The gown card reads “Squeaky wheel gets the flip.”

Sometimes there is a gap in the schedule.

And all the surgeons eye the gap and ask for one of their cases to be flipped into the gap.

Even if the case has ZERO chance of fitting into the space. And if the flipped case runs over, the scheduled case is delayed. This can set up a domino effect, leading to irate surgeon who got delayed by no fault of their own, more than irate and hungry patients, and a happy surgeon that got to slide into a space their case doesn’t really fit into.

It is kind of like Prince Charming accepting the Ugly Stepsisters who slice off part of their own feet to fit into the glass slipper. It never really works well and they’re gonna get found out by the visible blood on the glass slipper.

Even after explaining all of this to some surgeons they persist in asking if they can use the space as a flip room.

Over and over.

They send minions: the circulating nurse calls to the desk and asks, the scrub tech stops by on their way to lunch and asks, the anesthesiologist stops by and “casually” mentions that gee, Dr. Impatient really could use the empty space well.

You’ve already said no and the requests keep coming.

Drip, drip, drip.

It is the unpleasant task of the charge nurse to not give in to the badgering.

Because if they do give in, and the flipped case goes over, and the next surgeon is irate and wonders why there was suddenly a case in their room that wasn’t there an hour ago, and Dr. Impatient’s original room is already setting up for their next case, not a care in the world when Dr. Irate’s case could have gone in there and started on time. But no one ever thinks that far ahead.

And all Dr. Impatient has to say for themself is a giggle and an “Oh, well, I guess I was wrong.”

Yeah, no shit you were wrong. But the blowback is on the charge nurse who let the squeaky wheel get the flip unless they’ve already left for the day, early don’t you know.

The real blowback is on Dr. Irate’s patient and subsequent patients who have to wait for a room to be ready.

Because the squeaky wheel gets the flip.

Sometimes no is the best answer we can give.

It is officially the last month of the Spring semester. And the April PhD report.

I did not fail my mid-semester project. As always, my writing saved me. Don’t get me wrong, I could have done better. But I did not fail.

And for a program that feels like it is reprogramming me every day, I count that as a win. I joke to my cohort that I think that Lee Majored should be a verb for what we are all going through. You know, the 6 million dollar man. Every class, every assignment we are being rebuilt. They have the technology. I know that this is growing pains and everyone must go through it but it can suck in the moment, you know.

As I wrote last week, the end of the semester is so close I can taste it, and freak out about the amount of work. All at the same time.

In my Informatics of Healthcare course, the end is swiftly approaching. There is a quiz that is due tomorrow. And a PowerPoint presentation due next Sunday on a topic that I chose back in January. I am creating an 8-page PowerPoint and/or an 8-minute presentation on the Art of Caring in a Technically Laden Environment. I mean, have they ever seen an OR; high tech is what we do. But, after the pandemic, and even before, all the hospital units are technically laden. Especially since the EHR era began with the HITECH Act. My presentation is about how nursing caring can still be done in such a high-tech environment. And then I have to respond to someone else’s presentation. And a final discussion round at the end of the month and I will be done with that class. I have found it very enjoyable and recommend it to others in my cohort when they are looking for an elective.

In the Statistical Interpretation class, there are two homework assignments and a final to go until the end. One of the homework assignments is due Tuesday at midnight. I understand what we are doing. I still have no math brain. I will be spending time revising (a British term that I adore, means studying) the contents of the entire semester in preparation for the final. Which is due on 4/30/23.

In Nursing Theory I have a presentation and a paper from the presentation, or vice versa, due on 4/28/23. I have to do a deep dive into a selected nursing theory that goes along with my phenomenon of interest for my dissertation. I have been reading books, and articles on the theory.

But my personal White Whale lately is my brain block on looking at my grades.

Yes, still.

I think I will set a deadline of Tuesday to look at the past Theory papers. And apparently use some of the feedback in the presentation and paper.

Lots to do.

And only ONE more in-person class for Theory and Statistics on 4/21. The others on 4/14 and 4/28 will be virtual.

I still show up at the university every Monday to be a research assistant and I am learning so much there too. Experience is a good teacher.

Don’t mind me I am just being re-built every class. They have the technology.

The April theme for Cookie Thursday is a Thing is Spring has Sprung!

April is wonderful in North Carolina after you get past the pollening. It isn’t as cold, it is not yet humid and gross. The trees are budding out, the weeds have just started, and are not yet overwhelming. The birds are chirping.

Peeps have a checkered appreciation. People either love them or hate them.

I love them. I get gifted a LOT of Peeps.

Did you know you can microwave Peeps for 10 seconds and it turns amazingly caramelly? True story. Try it.

And everyone knows what goes into a s’more: graham cracker, chocolate, toasted marshmallow.

I’ve made s’more cookies before, adding marshmallows to a standard chocolate chip cookie. And when I was deciding the theme for April I decided to see if Peeps could be used instead of miniature marshmallows.

I took four strips of Peeps, 2 yellow, one pink, and one purple. I opened them and left them to dry out a bit. As I had never cut Peeps and I thought it would be best if they were a little stiffer.

In case you are wondering, the best way to cut up a Peep is by using a pizza cutter. Works great. I cut the Peeps into roughly the size of a miniature marshmallow and threw them into a standard chocolate chip cookie recipe.

The Peeps might melt a bit, but that just gives them more of a caramel taste.

Just like surgery isn’t every nurse’s passion, Peeps have their fans. It takes all types.

The case is winding down and you and the scrub tech start the closing count.

dun, dun, dun!!!

A sponge is missing.

This can be for a variety of reasons. It’s on the floor, it’s held in place against the patient by someone’s abdomen, it’s under the mayo stand, it’s in the mess of the back table because someone, looking at you surgeon, has been impatient and rummaging through the carefully set up table.

Or it’s in the abdomen/cavity/joint where someone, again looking at you surgeon, tucked it to control bleeding, or to get it out of the way, or used it to sop up fluids of some kind and forgot about it.

There are steps to follow

1. check the floor
2. check the kick bucket
3. count again
4. if you find it, count again

But you are still missing a sponge. Tell the surgeon to stop closing and announce that a sponge is missing.

9 times out of 10 a surgeon will say immediately when told the count is incorrect, “Well, it’s not in the wound.”

Often without looking.

Stare at them and if they continue to close, ask nicely for them to examine the wound for the missing sponge. If they continue to close, ask not so nicely.

Get anesthesia involved if you have to.

The scrub tech can also be useful here by declining to hand them requested items.

In a huff, the surgeon will search the cavity/incision/abdomen and find the sponge, tucked away safe.

Sheepishly they will announce, “Found it!” And they will continue on closing.

Feel free to raise an eyebrow in disbelief.

And return to counting. Beginning with sponges.

Counting is a process, after all.

Next week I’ll write about if the sponge is truly missing, what then?

This musing may seem a bit… unhinged.

What the hell is up to my husband’s uncanny calling of surgical cases, especially call cases?

Yesterday, when I was preparing for my Sunday afternoon nap that I take in case I get called into the OR in the middle of the night and still have to show up for my research assistant gig at the university on Mondays, he mentioned that he felt like there was a big belly case in the wind. Or an ectopic. Or both.

And there was a big belly case at 2100. Just when I started my call shift.

Of course, there was.

I got home and in bed at 0115. Never mind that I have to get up at 0545 in order to pack my lunch and his lunch, shower, and get myself on the road to the university by 0630.

And, of course, my brain went off at 0300. For no other reason than to remind me that I had to get up in two hours.

There is much to unpack here. I’m not sure if he is jealous that am no longer “working hard”, AKA all the hours that are, and wants to be an asshole about it. Or if he knows I love work and am a workaholic (recovering) and he just wants me to have something I enjoy. For example, a case.

But there is definitely something woo-woo about his ability to divine the cases out there and pull one of them down for me to do on call.

He does frequently mention that I am beloved by the surgeons because I get shit done. And he does acknowledge that sometimes they wait for me to be on call so they don’t have to wait forever on an emergent case while someone else does the pre-op checklist. This does happen. Or the glee with which a surgeon approaches me and is visibly pleased that I am, in fact, on call that night.

Once would be a coincidence, two would be odd, but this happens every damned month. Ectopics, lap appies, big bellies, bleeders of all sorts, the surgeon he doesn’t care for because I don’t care for them, called them all at one time or another.

In fact as we were just about to make incision on last night’s big belly, after the pause, and while I was doing the plugging of things, and as I was pouring the irrigation fluid I mentioned it to the team. And the surgeon and the tech turned to me and asked “Again!?!” Because they had heard me complain about this in the past. And the surgeon remarked, matter of factly, “Tell your husband to shut up”

Oh, Dr. Blank, I have. And I will.

The gown card reads “Don’t you hate following someone else’s setup. I do things deliberately.”

Nothing will throw me out of the flow of the case faster than taking over a room immediately before the beginning of a case. Nothing!

It is like when a record skips a beat. What happens to the beats that are skipped?

In the OR these beats are probably steps that are necessary for a smooth case. Things like grounding pads, or even turning on the machines. If I am dropped in a case, even one I know very well, ahem lap appy, I am probably going to forgo a needed step.

Nothing like a surgeon needing to use the bovie and nothing happens but a rude noise when the button is pressed.

And the stopping the entire case to pick that step back up? And put that grounding pad on, or attaching the grounding pad to the machine?

Excruciating.

Call it what you will: being caught with the pants down, being caught flat-footed, dropping a stitch, missing a dance step. It feels terrible.

Once upon a time, during a crash cesarean section, back when I used to circulate those, I could see that the grounding pad was plugged in, and all the lights were green. But same thing, rude noise, no electricity for the doctor. For the life of me, I could not figure out why the bovie was not working. There was a pad plugged into the machine, the bovie pencil was plugged into the machine,

However, a silver lining is that once a step has been discovered to have been dropped I would bet money that I won’t forget again. However, there are many, many steps in combination to starting a case. Drop one and all the balls come crashing down.

Yes, I am mixing metaphors.

As an illustration of what missing a well-trod step in the beginning of a case feels like.

Horrible, isn’t it?

I try to keep the ball dropping to a minimum. Being aware that this can happen is the first step to controlling the chaos.

This is not an April Fool’s post.

This is a post about how the student in your life might be going through the Semester Doldrums, interspersed with the Semester Terrors.

You see, this is the time of the semester where the end of the semester (where the break is) is too far away and too close all at the same time.

It is an icky, tricky time of the semester.

Your student may be concerned with grades. This is where the terror comes in. The all-consuming will I pass question may be top of mind. All students have that question in their heads, even the ones who are carrying a 95 in the class and there are only 2 assignments and a final left to the end of semester. And they could turn in none of that and STILL pass the class.

Before the end of the semester craziness with tests, and papers, and presentations, oh, my, give your student unconditional support.

They may be acting crazy as they try to fit the rest of the semester into a month and a half. They may be acting depressed. They may be doing none of this at all.

Just know that they are stressed. And let them know that you are there for them.

And remind them, gently, this is for the future. Growing pains have to happen now so that the future might be better.

Hoisted on my own petard! I accidentally deleted the other post.

This week’s make is the pretzel bites. And it is saved under the super-labor intensive tab. Because of the complexity, I have only made it twice in the past. Perfect for the Blast from the Past March theme.

Because, while the recipe itself is not hard, some of the steps are obnoxious.

The boil each piece in baking soda water, but only for 15 seconds mind in particular.

The dough must be made.

The dough must be rested.

The dough must be portioned out and rested again.

The pieces that will be the bites has to be carefully boiled for 15 seconds apiece.

The pieces must be baked.

Obnoxious.

And not unlike the beginning of an OR case. Lots of details to keep track of, constant interruption when things are needed.

I chose to serve these pretzel bites with a choice of cinnamon sugar or cheese sauce. Once the pieces were boiled I sprinkled half of them with salt, and I left the other half naked. It is these naked ones that I shook in a bag with melted butter and cinnamon sugar to coat them with awesomeness. If I had to eat the pretzel bites I am team cinnamon sugar, the whole way.

The cheese sauce was begun with butter and flour to make a roux. I kept an eye on it as I grated the cheese. When the roux was a beautiful brown shade I added half of the cheese, instead of the cream. And realized my mistake immediately. I hurriedly added the cream and stirred until it started to thicken, hoping that this would work. It did! I added the rest of the cheddar, and the pepper and stirred until the sauce was smooth.

Phew, rectified that misstep.

I took the bakes to the hospital. Immediately when I went into the lounge I was set upon by the hordes.

And as I was wondering out loud if I should have made a second batch, a nurse tossed over her shoulder as she walked away with a pretzel bite, “Kate, you should always make 2 batches.”

She didn’t hear my response, “And who is going to buy me the groceries?”

A day that wasn’t super long in the baking, but I had an almost mistake.

Never mind, it turned out alright in the end.

Say it with me folks, Cookie Thursday is a Thing is all about the experimentation!

We’ve covered the what of counting. And touched on the why, which is not leaving an item behind when it is not intended.

Let us discuss the when.

The initial count should be completed before the surgical blade makes the first incision. Or before the knife is passed over to the surgeon. Ideally, it should be before the patient is in the room.

Now that is not realistic at times. But try.

The count should be amended any time a new sponge, or blade, or instrument, or stapler load, or needle is added to the count.

Yes, every time. As soon as the addition is made, make the change on the count board. Don’t think to yourself, oh I will add that in a minute, let’s see what the email says.

Nope.

Don’t do it.

You will forget.

Oh, look! The surgeon has called for closing suture. Now is a great time to do the closing count. Depending on where you work, this may be different. At my hospital it is policy that the surgeons not interrupt the count for anything. And really, a count should be less than two minutes. They can close away, just make sure to give them scissors.

There are two types of closing counts. There is the one where a cavity has been entered, think uterus, or bladder. There should be a complete count at the closing of the cavity. And again for closing the abdomen. Don’t let the surgeon bully you into splitting attention away from the count to attend to them. Unless there is a catastrophic problem, such as the patient coding. And in my twenty-two years as a nurse that has happened ONCE!

The last count should be the skin count. The closing count for the instruments and everything has been done and is correct. And the surgeon is asking for the skin suture, or the staples. Time to count again.

We are count happy in the operating room.

But only soft goods and sharps are needing to be counted for this count.

And then the circulator and the scrub tech will be quite busy with the dressing, and the bed to move the patient on to, with calling for help during the day, and calling for the PACU nurse at night to help move. Isn’t it good to know that all the counts are done already?

Next week the counting basics subject will be what to do if the count is wrong.

To me off shift does not mean end of shift.

It means that I work a shift off of day shift.

In my 22 years as a nurse, I have worked 0630-1500, 5 days a week.

I have worked 0630-1700, 4 days a week.

I have worked 0630-1900, 3 days a week.

I have worked 0900-2130, 3 days a week.

I have worked 1030-2300, 3 days a week.

I have worked 1430-2300, 5 days a week.

I have worked 2300-0700. Both on-call as a nurse, and as a CNA in a nursing home.

I have been on call for any combination imaginable in 24 hours. And there are lots.

When I was in school at Creighton, I worked evenings, 1400-2300, in a clothing store.

When I was in school at Napa Valley College, I worked as a CNA in the hospital, I worked 1430-2300.

When I was getting my BSN at Creighton, I worked 1430-2300 as the evening charge nurse. Plus call 75% of the night/weekend call.

When I was getting my MSN at Queens, I worked 1430-2300 as the evening charge nurse. Plus call 99% of the night/weekend call.

Now I work exclusively 2100-0700 as a call nurse.

This is what I mean by off-shifter.

Can I claim strictly nights? Eh, not really.

The vast majority of my working life, both in and out of school has been evenings.

It is difficult to explain to my cohort that I work nights.

And when I want to engage with them via text or email they are asleep because they all exclusively work a day shift, either teaching, or mother/baby, or anesthesia, or ED.

I have a code not to text after 2200. Or email after 2200. I figure that out when my advisor emailed me back at 0500 because she had just gotten up and was leaving for the gym.

Unless it’s an emergency. And in my world, all work is an emergency.

But I am awake, often until 0100. Just in case I get called in.

Here I am; the odd duck out again.

Not that I mind. Odd ducks are awesome.