If I had a dollar for every time I pulled out and opened a suture packet, say a 3-0 vicryl SH, and it wasn’t. Instead, the suture that was in the wrong box was a 2-0 vicryl CT-1. Not even remotely the same. One is a cutting needle, the other is a taper needle and the suture, although the same type of suture, also isn’t the same size. Well, I would be wealthy.

Some people think that as long as the suture is replaced in a box, any box will do.

Deep breath to center myself.

No, no, no. Not any box will do. The box that matches what the suture is best.

If things are hopping, and the surgeon is waiting for me to open the requested suture to control bleeding, grabbing what you thought was the right one and having to go again out for the actual right one is so dangerous and can be detrimental to the patient. As a species, circulators don’t need to add to their steps that badly.

Could I look at the package that I pull out of the box?

Sure. I glance a the package to ensure that it is still in date. That’s what I do. But taking the time when I am running back to the room with suture in hand, not gonna happen. Therefore the wrong suture gets opened. A lot. Not only is that a waste of product, it is also a waste of time.

Just put the suture in the box it came out of. That’s all we are asking.

Also, the orthopedic supply that is one of a kind. I’ve heard about this happening too. At a glance, it looks like there is a very needed supply, but in actuality, someone returned the supply to the wrong box.

Years ago the OR was besides themselves because it appeared as if they had misplaced an entire instrument set.

Many, many people were on the hunt for this set. The department was set to be charge beaucoup bucks for the set if it was not produced by the end of day.

I walked onto the floor to start my shift, go to get something from the basement, and pick up the very set they are looking for. On a go back instrument table in plain sight.

No idea who put it there. Much panic to the day shift crew.

Don’t be that person who puts things in the wrong place.

If you don’t know where the proper place is, ask.

If you don’t care where the proper place is, ask yourself if healthcare is right for you.

I said it, well, I wrote it.

On this Tuesday Top of Mind is voting.

Do it before it is taken away from you.

Kind of like bodily autonomy.

Just ask all the women who are fighting to get it back from the scaley old white men and women in power.

Voting and abortion rights have a lot in common.

Some people want to take away the right to vote. To make it fair?

Do you mean so you can win?

Okay, got it.

Well, if it is the only way you can win…

NO!

2020 was a fair and free election.

As was 2016, 2012, 2008, 2004…

You get my point, right?

If your policies aren’t getting you the results that you want, maybe try to be less of an ass. And stop trying to take away rights.

It isn’t the 1950s. Women deserve more rights than we had in that era.

For that matter, so do trans women. They are women just as much as I am a woman.

Has your head exploded yet?

Darn.

Do you hear that?

That high-pitched whistling followed by the thud and an ewww?

Yeah, that is the sound of all the TERFS heads exploding.

Maybe try to act like you like other people that are not like you.

You know?

And stop trying to take everyone’s rights that you don’t believe in away from them.

M’kay?

Everyone else, vote in November. Yeah, it isn’t a very exciting election that will sway the balance of power in America. It still is vitally important.

Here in North Carolina early voting starts on Thursday and I and my husband will be there. Because if no one votes, the ones who got their supporters to vote using hatred as fuel win.

The only things on the ballot locally are the School Board, a bond measure to fund schools, the mayor of the town, and the board of commissioners.

I don’t care how little or how much there is to vote on, I will be there.

This is the week in which I discuss my personal PhD journey.

All of a sudden, we are on the cusp of week 10.

Didn’t school start like a week ago?

I have one assignment due this week coming up on Thursday night. I’ve already started writing it.

That assignment is in the Health Disparities and Outcomes class. This class also has a fairly big assignment due Monday, October 26. I’ve started that one as well and I hope to finish it and turn it in next Saturday.

The Quantitative Research class has a big assignment due at the end of the month as well. This is a draft of the research proposal the class has been building towards all semester. I have an idea of the research topic at hand, I just need to be able to discuss tools to get the hard data, and the group I am going to survey to get the data. This, unsurprisingly, has been the hardest class for me this semester. I mean, it’s statistics adjacent.

At the beginning of the pandemic, when details were kind of light on the ground and the world seemed to be on fire, I began a daily practice of reading newspapers and news sites. I’ve kept it up. I have the sites that I think have proven accurate and fact-based and I rely on those. Of course, like any former high school journalist, I know that the best information comes from a variety of sources. Some of these sources I use when I am writing the Tuesday Top of Mind posts. I read about the coronavirus and all its updates, I read about abortion and the cluster fire the Dobbs decision has enabled states to become. I read about climate disasters and the sequelae of climate change. I read about LGBTQ+ issues, including the war on trans people. I read about healthcare because I’m in the industry. The point is, I read a lot of different things. I think it behooves us as citizens to engage with the world.

This brings me to my third class, Advanced Health Policies and Ethics. This is, by far, my favorite class of the semester. Not only because being informed makes for better discussions within the group, but better discussions outside of the group. I find myself wanting to know and understand more. This does lend itself to being more politically involved. During our class discussion on Friday about political activism as nurses, I vowed to email my representatives monthly about what I see as the major political issues. I have thoughts on this versus the money from the lobbyists and special interest groups but I have to start somewhere, right?

This class, too, has a major project due just at the beginning of November. With PowerPoint presentation. I must start on the research for that.

That’s what I do, read research, and plan assignments.

And stack books I would otherwise be reading on the towering to-be-read pile.

Someday.

This is the second week of this month’s theme of Gravestone Cookies.

That is recipes that are on tombstones, not in the shape of a gravestone.

This was the first recipe on a tombstone that I saw. I’m not much on candy making, I usually save it for October and the Halloween homemade candy that is the theme of the last Thursday of the month.

One thing that I do know about candy making is that humidity is a threat.

When I woke up this morning, of course it was raining!

I checked the humidity, 74%.

Therefore I waited as long as I could before I dared to start the fudge.

It is still cooking, but I THINK it is setting.

I put the batch into the fridge. We’ll see what that does.

If not, the batch will make fabulous hot chocolate.

Fingers crossed!

I hope Kay likes my reason for making the recipe.

Update from 6 hours later.

Unqualified fail.

I guess the humidity didn’t drop enough.

Hot chocolate anyone?

No, I don’t know where we would be without them.

Sterile processing is the department that takes the used instruments, that are no longer sterile because they’ve been in someone, processes them, puts them into sets, and sterilizes them. For use by the next surgery.

That is a very, very, very simplified discussion of what they actually do.

The instruments start in the decontam room. This is where the instruments are pre-washed for blood and pieces before they go into the big washer that washes them with detergent.

The sterile processing tech has to know the IFU or instructions for use on every single piece of instrumentation and also how to use the many pieces of equipment that are in the department to clean and prepare the instruments for sterilization. After their bath, of course.

The IFU is the sterilization manual for every piece of instrumentation. From the manufacturer.

How long does an arthroscopic shaver have to be cooked?

By cooked, I mean sterilized in the big sterilizer. It is a combination of pressure, and time, and steam.

Kind of like a big Instapot.

Each specialized instrumentation has its own sterilization instructions.

Milking has to do with oiling the hinges. So that the clamps can be open to clamp.

There are also ultrasound machines to get stuck stuff unstuck. And to shake off the bioburden.

There is the sharpener that comes to sharpen all the scissor blades.

There is the steam sterilizer that is run on steam, and pressure, and time to sterilize things.

There is the Sterrad that used to be to sterilize the cameras with a mild form of acid.

There is the plasma sterilizer. It’s not what you think, it is for the more delicate things like batteries that still need to be sterilized for use but can’t be cooked too long or they lose their charge.

There are the 5,621 types of instruments that the sterile processing techs have to be able to identify at a glance and know what kind of instrument tray the instrument belongs in.

This is probably a WAY undercount.

This piece went to ER.

This piece stayed in the OR.

This piece got milked.

This piece stayed dry.

And this piece went whee, whee, whee. All the way home.

You knew where I was going with that, right?

The point is, without the SPD and their specialized knowledge about sterilization the OR would be sunk.

To think that when I was starting in the OR we were still dipping instruments in Cidex. That smell will take you back.

I am not an SPD tech, all the errors are mine. Beyond Clean does that what can, you know?

Beyond Clean is an amazing SPD education hub. I have learned so much!

Words have meaning.

This has been shown over and over and over again.

Heck, Shakespeare’s Hamlet used the word in response to Polonius’ question about what he was reading.

He was reading words. He wasn’t going to tell Polonius what those words were.

In what he was reading, Hamlet knew that the very words were not important. Because words get carried on the wave of other words, in a never-ending maelstrom. By impermanence, I mean lasting for a very short period of time.

Not unlike social media these days and the impermanence of the videos on social media, or reactions to events in the real world. Or the thoughts and prayers that have been forgotten before the reverberation of the event has finished.

Knee-jerk reaction, those thoughts and prayers.

Do you mean them in the moment? Absolutely.

Does the moment fly away? Yes.

However, the meaning of the words can have lasting impacts, even in the far future.

For example, it irks me to no end to hear that everyone is present AND accounted for, instead of the appropriate phrase present OR accounted for. The first means that everyone is present. To say AND accounted for is saying the same thing twice and no one has time for that. The second means that there are some people who are not present but we know where they are.

There are some no-no words that have lasting impacts too. I will not be going into them. But you know what they are.

We will never know the true impact of the words we use until we ask the person. Even then, they may prevaricate or say it doesn’t matter.

But it does, doesn’t it?

Be careful of the words that you use, they may be in the moment and gone, but still have a lasting impact for as long as the person hearing them remembers.

And for some of us, that is a long time indeed.

Yes, I know that I covered thoracic incisions last week. And I was gonna cover head and neck incisions.

oops

However, I realized that I was remiss in covering plastic surgery incisions on the chest. Or breast cancer at all.

These are incisions that don’t go into the thoracic cavity. As they are only skin deep.

I know that they are more than skin deep, I am attempting a metaphor.

Moving on.

October is Breast Cancer Awareness Month here in the United States.

There is so much information out there about breast cancer. Most of it is viewed from a womanly lens.

Cancer doesn’t care if you are a man or a woman.

Breast cancer also doesn’t care. I’ve done mastectomies on men. Men can also be impacted by breast cancer. 1% of all breast cancers occur in men.

In the US, this is 2300 cases of male breast cancer per year. As a diagnosis, it is also becoming more common. Where it was 1in1,000, it is now 1 in 833, according to the website Go Beyond the Pink.

The CDC numbers are that for every 99 women who are diagnosed with breast cancer, 1 man is diagnosed with breast cancer.

Don’t think that because you are a man with a family history of breast cancers, of BRCA1 or BRCA2 family history, you are safe.

Cancer doesn’t care.

Male breast cancers are more likely to be discovered later than women. Because they are discovered later, the disease is more advanced. And harder to treat. Leading to a higher death rate from breast cancer in men. The likelihood of surviving breast cancer in men is 77.6%, compared with 86.4% survival rate for women.

Risk factors include, from the CDC: age, genetic mutations such as the BRCA1 and BRCA2, estrogen-containing medication including estrogens that were used to treat prostate cancer in the past, or estrogens that are used in trans patients, weight, FAMILY HISTORY, liver disease, Klinefelter syndrome where there is an extra X chromosome, and certain conditions that affect the testes.

There are minimal guidelines out there for male breast self-examination. What to do, where to feel, when to do the self-exam.

Every little bit of education helps.

Every little bit of raising awareness helps.

Don’t be afraid of the pink.

Just like sands through an hourglass, this is the timeline of the semester.

Yeah, that is a reference to a soap opera.

But, depending on the start date of the semester, the time is really flying.

At the university I go to this is 8th week of the semester!

Or at the last university I went to for my masters this was the last week of the quarter.

Mind-boggling!

And true.

This is usually when the heat starts ratcheting up on students.

This is midterm week.

Tempers may be short, the caffeine money may be running shorter, and the to-do list per class may be just as long as the first day of class. Well, it might feel like that.

But learning has been going on in the past two months. Time to test that knowledge. Or time to write a paper or three. This depends on the curriculum of the school and the class.

There will probably be presentations though.

Take a deep breath.

In.

Out.

Maybe take a nap. Or have a mental break before hitting the books again.

Remind yourself that you have a family and you love them. Or remind yourself that you have friends and you love them. Remind yourself that you have pets and you love them.

Oh, and the last day to drop a class is right around here too.

That is always an option.

I cannot explain how long I’ve waited to reveal the theme for October.

Excited doesn’t even cut it.

The theme for October will be Gravestone Recipes.

I had been low-key aware of recipes on gravestones in the past but I didn’t see how I could use it as a theme as there weren’t enough recipes available. Until Rosie Grant, a librarian from LA, started making gravestone recipes and sharing them online.

Even my husband saw them and told me it would make a good theme. I know! I practically shouted, I’ve been waiting until October and spooky season to use it.

I have chosen 3 recipes to use for the month. The 4th CTIAT will be the annual homemade candy bash. I’ve been collecting recipes and ingredients for that and I have the CUTEST theme.

The thing about gravestone cookies is there isn’t a lot of room on a gravestone to write. These recipes will be rather simple.

Today’s recipe is a version of the cookies I’ve made many, many times before.

The recipe is titled “Chocolate Oatmeal Cookies (no bakes).

The recipe is practically identical to the fudgy cocoa no-bakes that I make.

I usually dole out the mixture on waxed paper and leave it to dry. But I had a brain wave and decided to use the cookie sheets with the silicone liners. Worked very well, but the metal of the cookie sheet got rather hot.

I will probably use the cookie sheets and silicone liners again. After the cookie sheet cooled off, the cookies dried as usual.

Every three years the joint commission, formerly and forever known at JCAHO (JAYCO) to those who have been around since before the rebradining, visits each hospital is is responsible for surveying. They just want to ensure that the hospitals are actually doing what they say they are doing.

And you have never witnessed a tizzy like a JCAHO tizzy.

The hospitals are buffed up and painted and cracks are repaired and ceiling tiles inspected.

Employee files are inspected for completeness.

For the OR, there are a couple of different things that can go on. A suveyor can follow a patient through admission to discharge. This can be done to make sure that all the pieces that the organization says it does is actually done in real time. This might take a lot of time and definitely makes the team in the room nervous. Or the surveyor can watch a time out to make sure it is done appropriately. This still makes people nervous, really nervous.

I tell people when they are face to face with a surveyor to always be truthful with their questions. If you don’t know the answer, you can find out. Or you know where to find out.

But most people just hide when the Joint Commission is at the hospital.

Covid gave the Joint Commission a bit of a bumpy time.

At my hospital (we were due in 2020), they had suspended in person visits because of the pandemic. This led to a delay in the survey of about a year, it might have been 18 months.

The Joint Commission is interested on restoring the normal calendar, even if that meant another visit 18 months-2 years after the last.

Same tizzy,

The surveyors will come. Like clockwork. It is to the hospitals advantage to keep key players in place to help guide departments in preparations. This way they will have a front facing person for the surveryors to question.

Speaking to a surveyor is not unlike meeting a wild animal in a dining room. Stay calm, be deliberate in your actions. To quote Phil Slott, an advertising man, “Never let them see you sweat.” Most imporantly, you don’t have to have all the answers, only a few people know and remember all that. It is better that you now where to find the answers and who to ask.

The extra most important thing is to conduct your life as if they can drop in at any time. Because they can. And will, for a sentinel event.

Keep up on damage repairs, always be on the lookout for issues such as stained ceiling tiles. An ounce of prevention will save the hospital hours and many dollars in repair later. My hospital does a really good job in maintaining the hospital plant (that is what it is called).

Also know that there will be a tizzy when surveyors come. A flurry of activity as the water bottles are hidden, as the visible expiration dates are checked, as people are coached, yes, again. As people scurry and hide or walk quickly with purpose if they come across a surveyor.

It’s going to be okay. Just take your mask off when you are done with it, alcohol in and out of rooms, and after an action where you touch a patient.

Take a deep breath.