Best Kept Secrets of the OR # 17- December blows

I know I have written about this before but it bears repeating.

When you are working in healthcare, December sucks for a variety of reasons:

Labor and Delivery has all the babies due that were conceived in the coldest month of the year. We know what some people do to keep warm and entertained during the long winter’s night.

Emergency Room has all the people who did not get any of their vaccinations and NOW want the ER to save their asses. This department also has all the slip-on wet leaves and fall patients. Add a soupcon of all the patients who don’t care what they are eating because it is the “Holidays!” and have probably gone off their prescribed diets.

Med-Surg has all the post-op and post-procedure patients and the emergency room patients who have been admitted.

Cath Lab/Endovascular- similar to the operating room. Also a consequence of all the rich eating that takes place during the holidays.

Operating Room has all the patients who have met their deductible and require surgery before the end of the year. After all, that is when the deductible ticker will click back to zero and the paying of the deductible starts again.

Oh, and everyone would like to 1) have their babies, 2) get that rash looked at, 3) go home after recovering in the hospital, and 4/5) have their procedures done while they have maxed out their deductible before Christmas. So they can be home to celebrate with the family. And eat all the things they couldn’t have in the hospital, which lands some of them back in the hospital, to be admitted, to be discharged, to eat all the things they couldn’t have in the hospital… Etc.

A vicious cycle.

Isn’t American healthcare fun?

Tuesday Top of Mind 12/10/24- Sympathy for the devil?

This is a follow-up from last Wednesday’s post when there were 2 separate healthcare related breaking news items. The United Healthcare CEO who was shot and the Anthem Blue Cross Blue Shield only paying for X amount of anesthesia for any given case. And the insurance company solves for X.

The entire US was on edge and reacting to both these news items ALL WEEK LONG.

On Friday, December 6th, Anthem came out and rescinded the suddenly toxic policy. You know what dispells gloom in a fairy tale? Or what gets rid of mold in the house? Light. If you shine light on an issue the rats will run. Yes, I am aware that I am mixing my metaphors. The sentiment is true. If we pay enough attention to the shitty things that corporations do, we might be able to stop some of their worst impulses as they chase profit.

I have additional thoughts.

The reaction to the shooting and subsequent death has been fascinating. It has been the man is dead, yes, his wife widowed, yes, and his children half-orphaned yes. But people are flipping the script and talking about how many people have died because of the policies that enriched the insurance companies. Some people are even sharing what happened to them or a loved one. The stories of denial of care are heartbreaking.

Can we have compassion for his family? Yes. Can we hate what he worked and stood for? Another yes. Does the American public who has had their care nickeled and dimed for years have sympathy? Not many, and more would sooner have sympathy for the devil.

No American, not even a rich, conservative Ivy graduate like the accused, hasn’t been harmed or denied by the privatized healthcare in this country.

Note- he has only been charged, there has been no trial, and he is fighting extradition back to New York.

The First Rule of Acquisition is once you have their money, you never give it back. Sounds a lot like healthcare in the US does it not?

I am referring, of course, to the 285 Rules of Acquisition that were set out and explored on Star Trek: Deep Space Nine.

If they can deny and delay and deny and delay and outlast you, the insurance companies don’t have to pay and they get to keep the money. For whatever it is you want them to pay for, all they have to do is make up arcane rules that the consumer unknowingly violates. Oh, they don’t tell you what the rules are. That would be cheating.

Kind of reminds me of “ignorance of the law is no excuse”; which is a legal principle.

The question remains- which one is the devil?

Post-it Sunday 12/8/24- Circuses every where

The gown card reads “Sometimes I feel like running away to join the circus but, really, how much different would that be?”

Dat-dat-dadadaditda
dat da dah
dat-dat-dadadaditda.

You tried it in your head and recognized it immediately, right?

So starts the screamer theme song for many circuses. Because that is what they are called- screamers. These are the marches that the circus is most well-known for. That’s something I learned today.

But this post is about another kind of circus.

The shift circus or the unit circus. It’s all the same.

This person is new and says it was better at their old place and this new place should change so that they are not uncomfortable learning new things anymore.

That person wants to go home early. Again.

That person wants to ride the clock but does not want to actually do work.

This person is riding the clock, waiting to complain that they are being sent home early.

This person has too much education and will not be going home early but will also not do any additional work. Even when asked by the charge nurse.

That person disappears after being sent home and the charge nurse thinks they have left. Only for them to pop up after several hours to inform the charge nurse that it is time for them to go home.

This surgeon is three hours late and wonders why they got bumped. Doesn’t the OR know they are very important? The charge nurse points to the policy that states the next case can begin if a surgeon is more than 1 hour late.

This surgeon wants to add on a surgery, what do you mean there are several cases ahead of me, don’t you know who I am? And they have a tee time/flight/dinner with the family to get to. And they simply cannot be late.

This policy has been changed because the laws in your state are stripping the bodily autonomy away from women. But don’t worry, it isn’t as bad as those other states.

This patient is crashing because no one did a complete history and physical on them. They are crashing because there was no lab work. If a simple CBC or H&H was done, the low blood count would have been picked up on, or the extremely high white count indicating infection somewhere would have been caught and a new total joint would NOT have been put in.

Boy, do I have bad news for myself.

Every hospital/operating room is a circus.

Sometimes in running away from one circus you go from the frying pan into the fire with the next hospital circus.

School Me Saturday 12/7/24- last class blues

Someday, when you are nearing graduation, you will experience the last class blues.

The last class is a fencepost. Over the fence is post-graduation, and on this side of the fence is the last paper and the last test and the last lecture that you will experience as a college student.

It is normal to feel a bit sad after each of the lasts.

The last paper you are ever going to write for a class is happening soon or has happened. You might not care what grade you get. Or you might be haunting the Canvas page, waiting for the grades to drop. Both can be true. But the last paper is special.

The last test you are ever going to have to take in college is happening soon or has happened. Again, you might not care what grade you get. You might’ve calculated how many questions you can miss and still pass the test and the program. This last test can be special.

The last lecture you are ever going have to pay attention in and take notes in college is happening soon, or has happened. Whether you are a prodigious note-taker or not, these will still be your last lecture notes. Use them well in writing the last paper or studying for the last test.

The ever-present what do I do with all these notes and textbooks will flash before your mind. This question has different answers for different people. Heck, I still have notes from 1993 and my first nursing school.

You’ve experienced all this lasts before with other classes. But this is different, isn’t it? These are the lasts of the program. Attention and solemnity is appropriate for these.

Some people are saddened by this inevitable end to an era. The era of your college student career, that is. Some people are not and are ready to party. Some people are in between. Some people just want to sleep for a week. All of that is normal.

The gate? The one that separates the college life or paper and tests and lectures, and the post-graduation life?

That’s graduation.

Until grad school, that is.

This might not be your path. You might be a one-degree and done person.

But never, ever, ever, stop learning.

FFS Friday 12/6/24- Forget

Today’s F word is Forget.

Just like the red states want us to do when women die from not having access to abortion care.

Let’s look at two states that have been wishing really hard, with their fingers and toes crossed, that we will forget that women are dying. These women are dying from their policies and their need for control of women’s bodily autonomy.

And they don’t want you to know about it.

Texas announced that the committee that oversees maternal health and death will not be examining the deaths that occurred in 2022 and 2023. We all know what happened in 2022 and the Dobbs decision.

The committee says there are too many deaths to investigate. No, what they said is that the backlog is too big and doesn’t let them examine more recent deaths.

Think about what that is saying.

women are dying from being denied healthcare
women are dying a LOT from being denied healthcare
so many women have died that they can’t be bothered to look at the past and prefer to look at the more current deaths
the deaths from 2022 and 2023 should not be looked at and we should just forget about them
they don’t care about the women

This leads me to conclude that there have been more deaths than have been disclosed publically. Point 5 is my favorite. They haven’t come out and said this explicitly but I can read subtext.

Don’t forget this is the Texas Maternal Mortality and Morbidity Committee. Morbidity is everything else but death. It does not imply that the women are okay, just that they are not dead.

They don’t care about women.

Georgia dismissed the entire maternal death review committee after there was a leak about two women’s deaths after being denied the healthcare that they needed for a miscarriage. They said it was because the sharing of the information, whoever it was, violated state law.

The review committee had found that the women had died from a preventable cause but also that doctors did not adequately treat them due to fear of reprisals.

Let me sum up. Two women, probably more but these two women who have died and the details leaked, died from a pregnancy complication that we have the tools to treat and doctors have the knowledge of how to treat the complication. But they didn’t get the care they needed to save their lives because the doctors were concerned about their freedom.

Let me put it baldly. Georgia doesn’t care about women. They want us to be unaware of the deaths that their abortion ban is causing. Because there have been deaths.

This entire thing boils down to if you don’t look, no blame can be cast. Because they don’t want us to blame the laws that are killing women.

These stories need to keep coming out because we won’t forget about the loss of our bodily autonomy, or the needless deaths, or the continued suffering of women.

Don’t forget about them.

Cookie Thursday 12/5/24- It’s beginning to look a lot like Chex-mas

New month, new theme. This December’s theme is Holiday, just like it has been so many years.

I always start December off by making Chex mix and I only make Chex mix in December. I start buying the ingredients when there is a good buy or a BOGO.

The ingredients that I buy are

garlic powder
onion powder
I use the same Lawry’s seasoning salt because I use much less than the recipe calls for. Too much sodium
family sized Chex mix- Corn and Rice
1 box of wheat chex
pretzel rods
containers of deluxe mixed nuts. I find I don’t care for peanuts so I don’t make it with them
And the most important ingredient of all- butter
Worcestershire sauce/I also use powdered. I find that it makes a big difference

Each batch is made in my turkey roaster. 1 box each of rice and corn Chex and 1/2 box of Wheat Chex. 3 melted sticks of butter, 2-3 tbs each of garlic and onion powder, 2 tsp seasoning salt, 3-4 tbs Worcestershire sauce or 3 tbs powder, 1/4 bag pretzels, 1/2 large container of nuts.

I make the seasoning liquid all together in a small pan, over low heat. The butter is melted first, almost browned butter, add the rest of the seasoning and cook until simmering, stirring occasionally as you mix the rest of the dry ingredients.

Low and slow at 350 degrees Fahrenheit, stirring every 20 minutes for 2 hours.

The first two batches I make have gluten in it and the rest are gluten free.

I probably make 4-5 batches as it is a crowd favorite for Cookie Thursday and a family and friend must have.

The nuts and pretzels can be measured with your heart and any additional addins are allowed and encouraged.

Funny story, today I was dropping off the leftover cinnamon rolls from the nursing awards ceremony at around 1130 to the OR lounge. Someone asked me what was going to be the make this week.

Everyone else had their heads bent to their phone or their food or both. I mentioned that I would be bringing in Chex mix. Everyone stopped moving and raised their heads.

Like I said, department favorite.

Breaking news 12/4/24

It is rare that I get to write about kind of breaking news.

Today there were two separate reports about insurance companies.

12/4/24- United Healthcare CEO Andrew Witty was fatally shot by an unknown assailant outside of a hotel in New York City, and the killing was captured on hotel surveillance. The victim was due to host an investor day in a Hilton hotel. The suspect has not been located. United Healthcare is the largest private health insurer in the U.S.

I don’t have a lot to add except that United Health Care had the largest denial of care rate of all the major insurers.

11/14/24- (not sure why this is just gaining traction today)- Anthem Blue Cross Blue Shield announced that it would not be paying anesthesia costs for the entire duration of a surgery in 3 states. The states are Connecticut, New York, and Missouri. Instead, it would only pay for a certain amount of hours of surgery. Presumably, the patients or the hospital, or the anesthesiologist would have to eat the remaining cost of the anesthesia.

Wow.

No idea where this idea came from. Greed, probably. The insurance parent company reported a 24% year-over-year profit increase in June 2024.

No idea how the decisions were made for how long each surgery will be covered. Presumably not by surgeons.

Because a surgeon would know and understand that there are unforeseen things that can happen during surgery that would make it longer. Does the insurance brain trust that came up with this think that surgeons are just making surgeries longer for the hell of it?

To me, 2 1/2 years into a research degree, this smacks of pilot study.

To be expanded to other states when they can.

You know, for the money. Certainly not for the patients.

Tuesday Top of Mind 12/3/24-Bullying on the Silver Screen

This afternoon I took myself out for a movie date. Just me. My husband doesn’t want to see the movie and there was no reason not to go this afternoon.

I saw Wicked.

Disclosure- the Wicked phenomenon happened WAY after I was out of my Broadway phase. In 2003, when it premiered, I was already deep into my workaholic phase. The term is musical awakening, when you get really into a Broadway show or Broadway musical and it can be defined as listening to the music on repeat. Well, I never had that. There were musicals that I watched many, many, many, many times as a child but they were movies. And only one was based on a Broadway show. Fun fact- I STILL listen to Little Shop of Horrors while doing yard work.

The point is that I missed being obsessed with the musical when it came out. Or any of the hot musicals of the 2000s, 2010s until Hamilton.

Second disclosure- I read the Wicked books years ago. Before I knew it had been turned into a musical. I also read the sequels. Gregory Maguire does some quality work and I highly recommend him.

There will be no spoilers because most of those are out already.

It is a very pretty movie. The music was great and the two leading ladies knocked it out of the park. The sets were great. The pacing was phenomenal and it certainly didn’t feel like we’d been sitting there for nearly 3 hours.

However, at its core, Wicked is about bullying.

Elphaba is different and she is at turns bullied, rejected, and ostracized. Her own father treats her like dirt and rejected her immediately at birth because she is outwardly different than the rest of society. He left her to be raised by the animal nanny bear. She is vulnerable but comes to understand that she will always be the scapegoat, even after scaring away other children who were making her sister cry.

The definition of bullying in the Oxford Dictionary is to “seek to harm, intimidate, or coerce (someone who is perceived as vulnerable).” Elphaba is plenty vulnerable.

I enjoyed the movie but I couldn’t help but overlay today’s political climate over it.

Like the Wizard of Oz says to Elphaba and Glinda, “The best way to bring folks together is to give them a real good enemy.”

That line disquieted me.

That line explains what is happening with the illegal immigrant rhetoric and is at the base of all the trans laws. Basically pitting the “everyday Americans” against the “other”.

I want to shake people and shout “These people are not your enemy! Stop othering them.”

Othering, or giving people a common enemy, is just another word for bullying.

That line, in this political climate, was chilling and a bit enraging.

How many of the people in the theater understood the correlation? Or were they just watching the pretty movie with the pretty music?

Post-it Sunday 12/1/24- A Cultured Kind of Surgery

The post-it reads “Hey doc, are you expecting a different result from a mm away?”

A culture is a lab test that tests for infection in a location where the culture is taken from.

This location can be anywhere in the body. I’ve done cultures on abscesses from the top of a patient’s head all the way down to their toes. Different patients, mind you.

The reason behind doing a culture is twofold. It lets the lab and the surgeon identify the particular pathogen that is causing the infection. It also allows the surgeon to order the correct antibiotics targeting the pathogen. A third possibility is that there is no infection that is causing the symptoms. However, even that is an answer. A negative result and lack of a pathogen is still an answer.

However, this post is about a surgeon who is culture happy. They culture everything. And I mean, everything. Oftentimes there are multiple cultures, within the same geographical area on the body.

My question to that surgeon is why run these expensive tests when the area that is cultured is essentially the same place. I do understand pre and post-lavage cultures. This is when the body part is cultured before irrigation and after to see if there are any lingering bits after being sprayed with the equivalent of a garden hose.

What I don’t understand is the multiple cultures after the incision and before the irrigation. Please help me understand why this is routine for the culture happy surgeon.

Is the pathogen just under incision different than the pathogen 1 mm in? I guess it could be. Especially when there is a verifiable pocket of pus that looks different. And I understand culturing separate body parts, such as the heel of the foot and the knee. But how often does that happen?

And at what a cost to the patient?

School Me Saturday 11/30/24- Push on through (to the other side)

The song starts with a short cymbal warm-up.

Then the guitar starts laying down a beat.

Then the vocals.

“You know the day destroys the night,

night divides the day.

Tried to run, tried to hide.

Break on through to the other side.”

I am, of course, writing about Jim Morrison and the Doors and one of their best-known songs. It was the opening track on their debut album.

It is nearing the end of the semester. Perhaps you listen to music while you are studying. Or not. Perhaps you listen to music to wind down. Or not. But think about this song with me.

“Made the scene,

week to week,

day to day,

hour to hour.

The gate is straight, deep and wide

Break on through to the other side.”

I can take you all back with me to Peg Garner’s Advanced Placement English class in my junior year of high school, where I learned about poetry. In 1992. And how to analyze poetry. Because music is poetry. Or maybe they are complementary arts. I will let the philosophers decide.

However, music can teach us about ourselves. How to study, the cadence of songs helps here. It also helps if you are so familiar with the song that it ceases to be new and amazing and just becomes like elevator music. But you notice when it is gone.

Then a song like Break on Through (to the Other Side) speaks to you about endings. Because the semester is ending. It is nearly time to put up the books, and to put away the paper and pens and pencils. It is too early to worry about next semester; it is too late to worry about this semester. All you have to do is break on through. Finish the final papers, take the final tests. Do what you have to do to get through. Whatever it is.

Reflection is helpful here at the ending of one thing and not yet beginning of another thing.

Reflect on the semester and what went well and what didn’t. You can promise yourself to do better next semester.

Because there will be a next semester until you are finished with the degree program. And maybe even after that.

You might not be able to quit school.

But that is a problem for future you, isn’t it?