For years when I was the evening shift charge nurse, I kept a curated list in my head of people who would be willing to pinch hit in the event of an emergency. The reinforcements, to call them by another name.

And carry the battle theme of life in the operating room still further.

I knew who to call to ask for help.

More importantly, I knew who would not come in to help under any circumstances.

No shame to them, kids and other life commitments, including having healthy boundaries, can mean that not everyone is available to help at the drop of a hat.

I utilized the list when the scrub tech was in a car accident on the way to the hospital to do a call case.

I utilized the list when it became apparent that the patient needed another set of hands because they were that complex.

A facet of the list is knowing if the PACU nurse on call will be able to help if they were called in prematurely. Frankly, some are not able to help do the nitty gritty gross stuff. Again, that is okay; the OR is not for everyone.

In PACU terms, I have utilized the list several times, most often in hemorrhage cases where blood has to be ordered, and labs sent, and suction cannisters changed, and a higher level of care than med-surg has to be arranged for WHILE taking care of the field and their needs. In a true hemorrhagic emergency, the field needs a lot, such as suction, and lap sponges, and not to mention the needs of the anesthesia team.

Sometimes cases are nerve-wracking.

Sometimes the blood wells up after incision too fast for the suction to clear it.

Being evening charge with limited staff is curating a list of your own of people to call in as reinforcements.

Because, if when you call, they will come.

A story to end the post today, the longest day I’ve ever worked was 1030-2300 for my normal shift, call from 2300-0700 with four add-ons with just enough time between to get home and lie down for 10 minutes before the pager went off again, and the beginning of the Saturday call shift, with another four add-ons ready to go on. At the 27-hour mark, I called in one of the nurses who I knew would come and they allowed me to take a MUCH needed nap for 2 hours. I got up after a desperately needed nap and finished the last case of the marathon. Is such a stretch advisable, no, or against policy, yes but the cases were emergent and had to be done. BTW, this was YEARS ago and several policy changes since.

Know your reinforcements. Recognize that using your reinforcements is good for the patients and good for you.

This is very top of mind because it is a new presentation of a poster at a new conference.

The conference I am referring to is the North Carolina Nursing Association conference. It is on Thursday and Friday.

I will be unable to attend both days. I have two classes on Friday. With a 15-20 minute presentation to give about a research methodology: quasi-experimental nonequivalent control group.

When arranging for the poster presentation, I made sure that my presentation day was going to be on Thursday.

To that end, I have to make the cookies for Cookie Thursday tomorrow.

Not so coincidentally Cookie Thursday is a Thing is what the poster is about. The beginnings of CTIAT, the changes of CTIAT, the LONGEVITY of CTIAT, the favorite cookies of CTIAT, and more.

I had my first cold in years doing the layout of the poster and I wasn’t feeling my best but it will be fine.

To give a poster presentation at this particular conference, you have to have a free-standing tri-fold poster. You are given a segment of the conference to present to anyone who wants to know the idea behind the poster.

This will be the 2 of 3 presentations in a week. And I am ready for all of them. I’ve done the readings, prepared my speaking points, and gotten the poster printed.

I’ve only ever had one other poster that actually made it to printing. I had three but covid happened and the conference was cancelled just as I was preparing to get them printed. I had the poster layout already done and was able to present that.

I went with a new company. I have been treated very well by this company and will definitely use them next time I have to get a poster printed. I understand that the university also does printing but I want to rely on that only for university things.

I’m going to read research papers the rest of the day/week/month/semester, no wonder research is top of mind for me.

The post-it reads “pulling out clots and throwing them on the floor. 1) we have to measure that blood!”

File this under the hell?

I remember this case. There was blood in the abdomen and the assisting surgeon was helping remove the clots by taking them out of the abdomen and then throwing the clots on the FLOOR.

Don’t they know the floor is lava?

Or that the clots represent blood loss and we have to measure that blood?

Not to mention that blood clot is now a slip and fall hazard? In a room full of hazards, you want to add to them?

The scrub tech said something to them and they kept doing it.

Where was I during this?

On the phone to the blood bank/On the phone calling in reinforcements/On the phone with the nursing supervisor arranging for a higher quality of care bed/Fetching and carrying for the field/Fetching and carrying for anesthesia? Who knows.

I’m a fair shake at this guestimating blood loss thing. But I can’t guestimate blood loss from clots that have been ground into the floor and walked across the floor.

Blood clots from a clueless surgeon is the latest example of why the floor is not the trash can.

Hey, I wrote that book!

I wrote a little OR book (these are kid books that aren’t really kid books, more like grown-up parodies).

My book was called ‘The 2,465 Things that I Pick Up Off the Floor: an OR Counting Book.”

At the brass tacks level, things on the floor, cords included, are a slip, trip and fall hazard.

At the next level up, and I’ll say it loud enough that everyone can hear, SOMEONE HAS TO PICK THAT UP!!!

I personally think the practice of throwing things on the floor delays your turn over, doc. In fact, I am thinking of turning my PhD dissertation project into why it takes so long to turn over a room for another patient, and how to decrease that time.

So let’s agree to not throw things on the floor?

Mmmkay?

This past week, a scrub tech I work with approached me to ask me about going back to school. Nursing school.

A scrub tech can be a degree all on its own.

Often a 2-year associate’s degree. With certification exam immediately upon graduation.

There are also reports of hospitals building their own scrubs, with no degree and no certification.

A registered nurse is registered with the state. Most often there is a degree involved. There are still some diploma nurse programs in existence.

A diploma nurse, an associate degree nurse, and a bachelor of science of nursing nurse all take the same national certification test. The National Council Licensure Exam, or NCLEX, is a national test to ascertain the student nurse is ready to be a nurse in a hospital, in a doctor’s office, in a free-standing surgery center to name a few options. There are more, including working for insurance companies, or medical companies, or drug companies. There are probably still more.

While the scrub technologist can be a certified scrub technologist (CST) through the company CST, this is through the National Board of Scrub Technologist and Surgical Assisting (NBSTSA), they don’t have to be to gain employment. An RN must have taken and passed the NCLEX and be registered in the state they practice.

Can a scrub tech return to school to obtain a nursing degree?

Absolutely.

RNs get paid more. With more responsibilities, true. But they get paid more and have more options for life after the operating room.

I am unclear if some of the classes for scrub tech will transfer to a nursing program.

But all the nursing schools I know of in the state of North Carolina, require all nursing students to first obtain their certified nurse assistant, or CNA. I imagine this is so the school doesn’t have to spend the first semester teaching students about the minimum care for a patient. I had my CNA before I went to nursing school, and it gave me a step up above my classmates who did not.

Depending on the program, BSN vs ADN, there are also minimum standards for GPA. Most BSN schools require a minimum of 3.0 GPA, and ADN require a 2.0.

An ADN requires 2 years. A BSN is a 4-year degree. An ADN can absolutely go back to school after graduating and working as an RN to complete their BSN. Or higher (cough, cough, me). In the last few years accelerated BSN programs have started, often for those who have degrees in something else. I think, though I don’t know, the cost is higher to go through an accelerated program.

A BSN will open different doors for an RN.

Will I help this scrub tech who approached me for information about going back to school? Heck, yeah.

And I tutor.

And know a few things about obtaining scholarships.

If you are interested in certain programs, absolutely reach out to them to get more information. My information might be outdated.

But the first thing I am going to tell them is that they need the CNA certification.

New month, new theme!

When we were in Wyoming earlier this summer, my father-in-law gave us some sourdough starter to bring back home. Mindful of security, and the 3 oz fluid volume restriction, I asked him to split the sample into 2. That way both my husband and I could carry one on. It worked, the starter made it home and was put into a glass container with a loose top. I feed it weekly.

If you don’t know about feeding a sourdough (I know not everyone had time during the lockdowns of 2020, if you could even find flour), feeding it consists of taking some out, discarding it, and adding the same volume back in with fresh water and flour. This has always seemed wasteful to me.

Wasteful, you get it?

Apropos because the theme for the month is Sourdough Wastes.

There are recipes for using the waste material created when feeding the sourdough.

But, knowing the department as I do, I decided on sourdough chocolate chip cookies for the first make of the month.

The flavor is subtle, more of an aftertaste.

I am mildly concerned that not a lot of people will pick up on it.

As I read the recipe, the sourdough waste is added with the liquids; this is the butter, sugar, vanilla, and eggs. Nothing has to be taken away, this is just a flavoring addition.

I was remiss in mentioning the 13th counting basic during the Counting Basics series beginning in February. The 13th Counting Basic is you and all the other surgical teams are human.

Humans make mistakes.

Humans miscount

Humans forget to count.

Or, at least, forget to document the count. And we all know that is the same thing.

There has been a story in the news from New Zealand. A surgical retractor known as an Alexis got left behind after a c-section.

FOR EIGHTEEN MONTHS!

The Alexis is a self-retainer that is hard to describe. There is an inside-the-body retractor ring, an outside-the-body retractor ring and the plastic sheeting that connects the two. This plastic sheeting allows the Alexis to be used on any size person, it just expands along the plastic sheeting depending on the surgical wound depth. There are many sizes of Alexis, XXS-XL. This size range refers to the size of the ring. To pass a baby through requires the large, at least.

There are pictures online.

It is considered not countable.

This means it is considered something that is obvious if left inside.

I know a mum in New Zealand who would disagree. She had many doctor visits where she complained of pain in her abdomen after the c-section and she was always discounted. Because nothing showed on the X-rays.

This brings up the specter of women’s pain being ignored, but that’s another post.

It was discovered after a CT scan in the emergency department. The Alexis is not radio opaque. That means it isn’t seen fully on X-rays.

This is considered a never event.

It should not have happened, but it did. The surgical services lens should be to protect the patient.

According to the National Institutes of Health, of the 28,000,000 surgeries each year in the US, there are roughly 1500 retained surgical items.

I’ll do the math for you.

That is 0.0054% of the surgeries have a retained surgical item. Miniscule to some, but what if you or a loved one are of the 1500?

Even from the never events. Especially from the never events.

Because somehow, they keep on happening.

In the OR I work in, we use the Alexis retractor a fair amount, all sizes. Including during c-sections.

It is not countable.

But should it be countable?

Yes. This is ANOTHER covid post. It’s been months since the last one.

Yes. There is ANOTHER covid wave. It has not been months since covid disappeared.

Because it hasn’t.

It has been months and months since the United States decided en masse that they were done with masks.

And social distancing.

And, for all I know, washing their hands.

It has definitely been months since there has been a consistent centralized source of covid information, including number of deaths, number of hospitalization, and number of vaccinations. Yeah, since Johns Hopkins stopped collecting data for their one-stop coronavirus resource center. They stopped collecting data on March 10, 2023.

Now that there is a covid wave hopefully cresting, the information that is needed to discuss it fully is scattered. And hard to find.

People are thinking that this wave isn’t that bad, what are you talking about, Kate?

Well, we don’t know specifically how bad this wave is. All we have is anecdotal evidence.

There has been a marked increase in media discussing covid cases, alluding to the new wave.

Testing has been struggling to increase. This is a two-part fail. The first is because there is a vanishingly small number of people who report their at-home test results as they’ve been asked by the CDC. That is if the at-home tests that you have squirreled away haven’t expired. If they have there is a part on the CDC website to check to see if the test is one of the few that had their expiration dates extended. The FDA states that expired at-home covid tests might give inaccurate results when tested. Such as showing negative when it should be positive, and vice versa.

If they have expired, good luck finding some.

That is another way to know that covid cases are rising; the sudden decrease in available tests. It took me three drugstores to find a test when I was sick a few weeks ago. Even then I had to ask where they were and I got the last one.

It was negative, I had a summer cold. But my husband has been sicker for longer and has a cough that won’t quit. He won’t test, relying on my negative test. Man flu or covid? Hard to gauge. I’m completely back to 100%, he is coughing and sneezy still. You decide.

But, Kate, why didn’t you make him test?

I am not his mother. As the nurse in the house, all I can do is advise. Just like I advise diet and exercise and a good medication regimen.

The last harbinger of a covid wave is hospitalizations.

The hospitals around me had a few weeks of zero covid hospitalizations.

Now all I do is watch the number spike.

Some places are bringing back mandatory masking. I wear a mask at the university out of courtesy to those who are immunocompromised and STILL in danger. I have begun wearing one to stores, in addition to shopping when they are just open or in the last hour they are open.

Mandatory statewide masking is not going to happen in North Carolina. not with the political mix we have here. Hell, many vocal people in the communities still deny the existence of covid, or the advantage of the vaccines.

How about you?

The gown card reads “Opportunity is a dirty word.”

The thing about opportunity is that it is nonsense.

Oh, it looks good. The dictionary definition is that it is a set of circumstances that makes it possible to do something.

The set of circumstances and the definition of something is deliberately undefined.

But people love to talk about opportunity as if the playing field is the same for everyone. That every one of us can go out there and invent the next big thing. Or write the Great American Novel. Or go to bed with a full stomach.

It is not.

Which is why it is a dirty word.

In my fourth class as a PhD student, there was a lot of class discussion on what a paradigm is. And how to shift the paradigm in nursing. Also discussed were the meta paradigms of nursing.

Patterns.

A paradigm is a pattern.

There are 4 meta paradigms in nursing, that filter down into the patterns. Person, Nursing, Environment, and Health. Nursing looks at the meta paradigms and breaks them down into the paradigms or patterns. We use these patterns to guide how we care for patients.

When I walked into that class, the last thing I had read about paradigm was a Dilbert comic making fun of management speak. I was definitely confused for a moment.

Another buzzword that gets thrown around too often is spearhead.

I’m rather a literal minded person. To me, a spear head is a sharpened stone, used to hunt.

In management buzzspeak, it refers to the person being the boss of a project. Or being the point person, but might be TOO literal. You get it, right? Sharp stone, point?

The buzzwords are used to obfuscate (confuse) the true meaning. They can be useful speaking shorthand, but can also be used as a blunt instrument against the subordinates.

Hands up.

Nothing in your hands.

Put your phone in your pocket.

Or your bra.

Your hands should be empty as they are to the sky.

Don’t have anything in your hands.

Don’t.

Watch for the gunman.

Don’t try to be a hero.

Don’t approach the gunman.

Don’t.

Follow directions if you meet a responding officer.

Don’t ask questions; you will get your questions asked in a timely manner.

Don’t distract the officer.

Don’t.

*

I was on my way home after working as a research assistant on Monday. This was after a 10-hour shift in the research assistant workroom.

It was a standard day, some filing, some working on assignment from the PhD nurse I am assigned to. Some light Excel work.

I was released a little early.

You see, the head of the department knew I had worked half the night the night before. I wanted a nap before my shift started at 2100.

I was 60 minutes into my 90-minute drive home when I heard about the shooting at UNC-Chapel Hill. Details on NPR were kind of scarce and then on to the next story.

I read all about it before my nap after I arrived home.

Shooting at a lab. One person dead, shooter in custody.

In the immediate aftermath, the campus had been locked down.

Wednesday morning, the front page of the UNC’s student newspaper, the Daily Tar Heel was entirely text messages that had been sent during the lockdown.

Simple.

Stark.

From friends and family members reaching out to their loved ones on campus.

From students reaching out to each other, desperate for a connection.

To make sure loved ones were safe.

But are we safe?

If you haven’t seen it, Google the Daily Tar Heel.

Read the fear in the tweets.

And assure yourself that gun control is just someone else’s issue.

This week concludes the no heat month, where I don’t turn on my oven because have you heard July was the hottest month on record? EVER?

No bakes, ice cream, and edible cookie dough.

I don’t think I turned on my oven at all this month.

According to Google, a dessert called slice from Great Britain can either be a single mixture such as the cookie I made, or a combination of a base, such as shortbread, and a topping layer.

In my head, it means a dessert that can be cut and portioned.

A small voice pipes up, “Like cake.”

Shh, small voice in my head, no one asked you.

I can see how the recipe I chose might have started out with a base layer and a topper but that was decidedly not the cookie I got.

For this recipe, 500 grams digestive cookies, crushed, 395g or 14 oz sweetened condensed milk, 250 g butter or 1 c, softened butter, 1 tsp of vanilla, and an entire package of marshmallows cut small. If using mini marshmallows, you can omit cutting them.

*

Oh! Oh dear.

*

I skipped an entire ingredient. I was supposed to add 4 tbs of cocoa powder. No wonder mine looked different than the reference picture. Besides the fact that I didn’t have pink marshmallows.

Oh, well.

This is a happy accident that made me think of another no-bake recipe, based on this one, for s’mores slice, on the fly. You see, if I substitute graham crackers for the digestive cookies, and continue not to add the cocoa powder, and add chocolate chips instead…

S’mores slice!

That is how to be an experimental baker; turn issues into opportunities.

This has a lot to do with the OR as well. You have to be able to keep your mind flexible and offer alternatives to problems.

For example: A surgeon has dropped the instrument for the second time and that was the remaining sterile one, because he, you recall, dropped the other one. You sent the original down for processing but it won’t be ready for another 45 minutes.

There is no reason to wait, twiddling your thumbs and staring at each other, while the patient remains under anesthesia.

There is no reason to flash the instrument because you remember that a very similar instrument is in another pan that is not in use. The very similar instrument is half an inch longer than the original two but should be used interchangeably.

The OR could have had an IUSS except for you.

Or the patient could have been under anesthesia at a considerable premium except for you.

A nimble mind can help in situations such as these.