Fair warning, I will be mixing my Shakespeare analogies. The title is a quote from Hamlet’s soliloquy. The following is from Romeo and Juliet and Romeo and Mercutio having a conversation.

Romeo: I dreamt a dream tonight.

Mercutio: As did I.

Romeo: What did you dream?

Mercutio: That dreamers often lie.

Romeo: In bed asleep while they do dream things true.

This is a play on words and a true statement all at the same time.

To lie in bed is to be prone. And dreams are sometimes true and sometimes false.

Okay, lit session over.

I did dream last night, lying in bed. I’ve had really vivid dreams about work before but I am rarely in the operating room, mostly I search for my med surg patients to give them their 0900 meds and it is 1430. But last night I dreamt of consents.

I was in an operating room, room 2 I think, and the patient was being induced for anesthesia. (that means put under the anesthesia). The anesthesia team and I were discussing the case as they put in the LMA and I was holding the chart in my hands, open to the consent.

When I spy what looks like a consent across the room, on the charting desk.

It was! A completely different consent, with different fingers than the surgeon marked and the room had planned for. With different instrument needs and a different implant system. The patient and the surgeon had both signed it.

Why was it not in the chart?

Why wasn’t it the most current consent? Or was it? Which had the latest signatures? Because there is a date and a time on each consent for each signer for a reason.

What was going on?

What is the appropriate response?

Anesthesia suggested that we ignore the older consent, the one that was what was on the schedule, the digits the surgeon had marked, and belied the conversation that I had had with the patient about their expectations of what was going to happen and the surgery plans all because the new consent that appeared out of nowhere was the newer consent.

No. Not even close.

The appropriate answer is to wake the patient up.

Yeah, I know that it is radical but they know best.

It is true that sometimes patients will just sign any paper put in front of them, even after reviewing the plan with the surgeon and the pre-op nurse.

It is also true that sometimes, immediately before a surgery, the surgeon will rewrite a consent and have discussion with the patient about the new consent. And sometimes they don’t have the conversation with the patient.

No. It is better for the patient not to do the incorrect surgery. It is better for the liability of all involved if everyone is on the same page (pun non intended) regarding the plan and the consent.

Have I had a surgeon off-handedly tell me that they had had a last-minute conversation with the patient and the plan changed?

Yes.

Is it the correct and appropriate thing to do to ignore what is not listed on the consent, thinking that the standard boiler-plate consent will cover you?

Not if you cherish your nursing license.

Yeah, it has nothing to do with the operating room.

Yet, it is heavy on my mind.

The Writer’s Guild of America called a strike on May 2, 2023.

Now that there has been a huge switch to streaming for entertainment, the writers are getting left out of the money they would have made traditionally. They are getting left behind and making pennies.

Not that the vast bulk of them made much money.

When the SAG-AFTRA contract with studios expired last week, they joined the WGA on the picket line.

For many of the same reasons.

Did you know that studios are willing to pay for a day’s worth of work, providing you sign over your likeness to them in perpetuity and use your image, in whatever form they see fit, forever?

Doesn’t sit right. Now does it?

It doesn’t really impact me because I gave up television years ago. But it impacts someone I know.

After all, the last writer’s strike in 2007-2008 poured gasoline on the dumpster fire that is reality television. Well, they say reality, I say poorly written and acted crap. One of the reasons I gave up television years ago, actually.

These writers and actors have something in common with the healthcare industry.

No, it doesn’t pay the majority of them a living wage.

No.

They do it because they love it.

That is the same reason I am not in management. I have had offers, believe me. A headhunter even wanted me to work as a locums tenens (temporary) OR manager around the country. No thank you, OR all the way.

Because I love it.

Also why I am working really hard on my PhD as a way to extend my workable life.

Because the OR is dangerous.

And any OR person, tech, RN, CRNA, surgeon is just a breath away from disaster.

Just ask my cheek with its permanent indention from a fall that employee health says is 1) just swelling and 2) they can’t see the difference.

The post-it reads “Jack of all trades, master of none full quote.”

Yes, I am aware that Shakespeare wrote it.

Which is quoted extensively by people apologizing for their existence. I’ve said it myself, calling myself the jack of all trades in the operating room.

However, it is not completely quoted.

Or even correctly attributed.

Not written by Shakespeare. Maybe? As this was 400 years ago it is a little murky.

The complete quote was the jack of all trades, master of none, but oftentimes better than the master of one.

In other words, it is better to have a wide experience pool from which to gather information and skills.

This is very true in healthcare. And doubly true in the operating room.

Some nurses work their entire lives in one small subsection of the field. In one specific surgery. Oh, they know it backwards and forwards, have done all the complications from surgery X.

I can imagine their distress and confusion when surgery X turns into surgery Q.

But the well-rounded nurse has experience when things go awry and the surgery has to be changed on the fly.

Because it is not how many times or how well one has done the surgery X in the past. One different patients, with different instruments.

It is about how well you can dodge roadblocks with the patient on the OR table in front of you.

It is to that person’s benefit to have a team that has the imagination to deal with the roadblocks.

When X suddenly becomes Q.

I no longer refer to myself as the Jack of all trades when it comes to surgery. Now I refer to myself as the utility tool.

As always, the Supreme Court has weighed in against all progress from anyone who is not 1) white, 2) male, 3) Christian.

The two recent decisions by the court that are head-scratchingly dumb definitely fit this mold.

High schoolers have been told for YEARS that they need to have a college degree to become “someone”. And millions flocked to colleges and universities and took on debt they didn’t fully understand to do so. After all, their parents were able to do that and live a semi-comfortable life. The corporations, because by this time there were corporations out for all the money they could get, hiked interest rates and made them compoundable. I have read reports of people who have been paying diligently for years, and they owe more than they took out at the beginning. What is this except for a cat-and-mouse game that enriches corporations?

Joe Biden promised to end some student debt. Unsurprisingly, the corporations objected, as did the politicians in their pockets. The meritless case made its way to the Supreme Court and debt forgiveness was struck down.

And people are mad at Joe Biden? For not being able to deliver on a campaign promise? Don’t blame him, blame those who stopped the program.

Definitely don’t allow this disappointment to be the reason that you don’t vote. After all, women have been doing this for years. Have a disappointment, stiffen up the upper lip, and go on. But what are we women to the Supreme Court but second-class citizens who are not worth the control over our own bodies? Especially if we are white and Christian. How else would the decreasing birth rate be changed? But only if we are white and Christian, women from other countries need not apply.

The second spurious decision was to strike down affirmative action. This was an admittedly problematic solution to a problem that they made.

Affirmative action, as written, was written to improve the employment and education for members of a minority group. To try to counterbalance years and years and years of selective admission to universities. The ones who had been getting into universities? White people. Specifically white men.

Affirmative action was a path to balance. A clumsy path, to be sure, but a path.

Immediately it was unpopular with the people who perceived they were being “robbed”. If the last 8 years have taught us nothing else, the persecution angle is HOT, HOT, HOT. Even if there is no persecution of white, Christian males. If you tell them and convince them there is, you can do anything.

There has been a nearly 60-year crusade to end affirmative action. Finally, after tilting at windmills for so long, they finally found the right lever. Affirmative action is no more for universities. Don’t worry, this will trickle down to all the other things affirmative action has touched in the last 60 years: employment, other schools that are not universities, and the like.

But, the Asian Americans who brought the suit that toppled affirmative action, what is going to be blamed next when you STILL don’t get into the universities? Perhaps the idea of affirmative action, although problematic, was not the real problem all along.

Now what?

The Christmas in July theme continues with fruit cake cookies.

I’m not even mad at the recipe.

No brandy though. I thought it was the brandy that made the fruit cake.

Back in the end of February, I stopped at the store for a few things on the way to the hospital. The candied cherries were on super mark-down. The Valentine’s candy was as well.

I cleared up. I called my mom to see if she needed any candied cherries for the December baking. As for the chocolate, the chocolate locker is always in need of a refresh. I bought them out of the candied cherries and so I had some on hand for this month’s theme. I did not buy them out of the chocolate. I figured six bags of Lindt Lindor balls for $2.50 each was enough. These will be featured on a Cookie Thursday is a Thing in the future.

In my head and in my recollection the one time I made fruitcake there was bathing of the cake in brandy. Hmm, no brandy in the recipe.

The recipe included 1 c Brazilian nuts (I substituted what I had on hand, which was pecans), 1 c candied cherries (chopped), 1 c raisins (chopped), and 1 c dried pineapple (chopped). Instead of butter, the recipe uses Crisco. Okay, have that in the baking pantry, good thing it lives forever. 1 egg, 3/4 c sugar, 1 1/4 c flour, 1 tsp baking soda, and almond flavoring.

No brandy.

But I thought that was not nearly enough liquids for the sheer amount of volume. But I will complete the recipe, and then mess with it next time. Maybe the recipe knows more than me.

It does!

Baked up nicely.

Maybe actual December has a new cookie in town.

Now what to do with the chocolate…

The turnover refers to the amount of time from taking that patient to PACU, giving report, seeing the next patient, and returning to the room to continue opening. Basically the wheels out to wheels in.

This is for the circulator.

While the circulator is doing that the scrub tech and the orderlies are to take the trash out and clean the room.

It is not time to disappear while the others do the work.

I am thinking this needs to be my dissertation topic.

How to get the most efficient turnover time possible.

On evenings our turnover times were 10 minutes.

And we got asked a lot how that was possible.

1. Don’t disappear. A quick trip to the bathroom is one thing, having a full meal is another
2. Know that there isn’t anyone available to help, it’s all on you, baby. There are no orderlies at evening/night
3. Toward the end of the case, start preparing the room to be turned over. Pull the trash bags, pull and put solidifier in the irrigation fluid and pull the canisters, pull the irrigation bag down when the field is done with it, dispose of it, make sure there is nothing on the floor, push the towers back after unhooking all the equipment
4. end of list

Basically, prepare the room to be cleaned by you.

I’m not sure which is more important.

The knowledge that it is all the circulator/scrub tech combo to clean the room because there is literally no one else.

Or

Preparing the room for turnover.

Definitely preparing the room for turnover.

A little preventative tidying goes a long way.

Yelling at the surgeons who deliberately drop suture ends also is useful.

At night our turnover times are about the same as they were on the evening shift.

Oh, I almost forgot the second most important thing.

Have a discussion with the team in the room: surgeon, scrub tech, yourself, and the CRNA and lay out how this is going.

After all, the team wants to be done with the case as much as you do. If not more.

Preparation is not only half the battle, to borrow and mangle the GI Joe quote, it is the only thing that is going to get the good turnover times.

This is more light-hearted Monday Musing than I’ve written about lately.

Well, I say light-hearted.

I’ve been working as a Teaching Assistant for the last 8 weeks and one thing I ALWAYS tell the students is that it is okay to take a break.

This is something that real-life me needs as well.

You, too, probably.

I would bet money on it.

Yesterday was a gloriously lazy day.

I decided that, since it was my birthday, no chores, or self-inflicted honey-dos would be done.

I did no dishes.

I did no laundry.

I did nothing at all, except read and play my computer game.

And it was great.

But at the end of the day, a little boring.

Now back to regularly scheduled laundry, and dishes, and chores.

You know what?

They didn’t miss me.

Like at all.

They were still there waiting when I got up this morning.

They are very loyal that way.

Life will wait for you to take a break.

Take five, will ya?

Where I live in North Carolina, summer has set in with a vengeance.

The beginning of the fall semester is a bit off, summer classes are winding down.

What is a student to do?

This student is preparing the poster for the North Carolina Nurse Association convention. It is due at the end of July.

Also due at the end of July are the virtual convention hours from AORN.

Other students may have their eyes on vacation on these hot days.

Hours at the beach, if that is your thing.

Hours hiking in the mountains, if that is your thing.

Hours huddled in the air conditioning, if that is your thing.

Hours reading books that you don’t have time for during the school year.

You do you.

The point is that there are very few weeks until the end of summer and the beginning of the fall semester.

You might as well enjoy it.

It will be time soon enough to buckle down for the 16 weeks of the fall semester.

Time to recharge and get the brain cooled off so that you start the fall semester with a cool brain, enough sleep, and ready to tackle the classes.

One of my favorite mantras is useful here “the only way out is through.”

I took a poll, on two different pages about what the theme for July should be.

The options were 1) Christmas in July and 2) Fake-out cookies (these are homemade versions of commercially available cookies).

Of the people who voted, 90% of them voted for Christmas in July. Only three people wanted the fake-outs.

I still want to do fake-outs, that will be at a later month.

What is the hands-down favorite that I make at Christmas?

What was requested in the response to the poll?

Chex mix.

Okay.

Easy enough.

I don’t even need a recipe.

Which is good because I worked all night last night. And the cat kept me up most of the morning with her need for attention.

Not a lot of sleep was had.

It’s a good thing this is a fix it, stir it a few times during baking recipe. Which enabled me to zone on the couch until it was time to stir the chex mix every 20 minutes.

How popular is my recipe?

Several people asked for baggies. You know, in case they missed out.

That is a sign of a good Cookie Thursday is a Thing make.

Chex Mix

1 box each of whatever kind of Chex you want- I use a family-sized box of Corn Chex and a family-sized box of Rice Chex. You can also add a small box of Wheat Chex.

Any add-ins that are desired. Pretzels, mixed nuts, new this time I added Specialty rye crisps. You know the ones.

The sauce (AKA the good stuff)

For this amount of cereal I used 3 sticks butter, melted, 2 tbs seasoning salt, 2 tbs garlic powder, 2 tbs onion powder, and 1/2 c Worcestershire sauce. Melted and mixed together on the stove and pour over cereal and add-ins.

Bake at 250 degree Fahrenheit oven, stirring every 20 minutes, for 1 and half to 2 hours.

Let cool before eating, this will allow the nuts and cereals to firm up and become crisp again.

This is Christmas in July.

As long as there has been modern nursing there has been charting.

Yes, starting back with Florence Nightingale.

How else would you measure improvement?

And did I tell you that Florence Nightingale was the first nurse statistician?

Yeah. She measured and remeasured the soldiers to ensure that her interventions were making the impact that she wanted. What is that but pure research?

Where there was nursing, there was charting. The noting down of a patient’s symptoms/wound size/progress toward goals kind of charting.

When I was at the California hospital, we had a hybrid system. This was 1999 after all. There was computer writing of nurse notes that would be saved to the mainframe at the hospital and physicians could read them. If the computer charting system was down, the nurse wrote notes on paper. Physical therapy and physicians wrote notes on paper.

Not all of the notes were legible, though. Most of the notes required another nurse who could read the handwriting.

Many medical mistakes were made due to poor handwriting.

Fast forward to the electronic health record.

A mere 10 years in the future.

Now there is the electronic health record that is purportedly easier to chart with.

I’ve never charted in the EHR as a floor nurse and I am not the most up-to-date on the EHR for narrative nurse notes.

Medical mistakes went down when there was a clearer way to convey progress.

EHR has some naysayers.

I quite like it.

After all, I had a hand in creating the hospital system’s EHR. I was a subject matter expert who had input into what must be included or not needed.

It has definitely cut down on complaints over my own handwriting.

I can only think it helps with patient safety.

If only from the doctor’s illegible handwriting.