What does it mean to be on call? Part 8-Closing time

In the last installment of this series, the medication on the field was discussed. It doesn’t matter what kind of medication it is, it must be labeled.

Now that the appendix has been visualized, stapled, and bagged like a prize steer, the MD’s thoughts turn to closing.

At least mine do. Because there is still a lot of things that have to happen, from my point of view, prior to closure.

And also from the surgeon’s. He has to monitor the staple line for a moment, watching for bleeding. If there had been pus in the pelvis and he called for a suction irrigator that will be used at this time.

But I have already opened the irrigator and hung the warmed bag of saline. I also plugged it into the machine and also spiked the saline. After the suction is turned on, the field is good to go and I can turn my attention back to the chart.

It is at this time that I confirm with the surgeon that Mr. A is going home. If he was staying he would need an inpatient bed at the end of the case. He is going home after PACU and Phase II type tasks. Phase II is the after PACU care. The patient will no longer need the intense recovery room care that keeps their pain under control and their vitals where they need to be. Phase II is the step before discharge. The patient relaxes, drinks a little something, and we make sure their pain is controlled before they are discharged.

I do a visual check through the windows to see if I can see a PACU nurse. With the call gig, the PACU nurse will come by the room when he gets in to check on us.

And, if I’ve timed it right, this is about the time that the PACU nurse should be arriving.

Irrigation is done. The surgeon makes one last visual survey of the abdomen, again inspecting the staple line for bleeding. Finding none and no identifiable issues within the abdominal cavity he starts pulling out trocars, beginning with the one that the scope is through.

The appendix is still not out, the bag’s string is through one of the trocars. The surgeon will “deliver” the bag and appendix through the trocar site. Because of an incident that happened when a bag full of blood and an appendix that tried to make a run for it, the surgeon must palpate the bag, to ensure that there is tissue inside of it. He announces to the room that the appendix is in the bag. Some of this is done in jest, but some in complete seriousness. No one wants to go back in, after closure, to retrieve a specimen. That is known as a sentinel event for the Joint Commission and much hullabaloo surrounds a sentinel event. The less their eye is on us the better.

After the appendix and bag are palpated with announcement, the surgeon pulls out the rest of the trocars and calls for camera off, gas off. For me this is the indication that I should turn on the overheads and the spotlights, turn off the gas, turn off the camera light, and unplug everything from the tower. All within 20 seconds.

There is a rhythm to how I do this. While he is calling for closing stitch, I turn on the overheads, hit the spots as I turn to walk to the tower, turn off the CO2, turn off the camera light, and unplug all the equipment, taking care to cap the camera so that it does not get wet and ruined. Next I walk back to the workstation and hit the closing button. This changes the case color on the caseboards that are in the waiting room and PACU. This indicates that we are closing.

I ask what the name of the specimen is, take control of the specimen after showing the tech the label on the specimen container. After she passes it off to me, she moves smoothly into counting sponges and sharp things. This is our closing count. There will be one more, the skin count in less than 3 minutes, mostly while the surgeon is injecting local medication.

I still have more to do after the specimen is handed off. I do a quick mental check: cords disengaged, machines turned off, tower moved back, ring stand stripped of the basin and the basin drape, ring stand moved back.

Now that the lights are on, I do a visual survey of the ground and pick up anything that has been dropped. The secret to a quick turnover is making sure the room is as picked up and clean as possible. This means that the irrigator is disconnected and the bag of saline left to drip in the sink in the substerile room. I add thickener to whatever fluids are in the suction cannister and take it out as well. Depending on the surgeon, I will disconnect the bovie and turn it off. I have been burned by this before and I make it the last thing I do.

This is the time we do the final count. And the RF wanding of the patient, prior to last stitch. I announce the results of the count and the wanding to the room and go through the post-procedure time out with the surgeon. This time the room agrees that the surgery was X, the specimen is Y, the patient is expected to be discharged, the wand was good, there were no issues during surgery that need to be addressed. A smaller version of the pre-procedure time out.

Today, June 8th, is national timeout day here in the US. And a big deal should be made of it.

When the last stitch is placed and the skin glue applied, I click the wound closed time on the chart and call the PACU for moving help.

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