What does it mean to be on call?Part 6-hide and seek appendix

When we last left our OR call team during the lap appy, surgery had just begun.

To recap, it has been 45 minutes since the page. In that time the RN and the scrub tech drove to the hospital, got dressed in scrubs, picked the case. The scrub tech opened and set up the case. The RN grabbed a unit phone, went and picked up the patient from ED, and started the pre-op work. Anesthesia came and did their part. The surgeon came and explained the risks and benefits of surgery to the patient. The RN witnessed the patient signing the consent for surgery, and anesthesia. The first time, the pre-procedure time out was done, the H&P had been put in by the surgeon, the patient and his wife said see you later, and anesthesia took the patient to the room. The RN walked the wife to the waiting room, explaining what was going to happen next, and stressing the importance of answering the waiting room phone call, and returned to the room. The scrub tech and RN put the sequential stockings on the patient, made sure his seatbelt was secure. And anesthesia put the patient to sleep. The scrub tech used Avagard to cleanse her hands and put on the sterile gown and gloves. The RN clipped the hair on the abdomen, prepared the skin of the abdomen with chloraprep, and while that was drying, put am electronic grounding pad on the patient. The surgeon used Avagard to cleanse his hands and the scrub tech put on his sterile gown and gloves. The RN moved the tower into position after spinning the surgeon. While the surgeon waited with blue towels to square off the incision, the scrub tech and RN counted soft goods such as sponges, blade, needles, fog reduction liquid, and instruments. By now the 3 minute wait time has expired and the RN gives the surgeon the okay to drape. The scrub tech hands off the camera, light cord, CO2 tubing, bovie, and Enseal to the corresponding sides of the table where the RN plugs them in. The RN puts the consents on the prep table where she can see them during the pre-incision pause, the pre-incision pause is done and the fire risk pause is done. All is in agreement. The scrub tech hands off the blade and the surgeon makes incision.

Are you tired yet? This is a lot of accomplish in 45 minutes. And the case has just started!

I turn on the radio after incision to whatever I know the MD listens to, or what is listed on his preference card if I don’t know it.

The cut down incision is made at the umbilicus (belly button) and the initial trocar is introduced. This is usually the largest one.

The surgeon calls for the CO2 to be turned on. On full. This means 30 liters per minute, to an abdominal pressure of 15 mm Hg.

The surgeon scans the abdomen with the scope, looking for adhesions, looking at the liver, looking into the pelvis. He then asks for the blade and the next trocars, which are placed.

The lap appy can not begin in earnest.

The surgeon trains his scope at the site that the appendix is anatomically; the junction of the small bowel and the colon. With luck the appendix is sitting there on top of the bowel coils, ready for its closeup. Sometimes the appendix is buried under the coils of bowel, sometimes it is retroperitoneal, or behind the colon. It just depends on the patients anatomy. And whether or not there is purulent material or pus, depends on how bad the appendix is. As a surgeon put it this week, sometimes the patient can have appendicitis for a week with no rupture, or 6 hours with rupture. It depends on how mad it is. Sometimes the appendix has ruptured and begun to wall itself off in an abscess construct. This is not good because after 3 weeks or so this walling off will break down and the patient will be even sicker. Sometimes the appendix has ruptured so badly that the appendix is not evident because it has burst like a balloon. I’ve only seen a few of these in my 21 years of OR.

While the surgeon is searching for the appendix my job as the circulator is just beginning. There are many things that I, as the circulator, need to be doing. The next thing that the field will be asking for is the stapler, with a load. I do a quick scan to make sure they are in the room and the retrieval bag is on the sterile field. I also do a check that there are more than 1 reload, in case the appendix is larger than the usual stapler and a reload is required. I do a quick glance at the bag of LR that the CRNA is using, to make sure that they have enough fluid still in the bag for the rest of the case. All the while, I am listening to the beeps that the monitors make.

Much of this is not done on instinct, but done on experience. If the patient were to go bad, and the CRNA to begin noticing trouble with the patient, these monitor beep changes are often the first things. Or there is a lot of movement, behind the drapes, of the CRNA. A flurry of movement can indicate the CRNA is pulling meds to counteract a vital sign reading. If that is the case, I move to where I can see the monitors and pull out my phone to contact the anesthesiologist if required.

If I am fairly certain that I have everything they need, I begin to chart. Charting is always the least of my worries. What is happening in real time is more important. And I have a secret weapon, a macro that I created for the surgeon, for the case. This will fill in a lot of the holes that I need to chart. But that will be part 7.

Cookie Thursday 5/26/22- pimento cheese

Pimento cheese?

That isn’t a cookie, you say.

True. But it is one of my go to potluck staples.

And today is an orthopedic surgeon’s last surgical day before his retirement.

And there is a potluck. Any excuse for a potluck in the OR.

We like to eat. I have always said that the OR is an army that marches on its stomach.

Instead of making cookies this week I decided to make pimento cheese instead. The party was near the time I bring cookies. And the eating of the cookies go down when there is a party. I brought something to the potluck instead.

The number one requested savory that I make for potluck is the pimento cheese.

This is a food stuff that I embraced upon moving to the south.

It is simple; only four ingredients. But so good. I give out the recipe every potluck.

8 oz finely shredded sharp cheddar

1/2 small jar of pimentos

12-15 shakes of Tobasco sauce- this can be done to taste

2-4 tbs mayonnaise- this can be done to taste. I do not like a goopy cheese

Serve with crackers.

So long and thanks for the fish, doc.

We’ll see you in a couple of months when the idea of retirement becomes boring.

To those who think that pimento cheese cannot be put in cookies, to date I have used pimento cheese in

  1. baked pimento cheese crisps which is baked circles of the cheese as prepared
  2. pimento cheese thumbprints with triple pepper jelly
  3. cheese straws
  4. pimento cheese shortbread
  5. pimento cheese cheezits

Active Shooter- words that chill

I was going to write part 6 of what does it mean to be called in.

But this is more important.

19 children are dead.

Yesterday, May 24, 2022, a gunman walked into an elementary school that was near his high school, walked into a classroom, and killed many of the students and teachers who were in it.

The suspect was subsequently killed by responding officers.

19 children are dead.

2 adults are dead. I presume these were the teachers.

Is there an idea about motive?


Does there need to be though?

I try very hard not to make Dispatches from the Evening Shift political.

The OR doesn’t care about my political leanings.

My political leanings do not color the quality of nursing care that I give my patients, no matter how I feel about their stances. If I even know what they are. It’s not something that comes up during a pre-op conversation.

I am upfront about not having children.

Does this mean I can’t be horrified and shattered by what happened in this elementary school? I have nieces and nephews that I love.

I can have an opinion on the events that took place yesterday in Texas.

And my opinion is valid.

I have been hesitant to say anything as I know that will lead to me feeling dismissed about my feelings of outrage and grief.

Kind of like my feelings about the Covid pandemic and those who choose not to get vaccinated to shorten this pandemic or protect others. Or people who won’t wear a mask in public because they don’t want to. And these feelings getting dismissed because they don’t want to apparently supersedes my desire to care about the welfare of others. But sure.

Because I am not a parent. Because I am not a mother. Because my husband and I aren’t parents.

And how would I know what these parents feel?

I don’t. But I have a good imagination. And because I’m human and don’t want to cause people to suffer, that’s how.

In the hospital we drill for an active shooter. In case someone gets a wild hair and their gun and decides that their need for vengeance, or to feel powerful, is greater than others need to survive. And my nephew throws out in casual conversation when his school has an active shooter drill.

It is so very sad that society has come to this.

In the plain language codes that my hospital system has adopted, active shooter is the scariest.

Monday’s Musings 5/23/22-yes, that sign means you

I went to the eye doctor today. My yearly appointment/screening is usually in October but there is exciting things happening starting in August. I want new glasses for London and for university.

Prior to entering the office I noted that there were 2 signs indicating that mask wearing is required on the doors. There were also plexiglass dividers at the receptionist and another sign, with a box of masks saying, again, that masks were required. Everyone in the office was masked.

I checked in at took the paperwork to the chairs to fill out.

Normally I go to the first appointment of the day, usually 0800, and there were more people than I’ve been around in the office. All masked. But I made the decision to get my exam early, even if my normal doctor is out until August.

Two other patients followed me in. One, a woman, was masked. The other, a man with his 7 year old, was not. The receptionist asked him pointedly if he had a mask. Because masks are required, as evidenced by the three signs that he had to pass to get to the desk.

Caught, he mumbled, “Oh, I did not realize we were still doing that.”

I am not sure what he thought after passing the three signs, and reading one aloud to his kid. Did he think that the receptionist was going to smile and tell him never mind?

Unsmilingly she passed him a paper mask. Didn’t give one to the kid, but whatever. He sheepishly put it on and took his paperwork to the chairs to fill out.

Let us unpack that a bit.

The eye doctor is examining your eyes.

Which are separated from your mouth by your nose. Both of these are prime droplet spreading suspects. And, I’m not sure if he knows this, we are in the middle of another surge. And a very devastating milestone just passed. 000

Because the pandemic is not over just because most Americans want to go back to their lives.

Insert eye roll.

Yes, wear your damned mask to protect the eye doctor and their staff.

No, don’t pout when the receptionist gives you that soundless look and passes you a mask from the box of masks on the desk.

Be a good role-model for your kid.

The rest of my appointment went by.

I chose new glasses that will be ready in about a month.

Well ahead of the events in August.

After I paid, half listening to the same man saying loudly that he preferred blue or brown glasses, I chose a lollipop to take home.

Because I was a good patient and not snarky.

Post-it Sunday 5/22/22-gallows humor

The post-it reads ‘if we didn’t have gallows humor, we wouldn’t have any at all.’

This is very true. There is little to laugh at in health care. There is little to laugh at in witnessing suffering. Sometimes there is something that we can do to alleviate the suffering, oftentimes not.

You could say gallows humor is in response to life-threatening, disastrous, and terrifying situations. And the Merriam Webster did that as that is a direct quote from the dictionary.

In healthcare much of what is witnessed by us is life-threatening, disastrous, and terrifying. To the patients, and to us who are striving to ease all of those conditions for the patient.

Yes, we make inappropriate jokes, but I say it is in response to what we are witnessing. A bit of whistling past the graveyard to give ourselves courage in fighting what the patient is going through. We don’t have the privilege to act as if we are afraid or unable to fight the current battle.

And for pete’s sake, don’t let the patient see you sweat.

Or your coworkers. There is an art to keeping cool under fire.

A prime example of this is my response to a post on Facebook. This is a group of women who are not medical. Like, at all. And one made a post about how her husband was home from the hospital after undergoing a colectomy. At the end she made fun of the fact that he wanted to keep the removed colon. Why? Who knows. My response was that I tell people all the time that the lab has to have whatever is removed for testing. And that the weirdest thing that someone had wanted to keep was toes removed for gangrene. I wrote back that we could have a what is the weirdest thing ever sent/seen in the lab but I did not want to gross the group out. Some of the women got it, I am sure that some were icked out by the comment. Me? I thought the entire exchange was funny.

What does it mean to be called in? Part 5- the camera, light, and CO2. Room lights down.

The pause, or time-out has just been done and the incision has been made.

For a lap appy this is no time to chart and rest on your laurels. Or on your phone, if you’re that type. We all know them.

Everything may be hooked up and ready to go but you, as the circulator, has to be prepared to dim the lights, turn on the camera light, and turn on the gas.

During a lap appy, carbon dioxide or CO2, fills the abdomen and expands the open area between the abdominal wall and musculature and the internal organs. Doing this allows the surgeon to direct the camera in different directions and see different things. The surgeon has be mindful of the angles in placing his trocars. The trocars are the working channels for the instruments. Basically a tube with a sharp end that is introduced through the skin and muscles into the abdominal cavity. There is an art to placing the trocars in. There has to be enough force to go through the muscle layer, but not enough force to damage the organs. It is a fine balance, especially on a skinny person. What most of the surgeons that I’ve worked with do is place the largest trocar at the belly button, take a peek with the camera to make sure they are through the muscle, and call for CO2. This will begin to expand the cavity and make the other smaller trocars easier to place.

I have a story here. In my first hospital in CA, when laparoscopic surgery was first beginning, a surgeon who had been through classes with pigs was putting in the opening trocar. He was unsure of how much resistance the abdominal wall would give so he took this bladed trocar and shoved it in as hard as he could because that was what he understood. You know what is immediately underneath the belly button? All along the back of the peritoneal cavity, underneath the colon and small bowel?

The vena cava.

This is the largest vein the body. It carries all the blood from the periphery back to the heart where it can be re-oxygenated and pumped back out to the body. Yeah. The surgeon knew enough not to pull the trocar back out, and luckily a vascular surgeon was nearby to open and cross-clamp the vena cava so the patient wouldn’t bleed to death. That lap case turned into an open case real quick. But that was years and years ago.

But for this lap appy and patient A, the large 12 mm trocar was introduced without issue. A quick visual was obtained and the surgeon called for CO2. Me being who I am, was standing next to the tower and turned on the flow of CO2. The machine can be tricky, sometimes you have to hit it twice because the first time only turns on the potential for airflow. A pro tip is to wait for the numbers to begin to go up. These numbers refer to the amount of CO2 given. If the numbers are not going up, the trocar is not in the abdomen and must be withdrawn and the cut down began again. Depending on the size of the patient, and the fluffiness of their subq this can happen.

Finally the CO2 numbers are ticking up. This is a good time to do two things at once. Ask the surgeon if the screen is in a good position and check how many bars the CO2 has on the machine. This indicates how much CO2 is in the tank.

If the screen is in a good place, leave it be.

If there are more than 2 bars on the machine, you are probably in a good position. If there is 1 bar, be prepared to change it. This should be part of your pre-case setup but everyone does things a bit different. I always check the bars when I am turning on the video tower, others do not. There should be a spare, unopened tank on the tower. If you have a suspicion that you will run out of CO2, make sure you have a spare and a tank key to switch them out.

You’ve started gas and the abdomen is filling nicely. The next thing that needs to be turned on is the light cord for the camera. Otherwise it is going to be mighty dark in the abdomen. I will discuss the make-up of the light cord at a different time. It is fascinating.

For laparoscopic cases you need lights, camera plugged in, and action by the surgeon.

Sorry, couldn’t resist.

By now the 5 mm working trocars that the laparoscopic instruments can fit down have been inserted. Depending on what kind of case this is there can be 2-3 5mm trocars. Most surgeons use 2.

Take this opportunity to turn off the room lights. This refers to the overhead lights and are controlled by switches by the door.

And dim the spots, or surgical lights as they are very bright.

One can be turned off completely and the other can be dimmed so that the scrub tech has a small amount of light over their back table.

This is now the time to ensure that the auxiliary monitor that the scrub tech uses is in a good position and they can see what the surgeon sees.

With luck the appendix is sitting in plain view on top of the small bowel coils. Otherwise the surgeon might have to go fishing.

Cookie Thursday 5/19/22-sad cake

Inflation baking continues this week with the sad cakelets. By cakelet I mean an entire batch of a cake re-imagined and baked in the mini muffin tins. A little cake.

One of the most intriguing cakes I’ve had in a while is the sad cake. This was brought to my attention by one of my favorite pre-op nurses.

Apparently it is so named because you are sad it is gone after you’ve eaten it.

And this is true.

She always saved me a bit if she ever baked one and brought it in. Otherwise the locusts that we work with would have eaten it.

It involves 4 eggs, 1 pound of brown sugar, 2 c of Bisquick, 2 cups chopped nuts, and a splash of vanilla.

Looking at the ingredients I thought that there was no way that 4 eggs would be enough liquids for the entire cake. But it is. And this is what earns it a week in the inflation baking month. It is no less impossible than the other cakes I have been making.

This is a dense, flavorful mini cake.

There is no reason this cake is this good, except for the pound(!) of sugar.

So often my recipes and Cookie Thursday is a Thing arises from the can I bake that into cookies question. And yes, yes I can.

Next time I will add more nuts. And, ooh, should I roast the nuts first.

Yeah, this is how the creative baking juices get going.

And there is a frosting. Of course there is. I’ve been clear on my feelings on making frosting. Which are usually negative. But they have been tempered by the decision to serve the frosting on the side. This way people can use as much, or as little frosting as they want.

What does it mean to be called in? Part 4- the PAUSE

When we last left Patient A, the case was about to begin. And the pause happens before incision, sometimes immediately prior.

The pause refers to an intentional pause in the activity of the case and everyone in the room focuses their attention on the patient and touches briefly on what has brought him to our OR.

The pause or time-out, as it is sometimes referred to, was started in 2003. Initially this was intended to ensure that the correct patient, correct procedure, and correct site were identified by all the team members in the room.

In his book the Checklist Manifesto, author and general surgeon Atul Gawande, explores the reasons behind the creation of this kind of checklist. I whole heartedly recommend this book, and Complications, his first book. They should both be required reading for healthcare professionals. Along with House of God by Samuel Shem but that is another post.

The idea was borrowed from airlines; they have a checklist for everything aviation.

This was where the pause or time-out began. The entire room has to agree to the correct patient, the correct procedure, and the correct site. I have memories of rolling this out to the OR in CA. Some surgeons didn’t care to mark the patient to indicate laterality. Until there was a wrong site surgery in our operating room and then they couldn’t get on the bandwagon fast enough. Too bad it took a tragedy to get some people to do what has been proven to increase safety.

The time-out has been expanding ever since.

There is a pre-procedure pause with the nurse who did the initial assessment and pre-op work with the patient. This involves much of the same elements of a pre-surgical pause. Correct patient as evidenced by name and birthdate, correct procedure as evidenced by the consent, correct site as evidenced by the laterality being marked, if there is a laterality. And the completion of a history and physical has been added. Also added is the appropriate antibiotic. I imagine that the next to be added to the pause will be a pregnancy test, if applicable. The medications that anesthesia uses are powerful and can be fetotoxic. That means dangerous to the fetus. And this is a discussion that some of us have added to our communication with the CRNA and anesthesiologist.

The pre-procedure time-out is also done with the nurse, the CRNA, and the anesthesiologist prior to any anesthesia procedure. This includes blocking of limbs, blocking of the abdomen during a TAP block. This refers to the Transverse Abdominis Plane as an exploratory laparotomy incision pain block. Also included is the spinal block. If the anesthesiologist is blocking a shoulder for example they should also mark the correct shoulder, in addition to the surgeon.

The pre-surgical time-out includes the same information as the pre-procedure time-out with the addition of the presence or availability of the correct instruments and implants, for an orthopedic case, the introduction of all people in the room, including sale representatives, and a discussion of the fire risk of the surgery. Some surgeons throw in a time estimation for the case, and with the exception of an orthopedic surgeon I am thinking of who does marvelous pauses, are invariably wrong.

The last part of the time out is the expected issues that may crop up during the surgery. This is usually patient condition related and may included discussions of the need for a higher level of care such as the intensive care unit.

The OR team uses this time-out to convey many pieces of information. This is all to keep the patient safe while they are in our care.

Monday’s Musings 05/16/2022- other writing

It has always been my grand desire to be a published author.

For my ENTIRE life.

You know, where someone actually pays me.

To that end I have sent off a letter introducing myself and by bona fides to all the AORN publications. I guess you could call it a query letter. I am querying if they need an article freelancer. But one who has broad knowledge and experience in the operating room.

Because, you know, I have all this free time now.

It’s a start.

I have also been signing up for all the free sites I can for recommendations on how to start at freelancing. Also a start.

And I have also been exploring the free offerings from the library. I have been to 2 gardening classes, a book club, and a writing club.

The last was yesterday.

Me, being who I am, was 15 minutes early. Clutching the first chapter in my zombie book and peering into the near empty classroom. Okay, let’s do this.

I had no expectations about the group, as this was the first one I had ever been to. Apparently it was a read a chapter aloud and discuss strengths and weaknesses. And I should have brought 5 copies of the chapter so people could read along. Now I know.

There ended being 4 other writers in the group. And the moderator.

I read the first chapter I had brought.

I wrote it several years ago, prior to the pandemic, and my MSN.

And, let me tell you, post pandemic it hits a little differently.

The lab where our main character works is developing a biological weapon around the zombie flu. In this universe the zombie flu is caused by a virus, that is carried in saliva. And 100% infectious and 100% fatal.

I need an elevator speech for it. A quick 30 second synopsis. What I have so far is that the scientist working on weaponizing the zombie flu accidentally infects himself, despite the lab protocols. He has to get to what he hopes is the cure across the country, accompanied by his ER doctor girlfriend. He is getting sicker, and sicker, and closer to full zombie. This is a high stakes race across the country at night, pursued by the man who wants to kill him, to prevent an outbreak.

After I had strong positive feedback from the group I pulled up the rest of the chapters I had written. And re-read them until 0200 this morning. I don’t think it is half bad, but it is a book that clearly needs to be finished. I have the beginning, the middle is plotted, and the ending.

It is called Calling in Dead.

The title came to me when I was waiting for the core elevator in the middle of the night, about to search for something that the case that was underway needed. This was the 3rd add on, it was the 0400, I had been at work since 1030 the morning before and I was tired. I looked at my reflection in the dull silver doors and said that I needed to call in sick the next day, hell I needed to call in dead.

The title is still awesome.

Post-it Sunday 5/15/22- RaDonda Vaught sentencing

The note reads ‘Just Culture, another RaDonda Vaught post.’

This is a short note. And this post is an update on her sentencing.

They moved the sentencing date, I guess, from the 12th to the 13th. From Florence Nightingale’s birthday to Friday the 13th. It still looks bad either way.

She was sentenced to 3 years supervised probation. At the end of the 3 years, her record can be expunged. I imagine she cannot get her Tennessee nursing license back but I think she can go to a neighboring state and petition for a nursing license. Or she may be able to get her TN license back, the state BON work with nurses who have been convicted of diversion after all.

I believe that this case should never have been brought for trial. She should never have been convicted. Apparently nurses are not allowed to be human and make mistakes any more.

I know that this has had a cooling effect on reporting medical mistakes. Nurses are afraid they are not allowed to be human. After all, RaDonda did everything right after realizing her mistake. She self-reported. And Vanderbilt swept it under the rug until they were found out. And then they swept RaDonda under the bus in the process.

She had already been punished. Not only by herself, but the Tennessee state board of nursing rescinded her license to practice nursing. This used to be enough until a DA, who had a primary election in 2022. And is a teaching professor at Vanderbilt University.

There is no fault that I am assigning. But there were systemic problems in place. Such as a powerful paralytic being available in the radiology pyxis and no flag on the medication, that I know the Pyxis can do. This does not excuse her error. As I tell the nurses I talk to about this she was absolutely stupid. And the swiss cheese effect led to the patient’s death. And, hopefully, this entire ordeal will spark change at the hospital. Because that is what errors do; they spark change.

Nor does it absolve Vanderbilt and the DA from sharing the blame for her conviction. This case should never have gone to trial. The trial was not about keeping the public safe. In my view this was a runaway case that pissed off a lot of nurses. Some of these nurses left the profession, disgusted by what was happening to the Just Cause tenet they had been practicing under for years. Others marched in Nashville, or in Washington DC on the day of her sentencing.

And as a society we cannot afford to lose more nurses.