What does it mean to be called in? Part 9-Waking up.

The call case is nearly complete. The surgeon has dropped, which means he has finished and probably left the room to put post-op orders in and speak to the wife.

The two most dangerous times in any case, from an anesthesia standpoint, is going to sleep and waking up.

There can be shifts in blood pressure at both occasions. The heart rate can be affected. The respiratory effort has to be engaged as the patient has to breathe on their own after surgery. All of the gas that has been maintaining the general anesthesia is turned off and the patient breaths off the gas, either by the machine, or on their own.

Different CRNAs will turn off the gas and begin the waking up procedure at different times. It all depends on what they are comfortable with. Many times the waking up process starts too soon and the patient starts to emerge from anesthesia at the wrong time. This is usually before the surgeon is finished closing and the surgeon will tell the CRNA that the patient is bucking. Or coughing against the tube. And the CRNA will need to add more medication (likely a paralytic) to the line or reestablish gas to get the patient deep enough to finish closing. This is fraught with peril if the case in question is a hernia, because the entire repair can be ruined with ill-timed coughing and must be redone.

Sometimes the case is quicker than anticipated by the CRNA and medication reversal must be given. There are several medications that can do this. And they all have an associated cost. The other option is to wait for the medication and gas to wear off naturally. This is frowned upon because it can take many minutes and there is always another case to get started. Also, OR time is charged by the 15 minute increment and it costs the patient money to have a slow emergence from anesthesia. It also exposes the patient to the risks of emergence.

The scrub tech puts the dermabond, or skin glue on the skin over the port sites. This is the dressing that the patient will go home with.

During this time, I keep an eye and an ear on the CRNA and the patient as I am doing my end of case work. I catch up on the charting of the times, except for out of room time. I bring in the gurney and untuck the arm, if that is the arm that is closest to the corridor door. I put the gurney next to the bed, adjusting the height as needed, put the slide board on it with a chux pad. I lock the gurney. After I have done this, I stand by the side of the gurney and am ready to assist the CRNA as needed. I have my OR phone in my pocket in case I need to call the anesthesiologist stat. I watch the patient and the CRNA closely, watching the color change of the face, and the monitor numbers. The scrub tech is breaking down her table and stacking instruments.

The CRNA is making final adjustments, checking pupillary position, checking patient’s response. Some will wait until the patient grimaces or opens their eyes to command. The patient will no remember any of this but this is a way to determine readiness for extubation.

Finally the CRNA is satisfied and, suctioning the mouth, deflates the balloon on the endotracheal tube and pulls it out. The entire reason I did not pursue CRNA work is that there is a year in ICU that is mandatory. I have no desire to work in the ICU and I hate respiratory secretions. That is a hard no for me and my nursing kryptonite.

Assessing for responsiveness the CRNA will put a nasal cannula on the patient. And a mask over it. Intubation and emergence are aerosol producing events and if covid has taught us nothing it is to control coughing. Extubation does not always lead to coughing but it most likely does.

If the PACU nurse or anesthesiologist is about I will ask them to grab feet and assisting with transfer back to the gurney. If the patient is over a specific BMI I will insist on this. Otherwise a pillow is placed under the patient’s calves. Or, better yet, a pad from the armboard is, slick side down. It slides better.

The CRNA controls the head and counts us in. The scrub tech log rolls the patient to their side. I always am the puller and I place the chux and slide board under the patient. We allow the patient to roll back to their back and glance at each other. I do a quick check of the locks on the gurney, by tugging on it, and I say to the group “Locked.” The CRNA counts us 1-2-3 and I pull the chux pad on the slider, the scrub tech pushes from the opposite side, and the CRNA brings along the head and shoulders. Presto, the patient is on the center of the gurney and the legs slid over on the upside down armboard pad. When I am the puller the slide board is visible on the other side of the patient, ready to be grabbed my the scrub tech. Sometimes we have to roll the patient a little to get the board out, depending on their size and the skill of the puller. I take the upside armboard pad out from beneath their calves and replace it on the armboard.

Why am I always the puller? I have a body mechanics routine for this. I do not use my back. Never. I have seen many nurses and techs get injured being the puller. I use my glutes and my hamstrings. When I was a CNA in a nursing home I assisted a 400+ patient out of bed every morning by honing this technique. I’ve tried to teach it to others but they prefer to rely on their back muscles, despite repeated warnings not to. Sigh, you can lead a horse to water…

Now that the patient is safely on the gurney, the CRNA assesses their breathing again. I pull up the side rail on the side I am on and grab the chart and the specimen bag, tucking it on the end of the bed. Using the OR phone I call PACU and tell them we are incoming.

The CRNA nods and connects the nasal cannula and to the bottle of O2 that is on the gurney. I unlock the bed and pull it away the OR table. Pulling up the other siderails, we get ready to move out.

Cookie Thursday 6/9/22- pancake bites

The Inflation Baking theme is continuing on for a second month.

But this recipe has 3 tablespoons of butter in it. That’s cool, I think, a normal batch of cookies has 16 tablespoons of butter in it.

Again I pulled out the mini muffin pans and filled each well 3/4 full.

I topped each one with one of three things.

Blueberries.

Raspberry.

Or mini mini chocolate peanut butter cup. These things are maybe a centimeter big. I bought them to use as a chocolate chip substitution.

One muffin pan always sticks. I think I will clean it up and find another use for it. Or donate it.

Covid is surging again. The hospital went from 1-2 patients to 8. All in a couple of weeks.

I’m just over here wearing my mask if I go ANYWHERE.

But, hey, at least there hasn’t been any mass casualty events because someone got mad and decided to take it out on the healthcare system trying desperately to help.

Knock wood.

Our London trip is in 8 weeks.

Sigh.

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.

Monday’s Musings 6/6/22- healthcare under attack

Tulsa, OK- June 1, 2022. 2 doctors, a receptionist, and a patient dead

Los Angeles, CA- June 3, 2022. 2 doctors and a nurse- injured and alive

Goldsboro, NC- June 5, 2022. 1 patient shot and wounded

In less than a week.

What the actual fuck?

This is insanity.

Again I am speechless.

In the blog post titled Post-it 3/20/22- J’Accuse, I discussed how healthcare workers, specifically nurses, are under attack. Because of what they did or did not do that could or could not have compromised a patient.

And the immediate knee jerk response by so many, including nursing itself, and doctors, and patients, and hospital administration is to blame the nurse.

Early in the morning on June 2 I was picking up a patient in the ER to take them to pre-op. This was about 0430. I knew of the fatal healthcare shooting in Tulsa the afternoon before. I thought that the staff in the ER would be on edge. I passed an armed security guard in the main ER and I stopped to talk to him. We discussed the shooting the previous day and I asked him if the powers that be (meaning hospital leadership) and the staff had their sphincters tightened. Thank goodness for OR humor and the security guards that understand it. Meaning if there was a heightened sense of caution and an even greater sense of situation awareness percolating in the hospital. He acknowledged that there was and the caution was likely to remain. But that he had our backs.

And this was after the first incident.

In March, as we were driving home from the AORN nursing conference my husband and I were discussing the RaDonda Vaught case.

I distinctly remember telling him that healthcare is under attack. And we should all fear for our freedom.

I did not think to mention fearing for our lives.

Because something has shook loose in the American psyche that allows people to believe that this is right course. I don’t think these people are mentally ill.

That is a fairy tale spun by the governor of Texas.

I was off Friday and Saturday. I wonder what the aura of the hospital is now.

In my head I think of it being like working the floor on September 11, 2001. For days and days we were hypervigilant. Unsure of when the next hammer was going to drop.

When the next attack was coming.

And from what direction.

Post-it Sunday 6/5/22- estimating urine output with a straight cath

This is a lighter side of the OR post. Some levity must be had.

The post-it reads ‘watching the urine pour out using a straight cath and the surgeon telling the room at large that the urine output was 200 when it was obviously at least 400, makes you realize they can’t do estimated blood loss either.’

First of all, the surgeon insisted on doing the straight cath. I guess we weren’t moving fast enough and they wanted to get the case started. This is rich coming from that surgeon.

The surgeon had trouble finding the meatus and asked for the spot to be redirected, which I did. When they put the straight cath, a stiffened catheter not meant to be anything other than a temporary outlet of the bladder, they had to had to switch sides of the bifurcated container from the prep kit. Each side holds about 400. They switched before the side was full, that’s true.

They pulled the catheter out of the bladder and coiled it neatly into the container. Looking to pass off the container, they announced to the room that the urine output was 200 cc.

The scrub tech and I looked at each other and laughed with our eyes.

Doc, if you think that filling the container that easily holds 800 cc half way on both sides equals 200 cc total your reasoning on estimated blood loss makes complete sense now.

Because it is consistently wrong.

There are memes about the surgeons inability to correctly estimate blood loss. The estimates are always woefully inadequate.

For example, a case can be an absolute blood bath; blood on everyone’s gown, blood on the drapes, blood on the towels that have been used to stem some of the bleeding, on the floor, on the sponges that were thrown off. Blood everywhere. And that surgeon will claim an EBL of 100 cc. There is 300 cc of blood in the suction.

No, doc, no.

The 300 cc in the suction, the blood decorating yourself, the scrub tech, and the drapes is probably more like 500 cc. And that is before I calculate the amount on the soaked sponges.

But it made us laugh when the surgeon said that what was obviously at least 400 cc was only 200 cc.

It is no wonder that the CRNA asks us what our estimate is.

And uses that one for the paperwork.

April 12, 1989- violence comes to Sonoma

This is going to be a more serious, off the operating room topic than I usually do. But with the increase of mass shootings and violence in the news and around the country lately, it has been on my mind. A lot.

I am not sure what has led to the rise of the gun violence in our schools. I have theories.

It brought to mind April 12, 1989, and the violence that shook the small California town I spent some growing up in.

This was not in a school.

This was not guns.

But it was shocking.

And still very much part of my growing up experience.

In the morning, Ramon Salcido took his three young daughters to a quarry that was near the town. And slit their throats. And left them to die. Two of them died; the third survived and was alone with her sisters’ bodies for 36 hours. Until she was discovered and saved.

Next he went to his mother-in-law’s house and killed her and two of her daughters.

And then his wife.

And then his supervisor.

And the town locked itself up tight.

There were news bulletins. The adults talked about the deaths in hushed tones and wouldn’t let their children play outside.

I remember the empty streets.

And, oddly, the empty driveways.

I remember not being allowed to ride my bike.

I remember talking about it in school.

I remember the fear in the town.

It was April and 65 degrees. I remember it being hotter. But that might have been the breathless anticipation of the town as he was searched for and later apprehended in Mexico.

I was 13 and an eighth grader.

It has been 33 years.

And still all of my friends and my sisters remember the day that violence came to Sonoma.

We didn’t live near their neighborhood. We didn’t go to the same schools as the daughters were too young for school. But we were still impacted.

I find it hard to imagine what the other children at the Robb Elementary School in Uvalde, Texas must be going through. I hope that life will be kind to them. Because they will remember forever when their classmates and teachers were killed. And the aftermath.

Because I remember when senseless violence came to Sonoma.

Cookie Thursday is a Thing 6/2/22- impossible carrot cake

The inflation baking month was so popular I am going to keep it going in June. But this is the last week that I am making impossible cakes as I am kind of getting bored with them.

Instead I made a list highlighting other low cost baking. As always this entire thing is an experiment so we’ll see starting next week. And these bakes won’t require frosting.

I hate making frosting.

And I also got a $20 donation for ingredients. This brings my grand total of donations to $50 and a bag of flour in 7 and half years.

I don’t want to be that person who asks for money to do something I enjoy but someone asked why don’t you? And handed me $20. I took it and thanked her. I explained that I had spent part of the morning looking at all the grocery stores in town, mapping out their sale ads and websites, looking for the best price on butter.

No, I won’t use margarine.

She said she’d bring me veggies from her garden over the summer too. I will have to plan for that.

The impossible cakelet for the week was carrot cake. Finally! I’ve been trying to make this one for three weeks. No eggs in this one; the apple cider vinegar and baking soda provided the lift. I used my mini muffin tins and baked for 15-18 minutes a batch.

And served the frosting on the side.

What does it mean to be on call? Part 7-medications on the field

When we last left the OR, the surgeon was searching for visualization on the appendix.

Hark, he has found it!

I open the stapler and the load as requested. After, I take a visual and auditory survey of the room. Anesthesia seems content, there are no alarms, they have enough IV fluid.

There has been no call for the irrigator. This means that the warm normal saline that is used to irrigate the abdomen through the laparoscopic trocar sites can stay in the warmer. I never pull the warm saline before it is asked for. Some nurses hang it on the IV pole prior to surgery; but not every surgeon uses irrigation. Instead, I head for the other warmer, between the operating rooms, and pull out a bottle of warm saline. If the bag had been used, I would have asked the scrub tech to squirt some in the graduated pitcher that is used as a sterile containment device prior to handing it off to the surgeon.

Not only is there a cost to the patient every time I open and chart a different fluid, there is a cost to the environment from plastic packaging. There is enough of that in the OR already.

This is the time I consider opening and pouring the local medication into a cup on the field. There will be local medication injected by the surgeon during the case. Some inject prior to incisions and you have to remember which surgeon is which so that the scrub tech has it prepared for them and when.

This surgeon is the inject prior to closure type of surgeon. The medication was pulled before the start of case as part of my case prep. All I have to do is confirm the desired medication with the surgeon, open and pour into the prepared cup the scrub tech has left available at the edge of her table. This is when I also discuss expiration dates, or show the bottle to the scrub tech.

All medications poured on the field needs to labeled. There is no way around this. What if the scrub tech faints and a replacement scrub tech appears from no where and has no idea which medication is on the field? I joke but it has happened. It is policy that the medication is labeled with what it is, concentration, expiration date and time (if applicable). I pour the marcaine 0.5%, expiration March 2023 into the specimen cup. And confirm the details with the scrub tech, as they label it.

When the scrub tech hands it to the surgeon, they will confirm with them what is being handed off. Rarely, this is when the surgeon will change their minds and ask for a different medication. But this is a rare occurrence.

All medication given to the field must be labeled. Have I made that clear?

But what if it isn’t medication that you are dispensing to the field? What if it is a betadine, or hydrogen peroxide? You know, stuff that shouldn’t be injected? This is why labeling is so important. As is the use of the opaque cups that are in the basin pack.

Labeling the medication is important. And safe for the patient.

Monday’s Musings 5/30/22- anticipation is the worst

On Thursday my boss texted all the call nurses: endo, PACU, and OR. And wanted to arrange a meeting with us all.

I said I was absolutely available for when she wanted to meet. As did the other two nurses.

Immediately, I got texts questioning what this was about. Immediately, everyone’s mind went to they are shutting down the project. And we are not ready for the project to be shut down. If they shut down the call project the nurses and techs will have to take the bulk of the call back.

I tried to reassure everyone that the boss did not include the tech in the meeting or the texts. And I felt the job class we are in now was safe. How long is it safe for? Who knows? I do know that the regular staff are enjoying the minimal call that they are taking. Of course, it is more than they were taking because I am no longer taking extra call. But people are being told when they interview that this project exists.

The other two were no assuaged. I knew I would have to bring out the big guns. I immediately texted the boss and told her that the others were panicking, a little. Nothing good ever comes from waiting to drop the hammer.

Anticipation is the worst.

She rushed to reassure everyone. She had no idea that we would take it as imminent danger.

But we are nurses, always on the lookout for danger and problems; the vital sign machine tone change, the increase in heart rate, the precipitous decrease in heart rate. We are always on the alert. And that is why anticipation is the worst, waiting for the hammer to fall.

I know it is human nature to try to shield people from unpleasant news. Just tell me. And just tell the other call nurses too. Because whatever is conjured in our heads cannot be worse than actuality.

It is just like when I took the NCLEX. I had to drive to the testing center, about thirty minutes away. There was more shopping centers in that city than in the town that I lived in. I took the whole day off, anticipating going shopping after the test. Well, the test shut down after 75 questions. There can be anywhere between 75-265 questions. They are weighted to judge the person taking the test’s over all knowledge and problem solving. And the minimum was 75. If the test shut off there, you either did really well, or spectacularly bad. Of course, I thought I had bombed and the test shut off in reflective shame for me. I wouldn’t get the results for 2 weeks. Now you are told almost immediately if you passed or not.

I did not go shopping as planned. I was too unsettled by having the test end after 75 questions.

I had to wait. And, as discussed, anticipation is the worst.

Luckily I got my results back in 3 days, not 2 weeks. And I passed! The hammer did not squish me like a bug. But I am always on the look for it.

And frankly this program is saving the department money, at least in my paycheck. If I no longer work all the hours that are, I no longer get paid at that level. I wonder if I can spin that?

Post-it Sunday 5/29/22-I see you

The post-it states ‘Healthcare has ceased to see the patient as a person. It has devolved into there is a problem I need to fix it.’

Eleven years ago there began a spate of simple cartoons on YouTube. They were from Xtranormal.

This is a website that you could build a cartoon around a script that you had written and it would be turned into a cartoon.

I have to confess I toyed with the idea of writing a script for the site.

But the cartoon Orthopedics vs Anesthesia is perfection.

And a prime example of the blinders that healthcare workers, including surgeons and nurses, sometimes develop.

In the skit, an orthopedic surgeon is telling an anesthesia provider about his patient in the ED. He begins the conversation by saying there is a fracture and he needs to fix it. When asked to tell anesthesia more, he surgeon repeats that there is a fracture and he needs to fix it.

The conversation goes downhill when anesthesia presses the surgeon to tell them more about the patient.

The surgeon doesn’t understand why he is being pressed for more information. As far as orthopedics is concerned there is a fracture and he needs to fix it.

There is some fourth wall breaking by the anesthesiologist when she looks at you, the audience, dumbfounded.

And the anesthesiologist drags more information from the surgeon. Piece by piece, when all they wanted to know is who the patient was.

The surgeon tells the anesthesiologist that the fracture is in the ED. And that the fracture belongs to a bone, the femur, and it is displaced, which means that is badly fractured.

The anesthesiologist is getting more frustrated, visibly so.

She comes out and asks who the patient is. And the surgeon tells her the patient is a 97 year old female. From a nursing home, with no comorbidities as she is otherwise well, and she is fasted. To him the fracture that belongs to this patient needs to be repaired.

After a pause, he continues that the patient is well, except for her temperature of 29 degrees Centigrade, which is roughly 84 degrees Fahrenheit, and a pH of 6.8. A normal blood pH is 7.35-7.45. Lower than that means that the patient is acidotic. And a pH of 6.8 is incompatible with life. So she is not otherwise well. And her temperature is way off as well, as a normal temperature in humans is 97-99. The anesthesiologist is dumbfounded.

But wait, the surgeon continues that the patient has a condition that he is unfamiliar. And he mispronounces asystole. This is when the heart ceases to beat, in other words death. The anesthesiologist’s mouth drops open. She can’t believe what she is hearing.

The surgeon rushes to console, telling her that he is very skilled with hammers and drills and didn’t tell her about the asystole to begin with as he doesn’t want her to refuse the anesthetize the patient. And fixing the fracture that he is fixated on won’t take too long because of how skilled he is.

The anesthesiologist tells him that CPR would be more useful to the patient. You know, to save her life. And he says that they have finished with that. Meaning the patient is dead. He tells anesthesia that there will be minimal blood loss. This enrages the anesthesiologist because of course there will be no blood loss because there is no cardiac output. He presses on telling her that he needs to fix the fracture and tells her she’s being obstructive in not letting him do the case. And if she breaks her hand by punching a brick wall, he will fix it.

This skit is meant to be funny. And it is. We all know surgeons like this.

This orthopedic surgeon is hyper-focused, only looking at a very small piece of the picture that is the patient as presented. Yes, there is a fracture. And that fracture would need to be fixed at some point. But there is more to the patient and to her entire healthcare picture than the fracture. Which is the point of the skit.

The anesthesiologist is looking at the entire picture and seeing that this is not a surgery that can be done at this time. The patient no longer has need for the surgery. You can feel her frustration at the surgeon as she declines his request for a case.

As healthcare providers we need to be less focused on the piece of the patient puzzle that we can fix, and more aware of the patient puzzle as a whole.

This post-it was written during a class I took about awareness of the whole patient, not just what can be fixed in the immediate future. And I made a note to reference the YouTube video.

And if you haven’t seen the skit, it is on YouTube. Just search for Orthopedics vs Anesthesia.