. I pass them the anesthesia consent and excuse myself to go count the instruments and soft goods with the tech. And probably alert the CRNA that anesthesia is with the patient as they are in the room getting ready.
By the time I get back to the PACU, the ologist is just finished their portion and is signing the anesthesia consent. I collect this from them as I will have the patient sign both at the same time after they are spoken to the surgeon.
And the double doors the PACU open. It has been 45 minutes since I was paged and the surgeon has arrived.
He greets the patient and family and begins.
Dispatches from the Evening Shift 