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

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

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

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

In less than a week.

What the actual fuck?

This is insanity.

Again I am speechless.

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

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

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

And this was after the first incident.

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

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

I did not think to mention fearing for our lives.

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

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

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

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

When the next attack was coming.

And from what direction.

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

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

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

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

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

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

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

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

Because it is consistently wrong.

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

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

No, doc, no.

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

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

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

And uses that one for the paperwork.

April 12, 1989- violence comes to Sonoma

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

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

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

This was not in a school.

This was not guns.

But it was shocking.

And still very much part of my growing up experience.

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

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

And then his wife.

And then his supervisor.

And the town locked itself up tight.

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

I remember the empty streets.

And, oddly, the empty driveways.

I remember not being allowed to ride my bike.

I remember talking about it in school.

I remember the fear in the town.

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

I was 13 and an eighth grader.

It has been 33 years.

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

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

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

Because I remember when senseless violence came to Sonoma.

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

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

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

I hate making frosting.

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

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

No, I won’t use margarine.

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

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

And served the frosting on the side.

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

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

Hark, he has found it!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anticipation is the worst.

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

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

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

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

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

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

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

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

Post-it Sunday 5/29/22-I see you

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

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

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

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

But the cartoon Orthopedics vs Anesthesia is perfection.

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

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

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

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

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

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

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

The anesthesiologist is getting more frustrated, visibly so.

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

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

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

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

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

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

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

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

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

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

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

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?

No.

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.