The OR being a clean environment full of clean edges, and sterile surfaces during a case, is a dearth of places to write. There just isn’t a lot of paper to write anything. Stacks of paper are frowned upon because they can be dust catchers. And blood can go flying, especially during a total hip.

You could theoretically write on the back of the schedule or the preference card. Those pieces of paper are handy. And since the schedule or the preference card is only printed on one side, the entire back side of the page is empty. Plenty of room to make notes.

The whiteboard is also a place to write. On the bottom, under the patient’s name, birthday, procedure, surgeon and allergies, there can be 18 inches of space. I use the whiteboard to write down things all the time; I note down times, and results from the pathologist if doing a frozen, I write down information while I am on the surgeon’s phone answering a page, I write down the name of the specimens, especially if the surgeon is rattling them off too fast for me to input the orders. If the case is over too quickly and I have not finished charting, I will take a picture of my notes and refer back to the picture when I am finishing charting. I very carefully do not take a picture of the patient’s name or detail and I delete the picture after I am done.

That’s why I don’t like to make important notes that I have to address and complete on the back of a schedule or preference card, there is the potential for too many HIPAA violations. And I’d rather not lose my job for a violation. And it is not appropriate for the patients to have their information bandied about.

Best not.

I am not talking about notes that are about the patient.

I am talking about notes to yourself about future self things.

The to do lists, the next case notes, the reminders about picking up little Timmy from afterschool event. All the things.

There is a dearth of writing materials in the OR. In a pinch, I have been known to write on my scrubs, or on my hand. I routinely keep a post-it on the back of my badge for when I need to take notes.

Another widely used writing paper that all the OR nurses and techs know about is the gown card. This is a 2.5 in x 4.5 in card that is attached to the gowns to allow the wearer to turn in a sterile manner.

These gown cards are useful as hell.

And I cannot keep from collecting them. They are that useful. I have about 10 in my locker at all times, and about 500 at my house because invariably they go home with me.

Things that I have on the gown cards on my desk:

1. to do list for home
2. to do list for work
3. to do list for school
4. Dispatches from the Evening Shift notes. This comes in handy on Sundays
5. Cookie Thursday is a Thing themes
6. Cookie Thursday is a Thing recipes
7. Christmas list
8. A reminder for the free library classes I have signed up for

The point is that the gown cards are really useful. And a recyclable resource that is self propagating. This is because there are at least 2 gowns opened per case, more if there is a break relief, or a PA.

I could make notes on my phone but I don’t like to be seen by the surgeon “playing” with my phone. It’s just not a good look.

This makes me analog in a digital world. And that is okay.

August.

Much has been written about August. According to the Farmers’ Almanac, July 3-August 11 are some of the hottest days of the year. The dog days, where colloquial wisdom explains that is because the dogs are panting in the shade because it’s so hot.

I mean, yes, but wrong.

Yes, these are the hottest days of summer.

No, that is not why they are considered the dog days of summer. The ancient Greeks noticed that the hottest days of summer coincided with the rising of Sirius, the dog star. Hence, these are the dog days of summer. Am I Sirius? You bet, and don’t call me Sirius. (Any Airplane! fans reading? just me, okay)

In my house the cats do not lie panting in the shade. They do, however, lie on the floor, eschewing the cat beds and furniture.

Yes, I don’t want to turn on my oven to bake cookies. It is too hot to add more heat to our house.

That is the origin story of No Heat August, a Cookie Thursday is a Thing exclusive. (I mean, I think)

Every week will be a different no bake make. Today’s cookie is the fudgy cocoa no bakes. I know I had these growing up, did you?

Of course, since Cookie Thursday is a Thing is about experimentation, I wondered a couple of years ago if I could add unsweetened coconut to the cookies. Would they firm up as much? Would there be any substantive change to the cookie? The answer is yes, they firm up just fine, just a little softer, and no there is no real change to the texture of the taste. There is a very slight coconut flavor to them.

There is another meaning to the word august. It doesn’t mean the 8th month of the Gregorian calendar. It also means marked by majestic dignity or grandeur according to Merriam-Webster. For men I think it is a double-edged insult. It sounds majestic, I mean that is in the definition, but I think it is as much an insult as calling a woman’s features handsome. This is done in many 19th century books and if you read between the lines the woman is to be pitied for not being pretty. Saying a man has an august bearing belittles them for not being handsome. At least it does to me.

Okay, tangent city.

The bake of the week is no bake cookies with peanut butter, oatmeal, cocoa. No flour or eggs required. Or oven, which is the point of no heat theme for August.

Before I start back up in school I’ve been reading and watching videos, I came across and I watched a video where a nurse was denied a continued discount being offered to nurses from a store. She got the discount at the time but was warned that she was not eligible for it in the future. She had her license pulled up from the stateon her phone, and her badge and these were both showed as proof that she is a nurse. Her takeaway, and mine really, is that because she is an LPN, and licensed by the state, she is a nurse. This is absolutely true. And enraging that she is second classed because she is an LPN, not an RN.

The definition of nurse, according to Merriam-Webster, is a ‘licensed health-care professional who practices independently or is supervised by a physician, or dentist and who is skilled in promoting and maintaining health’. The Licensed Practical Nurse (LPN) is a person who has undergone training and obtained a license (as from a state) conferring authorization to provide routine care for the sick. The Registered Nurse (RN) is a graduate trained nurse who has been licensed by a state authority after qualifying for registration.

This is a very dry way of saying that both are real nurses. Both take state licensure exams, both care for the sick and injured. From what I read when researching this topic, the LVN requires less education; an RN can have a diploma of nursing, an associate’s degree in nursing, a bachelor’s degree in nurse, or higher. For some people the education to be an LVN can be less daunting. Of course, others view it as a stepping stone before they continue their education.

Organizations also have to watch for classism, or othering of the LVN. In the hospitals that I’ve worked in, some in leadership look down on the LVN because they “don’t have the degree”. So what? They are caring for those who need help. There will be some things they are not qualified to do, and that’s okay. Trust me when I say every hand on deck is a release of the pressure on the unit. Clear roles and responsibilities go a long way for this. Just because the nurse is an LVN does not mean that they are not smart enough.

I’ve heard jokes that being an LVN means that they are not smart enough for an RN program.

Egad! Do you hear yourself?

Being an LVN does not mean that! It means that this is what they wanted, maybe because the nurse in question didn’t have the opportunity to do an RN course, which can be longer than an LVN course. I know lots of nurses who started as LVNs, went back to school for their RN while working as an LVN.

This is not a Pinocchio moment. The LVN is not waiting for a visit from the Blue Fairy for an enchantment so they can be a real nurse. They are a real nurse.

So sorry your narrow-mindedness and ignorance has got in the way of your recognizing an LVN is a real nurse.

The woman in the video seemed genuinely distressed over this encounter. And I hurt for her, and am mad for her and other LVN that are confronted with this every day.

Say it with me, everyone, PEOPLE!

(reminder that people IS a swear word that can mean many things, but most commonly it is a derogatory term when used in the correct context)

Yes, I am still pissed about the Dobbs decision to overturn Roe v Wade. My husband keeps bringing it up, asking me if I am still mad. And I have lacked the language and the words to explain why, exactly, it is so troubling to have a precedent where woman’s rights to bodily autonomy are summarily stripped away. This decision robs a woman of bodily autonomy and the right to make decisions over her body that are best for her.

Yup, still pissed.

And then we were having a conversation about it last week and I had a thought, after watching an erectile dysfunction medication ad during a newscast.

I turned to him and remarked, kind of in an off-hand manner, “Well, what if men were no longer guaranteed access to ED meds. Because it is God’s will not to have an erection in some men.”

Oh, boy. You’d’ve thought I had just kicked him where it hurts. Right in the babymaker.

He spluttered, incensed, “They can’t do that! This is my body, and I can choose not to have a limp dick!”

I considered this reaction to be a little extreme. And I told him so. He kept going on and on about ED is a medical process and nobody can tell him what to do with his, and other men’s, theoretical erectile dysfunction.

And celebration bells started going off in my head. I mean, ring-a-ding-ding! His reaction, I can use to explain why the Dobbs decision is so disturbing for women. He’s a man, he doesn’t understand, not really.

Next I asked him if a man can choose to have self-determination over erectile dysfunction, I could no longer be guaranteed the same protection over my own body. And is self-determination okay unless a woman is of childbearing age?

Watching realization dawn is a wonderful thing. Even if it is in a man who is very opposed to the Dobbs decision, just not as mad about it as me. At least, until I corresponded the thought that I am still angry to a thing he could understand.

Eureka!

He’s still mad I brought that up and used the argument to explain why I, and millions of women, are still so very pissed, even 5 weeks out. But I think he understands why now, a little bit better.

And he has yet to ask me again if I am still mad about Dobbs. Because he remembers the conversation and knows the answer is yes.

On the subject of men and Dobbs decision, more men are opting for permanent sterilization. I mean, it can theoretically be reversed. I read that a urologist has had an uptick in inquiries about vasectomy, it has gone from 15 a week, to a high of 72. Per week.

This opens a wider conversation about a man’s role in pregnancy as 1/2 half of the equation that makes a baby. And how, for years and years and years, the responsibility for reproductive planning has fallen on women.

It is about time that men realize that they have a stake in this entire baby making process. Welcome, boys, better to be late to the party than not come at all.

And some men are choosing vasectomies because they can conceive (see what I did there) of a time when even that will be taken away from them. Although there are no plans to attack a man’s right to choose or bodily autonomy, I can see extremists thinking that is a mighty fine idea in the future.

Nah, probably not because the conversation has never been about control over men.

This is a reminder that the entire construct has been a method of control over women, wrapped up in baby bunting and using a pacifier.

As always, this does not impact me, being a married woman of 47. Those days are over for me. This impacts all the other women in the country of childbearing age. Our nieces, our daughters, our young friends. I consider all of them under threat, regardless of where they live. Yes, I’m still pissed, and afraid for them.

The gown card reads ‘what happens the day after the worst day of your life?’

Kind of a downer question but very relevant to today. As always.

I really need to start dating the post-its when I write them so I can see when this was written, and remember the details of why I wrote this. That’s a tomorrow Kate problem, although I have been dating them for, checks notes, since November of 2021.

What makes this day the worst day of your life is a valid question. There are podcasts, and Reddit forums, and Facebook posts aplenty. This can also be a rhetorical, throw down with the universe existential question. I’ve heard it referenced when someone misses out on an opportunity. Of missing the callback at an audition, at being overlooked for the big promotion. I am sure that someone said it about losing the 1.2 billion Mega Millions jackpot.

In my experience as an OR nurse, it usually refers to a death. A death of a loved one, a death of a child, a death of a patient.

Saying that a certain day when shitty things happen the worst day of your life is valid. Only you know your life and where this particular day ranks.

But happens the next day?

That is the question that the gown card was trying to prompt. What happens after you don’t get the job, or the part, or the promotion? What happens after someone dies?

Life must go on.

The bereaved have to eat, and function, and sleep. Although they cannot fathom doing so with such a new hole in their life, a new reality of their life.

Someone somewhere is looking a positive pregnancy test in a state that does not support abortion and has to figure out next steps.

Because tomorrow will come and it will no longer be the worst day of your life. It will be a new day, with new opportunities and new griefs and grievances to weigh on you. The old adage is pull yourself up by the bootstraps. This is ascribed to a piece of fiction by Rudolph Raspe where the character pulled themselves out of a swamp by their hair. A task that seemed impossible, but was overcome by the characters grit.

Tomorrow will dawn, and it will no longer be the worst day in your life. How you react will be up to you.

Not to go full Pollyanna Puke on the blog, but Annie said it best ‘the sun will come out tomorrow!’

When I was a new nurse doing my year on medsurg the hospital I was working in starting “experimenting” with staff mix. And not for the better.

To set the scene, this was in late months of 2001, I had been a nurse for 4 months. I was a newbie, wet behind the ears, still afraid to confront doctors. Oh, how times have changed.

The first thing they did was go to ‘team’ nursing. I had an LPN, and 1.5 CNAs, and 20 patients, which was half the floor. I was expected to assess all the patients, give all the IV medications, and oversee the LPN and the CNAs. You know what is troubling in that set-up? One patient going south, and by that I mean coding, or falling, or pitching a fit and holding the other nurse who had the other half of the unit at knifepoint.

That really happened. The patient was psychotic and threatening to jump out of the window and threatened the nurse with the knife that had been in their bag from home. They wanted the window opened and they were not going to take no for an answer. Never mind that the unit was on the second floor of the hospital. Not a lethal distance. This is also when the hospital developed the code gray around threats from patients. Security and the police came, and the patient was disarmed and put back to bed in a room closer to the nurses’ station where there could be many people watching them. It was a tension filled evening. And charting happened until way after midnight because no charting got done during the crisis.

The point is that the entire evening was wrecked in terms of patient care. The LPNs and the CNAs had been medicating, and positioning patients, and getting them ready for bed; in other words, keeping them calm and unaware of what was going down in room 201. The other RN and I were trying to de-escalate the situation, struggling to assess our patients, making sure that all the orders were carried out. It was a mess. But funnily enough, not the shift that sank the new program, or not the only one. I had a patient who was a self-harmer for attention, a patient who had Munchausen’s. They were in their early twenties and had a self-reported history of cancer, a central line and they would pull blood from the central line and have “bloody emesis” to cause a ruckus and many phone calls to the doctor. This was witnessed and the patient referred to the local psychiatric hospital.

The RNs had been complaining for days about this new team nursing paradigm and several shifts that went sideways in a week was the impetus to change back to the normal workload of 1 RN for 10 patients. This is not the workload of nurses today, thank goodness.

And then administration glommed onto 12-hour shifts. Who doesn’t want two more days off a week? The units could be run with less staff. Think of the savinge!

This ended up happening. Two extra days off a week is not a gift. It is recovery time. Nursing is hard and physical work, not to mention the mental work.

However, this was not created with nurses in mind. It is, and has always been, about saving money by requiring less staff.

No cookies this week.

I have seen the wrong side of morning from the night way too often this week as I watch my 3rd sunrise taking a patient to the ICU after doing surgery on them all night. And it is only Thursday! This baker needs a week off from baking.

Because I’m tired.

I had a plan. I had a recipe all ready to go. But three-hour of sleep segments BID (that means twice a day) of sleep is not very conducive to wanting to bake. I’m afraid I’ll burn the batch because I am no paying attention.

This is the value of this call shift becomes even more glaringly obvious. Instead of staff having to work their shift and take night call and work all night and work their next shift, the burden is on the call team. But the team member could go home early. Yes, IF the schedule allows for that, and no one else has called in sick. Shockingly it transpires that the staff member who has worked all day the day before, had the evening off, working call cases all night, and is expected to work their normal day shift. Medical personnel fatigue is a real thing. And is against policy. And AORN standards.

I had a good friend die in a car accident after the end of a night shift while she was driving home. She fell asleep at the wheel on a winding mountain road that you need your entire attention on.

The call shift is a good thing. It allows for consistency for the surgeons 5 nights a week, and night rest for the regular staff 5 days a week. Now if I could only get a certain CRNA to show up on time after I text them that the patient is in PACU and ready to be seen. There is nothing I hate more than inefficiency and making the sick patient and the rest of the team wait for the CRNA clocks high on that scale.

No Cookie Thursday is a Thing this week. If you want to call it a week in the continuing one woman protest against overturning Roe v Wade, you may. But that is just a side benefit and not accurate. Because women in the 18th century didn’t get the day off because they were fatigued. Someone has to cook the meals and clean. Hell, weekends weren’t a thing until the late 19th century. The Oxford English Dictionary clocks its first mention of the weekend to 1879.

I am going back to bed to have the second 3-hour segment of the day.

All podium presentation applications are due on Sunday.

I have 2 ideas that I am considering.

Number one is the the phoenix rising of shared governance in a corporation. I am on that committee. It is very important work. I think I would have to get permission from the C-suite though. Or I can spin it as the using whatever the corporation comes up with in my home hospital as a test case. I don’t know, maybe. I like the imagery of the phoenix rising from the wreck of the last two and a half years.

Number two is Don’t Mind the Pager; or how to stop worrying and love the call. This would be soundly in my wheelhouse. Call should not be scary. I have a project going around call bootcamp in conjunction with my Call Preserver tip book. I am proud of this book, and for the unit for not getting rid of it when I started the call shift and stopped being the evening charge nurse. I know it has helped people and I show every new nurse when I am doing the call bootcamp. I just need to formalize it into an actual project. I wonder if I will need IRB.

Or I am just a unicorn who likes call.

All poster applications will be due at a later date, probably October. Okay, I quick checked the website, October 2. I will be writing up both these ideas for poster abstract. I’ve had two in one conference before, why not try both.

But the big question mark of the entire AORN conference for me is the location of the 2023 conference. The conference will be held in San Antonio, Texas.

I am of 2 minds about going. Yay! Conference. Boo! Texas and its extreme limiting of women’s rights. I have negative desire to go to Texas in this political climate. However, I am beginning a project with other AORN members regarding a novice OR nurse publication and I wonder if participation will be highly encouraged, if not mandatory. I can also get ideas for further projects of my own, this may be useful for school.

On the third hand I do not want to be a second class citizen and give money to the state that acts like I am less than.

Because I happen to have 2 X chromosomes.

It’s not a secret that I love to read. I am an equal opportunity book devourer; westerns are a little hard to get down but I’m game. One of my very favorite genres is medical. Fiction, non-fiction, it’s all the same to me. I’ve been reading it since I first read House of God by Samuel Shem in high school. But isn’t that a busman’s holiday? No, not really. These books have situations and patients in them that I will never experience but if I learn about an avenue to treatment I can utilize it in the future. The following is a section of my favorite medical reads, fiction and non-fiction.

House of God by Samuel Shem. This book was published in 1978. I consider this book required reading for all who want to go into healthcare. It is also where many of the phrases that are still used today come from. And when I use phrases from the book, I get a blank stare in response. To name a few is O-sign, that is a patient asleep on their back, with their mouth open. Q-sign, that is a patient asleep on their back their mouth open with their tongue hanging out. Buff the chart is to make the chart pretty so that a different department will accept the patient. Neuro or Orthopedic height refers to how high the bed or operating room table is. This means that a fall from that height will be a neuro consult because of a head injury, or an orthopedic consult because of a fracture. GOMER, which I know is still used today refers to get out of my emergency room, or a patient who may be malingering. LOL and LOLNAD does not mean laugh out loud, it means little old lady, and LOLNAD means little old lady in no additional distress. The original text speak is medicine because we love our shortcuts. Entire conversations can be had in letters. And my favorite phrase from the book is that there isn’t a body cavity that can’t be reached by a 14-gauge needle and a good strong arm. This is a sexist book, written in a sexist time, but I can read past that. In fact, I am due for my annual rereading, and I will definitely be packing it for the plane ride.

Walk on Water by Michael Ruhlman. This book was published in 2003 and opened my eyes to pediatric cardiology, which was a service line I had/have no experience in. There can be devastating birth defects that were a death sentence for the infant in years past. This is a powerful book. There is a scene where the primary surgeon, the resident, and medical student, and the scrub nurse are all hunched over a teeny tiny baby when suddenly there are graham cracker crumbs in the field. That the medical student, as I recall, had been eating in the lounge prior to the case with his mask dangling from his ears and under his chin. This scene made me change my own nursing process and I now remove my mask anytime I am eating.

Intensive Care: The Story of a Nurse by Echo Heron. Upon reviewing publication dates I was surprised that this was published in 1987 as it feels quite modern. The issues that nursing staff deal with have not changed; sick, sick patients, doctors who don’t really know what they are ordering, lack of higher up support. This book could be written today. Echo Heron is a nurse in San Francisco in the early 1980s, attendant with the AIDS crisis. She writes with compassion about nursing and the patients.

This is Going to Hurt by Adam Kay. This was published in 2017 and I read it in 2018. This is about a doctor in England under their system and deals with the punishing pace that doctors must train under. I reread it before the BBC miniseries came out and it was just as stunning this past year as the first time I read it.

Complications by Atul Gawande. This was published in 2002 and is about an MD and life on the wards. He is a surgeon specializing in endocrine and general surgery. In this book he explores the limits of medicine and what a doctor can do and cannot do. This was recommended to me several times since and each time I have to say that I read it when it came out and his subsequent books as well. The Checklist Manifesto, published in 2009, is a companion book I would argue, and speaks to using a checklist, much like an airplane pilot, to drive decision making and ensuring that all important steps are taken. The World Health Organization published the pre-operative checklist in 2008, which is funny because I distinctly remember using a prototype in California as early as 2005. Both are solid reads and worth a reread.

The Immortal life of Henrietta Lacks by Rebecca Skloot. This was published in 2010 and was very splashy at the time. Henrietta Lacks had cervical cancer and the cells that were biopsied went on to drive medical innovation and much of the processes that medicine uses today. She died in 1951 and her cells live on, multiplying and being used for medical research. This is the book that made me think that research might be a good fit for me.

Nurse by Peggy Anderson. Although this was published in 1990 the stories are from the 1970s. And they tell of a different time and place, where nurses were required to give up their chairs to doctors. I got my copy before the graduated high school at the used bookstore (shout out to Paperbacks Unlimited in Santa Rosa, CA). My mom graduated in the 1970s and this book made me feel closer to her college days. And how different life is now on the wards with the quick discharge of patients, both to make room for more patients, and to decrease the cost of hospitalization. Definitely will be reread in the near future because I still have my copy.

Notes on Nursing by Florence Nightingale. The OG nursing book was published in 1859 and concerned care of the soldier during the Crimean War. Things that we do today can be traced back to this book. Cleanliness, fresh air, antiseptic practices, this book has it all. In 1847 Ignaz Semmelweiss was discovering that going from cadaver work straight to delivering a baby was probably not the best practice. I can believe that Florence Nightingale was aware of Semmelweiss and hand hygiene’s impact on survival rates or it may have been convergent evolution of ideas. It remains one of the bestselling nursing books to this day.

Seven books that still inform and impact my nursing career. Are all of these worth a reread? Absolutely. I think I will get started.

The gown card reads ‘owning your personal empowerment through personal mantra’.

Because, really, the only person who can empower you is you. And if a personal mantra gets the job done, find a phrase that speaks to what nursing is to you and why should you continue on, despite setbacks and pressure to quit.

Not gonna lie. Sometimes the pressure to quit is internal. Because our brains love to lie to us, to get us to follow the easy path.

When I was running, I decided on a mantra that would keep me going. Because running is hard and is never the easy path. I decided on right foot, left foot. This signified more than just the act of running to me. It is also telling myself to keep going, despite my lungs and my legs and my brain all screaming at me to stop.

As an operating room nurse, this mantra reminds me that there will be an end. It may be the end of the case, the end of the shift, the end of the day, but there is an end. I just have to keep going in a forward manner.

Right foot, left foot.

On toward the next rest.

Right foot, left foot.

There is a famous WWI poem by Wilfred Owen “Dulce et Decorum Est’.

‘Towards our distant rest we began to trudge. Men marched asleep. Many had lost their boots, but limped on. Drunk with fatigue.’ This poem is about a troop marching in the midst of the carnage. They are battered, they are lame, they are tired but to stop means certain death.

Remind you of a certain healthcare circumstance that we are still in. I’ll wait.

These are selected lines about sleep and going toward rest.

Right foot, left foot.

And my secondary mantra that those words spawned in my head, but with almost the same meaning ‘the only way out is through’. I tell myself this when I am starting a new semester, when I am starting a forever taking case, when I am starting something I’d really rather not do. To get to the goal, the only way out is through. The case, the degree, the never ending shift; the only way out is through. By using the first mantra.

Right foot, left foot.

Mantras can be powerful reminders to keep going. To goad us to continue to work, and do something we’d really not care to. But in healthcare there is a person depending on us. We tell ourselves mantras to keep going in the face of difficulty. Because we’ve got this and the patient who is depending on us.

I have a third mantra that will be explored at another time. It doesn’t really fit into the somber theme of today’s post-it. Or rather, the somber feeling of my personal mantras 1 and 2 that I use to keep going.

And mantra number 3 is ‘Do no harm, take no shit’.

But for now, especially with school starting in 12 days, right foot, left foot.

What is your mantra?