In our previous episode I was called in, and I prepped a patient for surgery.
There are no consents signed.
Because the surgeon has not met the patient.
The double doors to PACU swing open and the surgeon, dressed in street clothes, walks in.
I am using he as a descriptor because that’s how I described the surgeon in the previous post. Nothing is meant by this. I’ve worked with many fine FEMALE surgeons.
He makes a bee-line for the patient and introduces himself.
With a half an ear I listen in while I am getting a clipboard for the signing of the consents.
Pro-tip: It is better to sign against something. And, as an ER patient, there is no hard chart. All I have are patient stickers.
After meeting the patient, the surgeon wanders off to do the history and physical. This is a must have for surgery. He has to attest in the H&P that he has gone over all risks and benefits of the surgery with the patient. This is where the informed part of informed consent comes from. The surgeon has informed the patient of the risks and benefits and alternatives the surgery. All I am doing when I co-sign a consent is that the patient signed it.
I review the consents with the patient. The anesthesia consent, and the surgical consent. I always encourage people to read the consents. I have read the consents, every line, to patients. The part I highlight, always, is that any tissue removed, in this case the appendix, has to go to lab for testing. I usually make a joke here that the patient cannot take it home for experiments.
The patient laughs and they sign the consent.
I follow up with a story of a patient that wanted to take a substantial body part home and smoke it.
Other people are avid fishermen.
Regardless this appendix that we are about to take out has to go to the lab.
The patient signs both consents. I co-sign both consents.
I ask if there is any last minute questions. I’ll answer anything. One time a kid asked me why the sky was blue. And was shocked when I had an answer.
I nod at the CRNA and show them both signed consents.
Logging back into the EHR, because you know it has timed out, I go to the part of the chart that deals with the timeouts.
A timeout is a pause that ensures that we have everything prior to surgery. Patient identifiers (name and birthdate), H&P, pregnancy test if applicable, antibiotic, it is all discussed here between myself and the CRNA and the patient. We both take another look at the consents that I just signed with the patient and it is time to go back.
I encourage signs of affection between the family member and the patient. This is the last time they will see each other before surgery is completed. The family member is always stressed. The patient has had a mickey from the CRNA. By that I mean the CRNA has given the patient sedation for the trip back. After consents, because legal reasons. But they are stressed too.
I wave at the double doors leading to the OR hallway and indicate that the OR itself is beyond those doors and visible from where the family member and I are standing.
As the CRNA and the patient go through the double doors to the OR, I indicate that the family member should follow me and I will take them to the waiting room. They follow me out of PACU.
As we are walking down this long corridor toward the surgical waiting room, I reassure the family member. Remember, they are stressed. I discuss, again, how they will be in the waiting room and if the phone that I am about to show them rings, they are to answer it. It will be me, for them.
I tell every single family member about the phone call that they are going to get. I tell them I have a 65% answer rate. I reassure them if they can’t get to the phone before it rings over to the answering machine I will call back.
By this time I have badged us into the waiting room. I talk up the charging station and invite them to charge their phone as it has all the cords. Years ago when cell phones were become popular, I kept charge cords at the desk to lend to families. Finally, administration listened when I told them that it was imperative that a charging station be installed. Yay for them listening.
I briefly show them around the rest of the room and am specific which phone will ring. I lift the phone up and make sure the ring is audible. I reiterate that this will be the phone that will ring. After I go back to their loved one, it may take me a few minutes to call but I will call.
I hand them the remote for the television and tell them that the restrooms are down the hall on the right.
Last reassurance that we will take very good care of the patient is given. I walk back to proper pre-op area, pulling my phone out of my pocket. I need to call the on call PACU nurse before the patient goes to sleep. That way they will be in the hospital when the patient comes out of the OR.
I walk back into the OR. By this time, the patient is on the OR table and the gurney is in the hallway.
After reassuring the patient their family member is tucked back in the waiting room and I will be giving them updates, and the surgeon will see them after the surgery, I do a visual survey that all is in readiness.
I chat with the patient as the CRNA and anesthesiologist prepare to put him under anesthesia. During this, I and the tech are doing many things.
Mr. A gets sequential stockings on his legs to help the blood return to his heart while he is in our care, the SCD machine is turned on, the seatbelt is applied, the armboards are put on the bed, the patient’s arms extended and secured. Warm blankets are refreshed. The temperature in the room has dropped 5 degrees again.
Sometimes during the whirlwind that is the preparation to go to sleep, I tell the patient that we used to ask people to count backwards from 10. And often they nod, familiar with the concept. They are shocked when I tell that this will not be happening. They look perplexed, and I inform them instead that they will be counting backwards from 100 by 7. I don’t always do this, but patient sometimes do better with a task. This is a task.
And it is time to start induction of anesthesia. The anesthesiologist and I take up posts at the opposite sides of the bed and prepare to assist as we can.
And the medication is started. I remind them to count backwards from 100 by 7. Often they only get to 86.
Lidocaine first. Because propofol is an irritate. Then the propofol, the so called milk of anesthesia, the Michael Jackson medication. Jokes are sometimes made. And then the paralytic.
Medication always wins.