The post-it reads “I’d say we’re too smart for this shift, but maybe that is why we’re on this shift.”

Nothing against day shift but evening shift has to be smarter. We have to move faster. We have to be able to make quick decisions, not be told what to do.

It is an entirely different mindset.

Day shift does the bulk of the cases. They have the bulk of the staff.

Evening shift does a fair amount of cases, less than day shift, with two people. Evening shift is also responsible for setting up rooms.

After we’ve cleaned up day shift’s detritus.

I’ll spare you the looking up what that means.

It means debris.

In fact, that is a much better word choice.

Evening shift cleans up day shift’s debris.

Many rooms are left in dishabille (messy) at the conclusion of the case or the day. At least the conclusion of the day shifter’s case.

My pet peeve is relieving someone and THEN spending 15 minutes picking up trash off the floor, and putting away supplies, all the while tending to the surgical team who are continuing to work on the patient.

I get that everyone has their own level of chaos they are comfortable working. My level of chaos that I am comfortable working in is shallow. After all, evening shift doesn’t have orderlies to clean the room prior to the terminal clean by EVS. There may be another case after this one finishes and the more orderly I keep the room, the faster it can be cleaned and the next case opened. Guess what? Evening shift doesn’t have people to do that either.

I think it all boils down to day shift and evening shift’s differing end games.

Day shift’s end game is to either finish the cases and do little toward the evening shift chores, regardless of how many cases remain on the board. Or ask to go home.

Evening shift’s endgame is to finish the day, so they can start on the evening shift chores and go home. Or hand off a case to the call shift.

There are different ends to the shifts. And I think that is where the struggle lies.

But, pretty, pretty, pretty please, with sugar on top prepare your room for the end of shift. No matter if there is a case ongoing, or the day has wrapped up in that room.

The best advice I can give is that your mother doesn’t work here, act like it. Pick up your crap!

Of course, my mother does work in the same department that I do. And I would never leave a mess for the next person. Because the next person for me is day shift.

Just be kind to your teammates coming after you.

Nothing strikes more fear into a student’s heart except for the three little words of the group project.

See, shudders.

I’d rather not, thank you.

There is always one of three archetypes

1. the overachiever who is in fear for their grade and does the entire project themselves
2. the slacker that might or might not come to the group meetings
3. the bubbly one who presents the group presentation

You can be all of these at the same time.

I know I can.

I just finished a midsemester project for statistics.

And by just finished I mean I turned it in at 1209, it was due at 1330.

And then we will have the PowerPoint presentations on the group project.

I will begin the way I always begin, by informing the group that I am not a natural speaker and to give me grace.

Back to the group make-up.

There is always the three; sometimes there can be more, but at least the 3.

For the group project in statistics, we were able to pair off to work on the project. There are 11 people in the group and before the first class had ended people were already pairing off.

I can do math. I know how this works.

Someone has to be the odd person out. I just assumed it was me.

Nope.

There are 2 groups and 7 singletons.

This is where I say that I wish I had had a partner to share the load.

To keep me on track.

To keep me from procrastinating, or showing my lack of knowledge to the professor. Because you bet I have already done that. And had to rework all the statistics overnight for the paper and the presentation.

Because all of this is self-inflicted.

I guess there re some good points about group projects.

I could have shared the misery.

And probably had a good night’s sleep last night, instead of the 3 hours I did get.

Pity party of one, in 7 separate locations because we all thought that all the pairs had been taken.

Or didn’t want to impose.

I will know better next time.

After the presentation-

well

I misunderstood that assignment

Clearly I would have benefited from a partner.

It was embarrassing to get up and present some half-done shit.

All the others were polished and pretty and got the math right.

Yeah.

That happened.

And now I wait to hear what the professor thinks.

The last day to drop the class is next Friday.

Stay tuned.

It might get bumpy from here.

Isn’t hubris fun? Asked no one ever.

Tuesday was Mardi Gras. The kick-off to Lent. Which is the road to Easter. Which can be a big thing to Americans. Certainly, it is the gateway to Spring Break. A traditional week-long vacation in the middle of the school year.

Tuesday was also Shrove Tuesday, a less well-known, at least to Americans, holiday where prior to starting the Lenten period. For some, it is the confession day before the Lenten period. For others, it is the opportunity to use up eggs and butter, and sugar before they went bad. And for others, it is the excuse and the opportunity to eat, drink, and be merry.

It is also International Pancake day. Because pancakes are the easiest way to use up these ingredients.

I am not going to be at the hospital working like a line cook, flipping pancakes. I have a project due tomorrow.

Instead, I pulled out a sheet pan pancake recipe that I made a couple of years ago. Made and baked the batter in a sheet pan and used a pizza slicer to cut them up into bite-sized pieces. Pancake bites is must less of a mouthful than sheet pan pancakes. There is something about the double use of the word pan in the middle of the phrase.

One good thing about these pancake bites is that they are quick and easy to make. And they are not sweet as the recipe uses no added sugar. You could top these with anything prior to baking.

I had mini chocolate chips. And I used those.

I was glad to see that the slight sweetness of the chocolate chips offset the rather plain-tasting pancake.

Because pancakes are traditionally served with syrup, but the logistics of that were not good.

There are only 4 ingredients in the recipe.

Oven 425 degrees Fahrenheit. Line the sheet pan with parchment paper and set aside.

2 cups pancake mix

1 c milk

3 eggs

Mix well and pour into the prepared pan and tilt to level. Top with whatever is desired: bananas, strawberries, chocolate chips. Bake until browned. Cool in pan. The pancake bites can be lifted out with the parchment paper or left as is. I found it easiest to cut with a pizza cutter.

Pancake bites, doing double and triple duty for Mardi Gras, Shrove Tuesday, and Internation Pancake Day.

Kind of like nurses being utility players, able to do all the things.

Now to the nitty gritty of counting: the instruments.

There are a few rules for when to count instruments.

The first is the beginning count.

This is the pre-incision count.

This is where it is established what instruments and soft goods have been opened for the case. Any discrepancy in this count will have reverberations in the rest of the counts.

Basically, don’t screw it up.

After the case has been opened and prepared by the scrub tech, ideally before the patient enters the room, the count can begin.

This is an auditory count where the scrub tech counts aloud, and a visual count where the instrument/soft good must be visualized by both the circulator and the scrub tech.

All the instruments on the table before the start of the case are counted during the initial count.

ALL the instruments.

Remember, any misstep here will echo through the entire case.

Everyone has heard about the misadventure of the retained surgical item. This is usually a sponge or a needle.

But the most egregious stories are the instruments left inside. You probably have heard the story of the retractor left inside a patient that was 3 inches wide and 12 inches long. Yeah, that one.

The count is one of the things that keeps the patient the safest.

What goes in, must come out.

Unless it is meant to remain there.

A simple surgery of a lipoma removal has an instrument set that is called a minor set. This is called different things in different ORs. But it is a basic instrument set, with a little bit of everything in it. The minor set in my hospital has knife handles, forceps, retractors, hemostats (basic clamp), kellies (a bigger basic clamp), allis (a tissue-holding clamp), babcocks (a tissue-holding clamp for thicker tissue), tonsils (a long clamp), needle drivers (to hold and manipulate the suture needles), different kinds of scissors (to cut tissue or suture), sponge sticks (to hold a folded up raytec), and towel clamps (to hold things together or on the drapes), and ednas (blunt towel clamps).

This totals 60 instruments that must be counted.

Now imagine a case with 4 instrument sets of 14-70 pieces (or more).

And the importance of the instrument count comes clear. Any of those instruments, if not properly counted, can end up in a human body and be left behind.

This is why the count is so important.

It is a matter of patient safety.

I know I have written recently about patients’ unrealistic expectations of pain after surgery. We cannot make the pain go away. At the very least there will be incision pain.

I will not revisit that.

Today let’s talk about the unrealistic expectations of a surgeon. In the middle of the night. When no one but anesthesia is at the hospital. I get called, not paged, called. Okay.

I can deal.

There is an urgent case.

This was 0415. I told the surgeon we could get the case started by 0500.

45 minutes.

That is a gift when the circulator and the scrub are at their house in their pajamas.

The surgeon pushed back on me. Asking why, since a body part was in danger, we couldn’t start in 30 minutes.

Deep breath.

That is because we, who are not at the hospital, have 30 minutes to get to the hospital. We still have to schedule the case, pick the case, prepare the room (which is the hardest setup to do in an empty room with no secondary video tower monitor, no positioning aids, no irrigation pump.

Did I tell the surgeon I would have put the patient’s information in with my fifth hand after I’d been running for things from the other room? Yep. To get the patient’s information into the video box they have to be in the room in the computer and I had just done that. Unrealistic expectations around the computer will be another post.

This was after I told the surgeon that the patient was too far down the bed. This impacts stirrups use. They assured me it was fine.

Spoiler alert, it was not fine. They spent the first 20 minutes of the case lamenting that it was hard to do things. Because the patient was too far down on the bed.

Next I asked if there was anything specific that they wanted for laparoscopic cautery. They said hot scissors. Cool, I already had that in the room. I had gotten a ligasure machine because I knew this was going to be the next request that they turned down.

Spoiler alert, they wanted a ligasure. Gritting my teeth, I asked my tech if that had been asked for previously. The tech said no, no mention of ligasure.

Ligasure is NOT hot scissors. That they didn’t even use.

They wanted laparoscopic irrigation next. Fine. I had already gotten it from another room. I put the suction machine together, turned on the suction, and said aloud, “Suction is on but no irrigation yet.” I said it twice as I was leaving the room to get the warmed irrigation fluids that are not gotten before time of use.

And they proceeded to test the irrigation. Twice.

I reminded them that there was no irrigation yet. They reacted defensively when the irrigation button was pushed that it was an accident. Once, I’ll give them, but twice?

I hung up the irrigation bag. And announced that there was fluid.

They asked me to call to the floor and get their assisting surgeon. I did. That surgeon arrives within 10 minutes and stands there, hands washed, waiting for a towel, asking if we had their gown and gloves.

Um, no. I’ve been too busy adding irrigation and getting the supplies that were not requested and also were not in the room as this WAS NOT THE CALL ROOM.

You know, the one that is completely set up for a laparoscopic case and the equipment and the supplies are in the room? Yeah, that one.

On and on the requests came. I was heartily sick of the case by now.

Day shift started to arrive. But no relief for the call team.

I could have taken 10 extra minutes to get the room prepared prior to getting the patient. But the surgeon made it seem like a super emergent case and the patient would die.

Patient was on the table at 0502, just over my 45-minute estimate.

Aargh!

Don’t worry, I anticipate being yelled at for this.

Joy.

The post-it reads “Barbara Billingsley in Airplane!”

That’s it.

It’s a good thing I remember what I meant by that.

There is a scene in Airplane! that is two men who are in absolute distress, and a stewardess asking what is wrong.

Yes, stewardess. It is a 1980 movie.

But she can’t understand the lingo that the two men are speaking.

Barbara Billingsley comes up from behind her (for reference she played Mrs. June Cleaver on Leave it to Beaver). She identifies the lingo the two men are speaking as jive, and she speaks it. She then asks the men what is wrong. They tell her and she interprets for the stewardess, who rushes off to get medicine. Which Barbara interprets for them.

The men dismiss her, telling her that they understood the stewardess but not enough was being done. ; she does not take kindly to being dismissed by them when all she was doing was trying to help. She dismisses them in turn, telling them if they don’t want help, they won’t get help. This is done by spoofing June Cleaver’s squeaky clean image.

I see this so much in healthcare. Yes, things are frequently terrible. But there is only so much the nurses can do without an order, and more is asked of us, all the time. It is the creation of this gordian knot of need and being unable to offer everything that nurses are faced with every day.

Sometimes I would like to tell patients, when they are being unreasonable, that help is coming, but patience is required. We don’t have the option of telling patients and doctors that if they don’t want the help that is on offer, they aren’t going to get any help.

Patients, always take the helping hand when it is offered. It may not be what is wanted, but it may be the only way we can help. Because we may be constrained in waiting for a call back from a doctor.

We are working to solve the issue as fast as we can.

Grades happen.

They are the output of the assignment that was turned in.

I’ve never really been into checking my grades.

When I was in high school and in the first three rounds at a college, I was confident that I would pass. And I never checked them. I would get the paper or exam back, look at the grade marked at the top, most likely an A. I would stuff it in my bag and go to my next period class. And my report care reflected the A and I would continue this.

Fast forward to my ADN program. I would keep on doing this, not investigating the grades or the comments on my papers and exams. While I am not the best in the class, I skated along with an A minus average. And then, in what I think is what started my hesitancy around grades, the head of my program pulled me in to a conference.

The class had been taking computer-based NCLEX preparatory tests. Computer-based because the NCLEX had started doing online testing sometime in the late 1990s. And this was in early 2001. I had gotten the best grade in the class, by far.

And the program head, who everyone was afraid of, wanted to know how I, not the best student in the program, had gotten the best grade in the class. Underneath the conversation was the subtle accusation of cheating, how had I done it?

Still makes me mad 22 years later. I was 24 at the time, just a baby, and this woman who was in a position of power was subtly accusing me of cheating to get the best grade in the exercise. Had cheating been happening and they were investigating? I don’t know. All I knew was that I was working Thursday through Monday evening shift telemetry tech/CNA, class Mondays and Thursdays, and clinical Tuesdays and Wednesdays. Rinse, repeat for the entire two and a half years I was there. And doing my best.

Side note, I’ve been a workaholic for a long time. Ask me about high school when I worked evenings at a department store, three nights a week, and all day Saturdays.

In that moment, I told her that I had always been a strong test taker. And she dropped it.

I graduated a few months later, took the NCLEX for realsies in July, passed in 75 questions, and kept going. I did not return to the school setting for 14 years. When I decided that if I got hurt I had nothing to back me up as an ADN nurse. This led me to get my BSN.

And then the MSN.

And now the PhD program.

But something had changed back in 2001. I developed a distaste for looking at my grades. Okay. I wasn’t in an educational setting anymore. Until 2015, 2017, and 2022.

Where I still find it very difficult to check my grades. These are all online now. And I know there are comments to them that I would find useful. The idea of looking at my grades, and the FEEDBACK, makes me uncomfortable.

But I have to. There is a strict grade policy in the program because that leads to being dropped from the program for anything less than a B-, and that ends at 82 percent. I have two grades that are sitting in two of my classes that I should look at. No matter how uncomfortable it makes me. I may need a gold star for this. Maybe a nap.

Nurses doing what is uncomfortable since 1850.

Today I made a recipe I’ve done many, many, many times before. Without problem. With a small change in detail. Who knew it would cause such an impact.

The recipe in question is the fudgy cocoa no-bake cookies. You know, the peanut butter chocolate ones. Again, I’ve made it many times, not just for Cookie Thursday is a Thing but also for potlucks and even home consumption.

I don’t even need a recipe but I always double check for Cookie Thursday.

1/2 c butter

2 c sugar

1/2 c milk

1/3 c cocoa powder

2/3-3/4 c crunchy peanut butter

2 tsp vanilla

3 c quick oats

In a large pan, melt butter, add sugar, add vanilla and stir, add milk and stir, add cocoa powder and stir. Bring to a boil, boil for 1 minute. Remove from heat and add peanut butter and stir until melted. Add quick oats and stir.

Really the entire recipe is adding and stirring, with some time components thrown in. Although to be fair the order of ingredients is important,

This week I read an article about toasting oatmeal before use, it was supposed to bring complexity to the oats. 10-15 minutes at 300 degrees Fahrenheit. I can do that. Y’all know I like to experiment on my coworkers. I let them cool for an hour while I worked on my paper. And then proceeded with the recipe, with all the same things that I have done so many times.

No.

No, this was a fail!

Well, not a fail but not what I was expecting.

The mix was very crumbly and did not form up well.

AT ALL.

I was able to get 30 crumbly cookies out of it.

If you have ever had these cookies, crumbly is the goal, but only after you’ve bitten into them. I have no idea what happened.

The only thing different was that I toasted the oats for a few minutes. Maybe that made them dry as the desert and they sucked up all the ingredients and became dry, dry, dry.

Very odd. That’s what I get for having an Eggceptional month and trying something that I never had before.

The rest of the mixture would be a fantastic topping for something. I think I will bring a tub of greek yogurt and put out the cookies, the yogurt and the rest of the mix that would not form cookies.

Everyone knows that the crumbles are the best part of the recipe.

But odd, very odd.

We in the OR count 2 kinds of things. There are the instruments. And then there are the soft goods. By soft we mean anything that is not an instrument.

In this series, I have covered sponges, the real soft of “soft goods” and needles, a not-so-soft part. Today I will be discussing other things that are included in the soft goods that are not sharp.

I considered adding this next one to the sponge count post but it doesn’t count, not really.

There are things that are soft that are not sponges.

These encompass things that have different uses.

There is the KD, aka the Kittner, aka the peanut. It is essentially a wad of sponge that is used clamped into a tonsil clamp, aka the Schnidt clamp. Well, was is a misnomer. If you take it apart, it is an itty bitty half-inch strip of sponge material that is rolled up very tight. It is used for blunt dissection or teasing away the layers of fascia. The reason they are called peanuts is because they are the size of peanuts.

There is the pattie sponge aka the cottonoid. These are strips of material that is not a sponge that is used to blot blood and other fluid away from a surgical site, not always an incision. They come in a variety of lengths, 1/4 inch to 6 inches, and a variety of widths 1/4 inch to 2 inches. And they come on cards in a predetermined number. 2, 5, or 10. This is dependent on the size and what is ordered for the department

Sometimes, especially in cardiac surgery, it is necessary to sew in a bolster along a suture line aka the retention bolster. These are little tubes that the suture is sometimes fed through and then secured. They are designed to distribute the tension along a suture line. Think of it like belt AND suspenders. These are can be little- 3/16th of an inch in diameter and up to 2 inches in length. But they are on the table and must be counted.

Sometimes in surgery, you need a strip of soft rubber. This is also known as the Penrose and can be used to hold important things, like veins or the inguinal cord during an inguinal hernia. This can and has been left behind inside a body cavity and therefore must be counted.

There are soft silicone rubber strips that are used to hold vessels such as arteries and veins, much like the way the above gently distracts and holds away the inguinal cord. These are called vessel loops and are 18 inches long. They come in a package of 2 and mostly come in 2 widths, maxi or mini. Again, they go on the back table and must be counted. If they are cut because they are too long. Surprise, each piece is countable. In a package of 2, and one is cut, this becomes a count of 3.

All or some or none of these can be on the back table. Both the scrub and circulator have to be aware of what is on the table. Yes, all of it. In many ORs, there is a large whiteboard that is visible from the field that is used for counting. Yes, yes, people will say that the whiteboard is too far from their seats and they’d rather keep the count on a clipboard.

Yeah, no. Don’t do that. The entire room needs to be able to see the count in real-time.

When is a routine a habit?

According the Oxford dictionary, a habit is a settled or regular tendency or practice, especially one that is hard to give up.

When is a habit a routine?

According to the Oxford dictionary, a routine is a sequence of actions regularly followed.

And what happens if something causes a deviation from whatever term you choose?

It is my routine when I am called in for a case to follow a series of set steps. Get dressed. Get in the car and drive to the hospital. Get changed into scrubs. Schedule the case. Pick the case. Get the patient. Prep the patient. Call PACU nurse in. Do the case. Stay with PACU nurse as the second nurse.

Or not. If there is another case, this opens up another set of subroutines.

Okay. I guess that is my answer. How I function when called in is a routine.

But the question remains what happens if something causes a deviation from pattern?

Entering the conversation: pattern.

The answer is sometimes I lose my place, especially if it is a call from the supervisor, not the surgeon.

Threw my entire routine off.

Add in a nurse I was doing buddy call with. Also a disruption in routine, but a normal one.

Maybe the best example is the call case is like a juggler, keeping all the balls in the air.

There are a lot of details to keep in the air.

Don’t drop one.