All last week I waited with bated breath watching for the FDA to finally approve the covid vaccine for children ages 6 months to 5 years. I have friends who have been waiting for this for as long as their babies have been born.

The approval finally came down on Thursday.

And the CDC followed up on Saturday and voted unanimously to grant emergency status.

Yes, it is true that kids don’t get as sick as adults. But it is still potentially lethal to children, as at least 450 kids under 6 have died.

I know people who have been in virtual lockdown as there is a member of the household who cannot get the vaccine and cannot send their child to pre-school or school in case they bring the virus home to their family member.

Is vaccinating their child a choice every parent will make? No.

Should they consider the options and not listen to histrionics who claim that the vaccine magnetizes your child or you, or has a tracking chip in it? Yes.

People like these who have politicized the vaccine roll out because it suits them and go on to poison others with their warped thinking are the reason covid is still a thing. And still evolving. And people are still dying.

There are new variants I’ve been watching in the UK-BA.4 and BA.5. This variant seems to be able to somewhat dodge the antibodies from vaccination and infection. But if we keep going like we are down this path of variants there will be a variant that can completely ignore the antibody status, regardless of how it is obtained.

And then we will be right back where we started. A virus with no vaccine that can teach your body to attack the virus.

And the hamster wheel would begin again.

Don’t make us go back in time.

Get your vaccine.

Vaccinate your children.

This is the only palatable way of ending this.

And if I have to plan my trip to the UK again for the 5th time, we will have words. And they will not be nice ones.

The post-it reads, ‘if you act like prey, you will be treated like prey’.

We have all seen or heard of the attacking surgeon, have we not?

The one who paces.

The one who complains when their case is late.

The one who complains when their case is early, why didn’t we tell them.

The one who complains about the team in their room.

The one who complains about the team from two weeks ago.

The one who complains that the scissors are dull.

The one who complains that the light source is not bright enough.

The one who complains about the room being too hot.

The one who complains about the room being too cold.

Okay. I was only kidding with that last one. The room can NEVER be cold enough for some surgeons.

Complaints aren’t attacks, although they can feel like them sometimes. And some surgeons live to complain. This makes their room unpleasant to be in. But they are not frightening.

But some of the OR staff may find them intimidating or frightening. And some staff may refuse to go in their room because of this.

This is the wrong approach.

If staff acts like prey-timid, questioning, afraid to speak up. This signals to the surgeon that the staff are not confident in their skills. Which makes them doubt the staff. Which makes them do all of the complaining above.

If a surgeon is acting like a jerk. Tell them. Tell them exactly what you find objectionable about their behavior.

In my experience, they will back off, if not apologize.

And if they don’t back off, report to management.

Do not act timid in front of them.

If any of the staff would like to borrow some backbone call me and we’ll talk through it.

At the end, everyone in the room just wants what is best for the patient. And if their behavior is causing the patient not to be safe because the staff in the room is too intimidated to speak up, tell them to knock it off. Or find someone who will.

The post-it reads ‘using scripts with patients’.

This is something that healthcare has been doing for years. And not just at my hospital.

Scripting is when you use words that you did not write, even if you mean them.

Healthcare providers as a whole are not eloquent. We use jargon too much. We forget to dumb it down for non healthcare people. Not that non healthcare people, aka patients, are dumb, but they don’t know the lingo. And they sometimes feel they are drowning in the alphabet soup that healthcare uses as a shorthand to get a lot of information across to someone who knows and can interpret the lingo. So ixnay on the lingo in front of patients and families.

Sometimes the patients think they know the lingo. This can lead to misinterpretation of the facts when they try to be hip and cool like the healthcare personnel. And cause a headache for the healthcare provider trying to be clear and concise when they are speaking to a non healthcare type person.

The worst kinds of scripts are the ones that are tailored to the patient surveys they receive after care. These scripts use the exact words of the survey questions in order to trigger a memory when it comes time to fill out the surveys. These are not bad on their own merits but feels like cheating. In fact the hospital has told us not to use exact wording from the survey questions. It seems that patients are figuring out that is what’s going on and leading to a mild backlash. They know they are being programmed, in a way, to respond to a certain question in the manner the provider would like. And if there is anything that has been made absolutely clear in the last couple of years, patients do not like to be told what to do. Even if it will save their lives or someone else’s.

Scripting is in fact a programming language that is used to interpret and execute one command at a time. Kind of like healthcare worker trying to get through to their patient the importance of this one little thing. Like the dangers of smoking. Of taking their medication as prescribed. Or avoiding covid.

When I tell you that the patient is an LOL, NAD, CAD, DNR, that may mean nothing. Or it may mean that the patient is an elderly woman, in no apparent distress, with cardiac arterial disease who is a do not resuscitate. Or, where it is dangerous and misinterpreted, when the family decides that all of that means we do not care about the patient, that she should just die. And instead it means that we will treat the patient, take care of her ills, until the time that her heart stops. Because there is a lot of things that can be done until then to make her comfortable.

I’m not sure how I got on to the alphabet soup from scripting conversations that healthcare providers have with patients that mimic the survey questions they will fill out after their care but here we are.

If you get a survey, fill it out. Be honest.

Healthcare entities use these surveys to fine tune care. But don’t let a bad day or a bad experience that is outside of the care provided, such as you got cut off by a driver leaving the hospital, color the survey.

The call case is nearly complete. The surgeon has dropped, which means he has finished and probably left the room to put post-op orders in and speak to the wife.

The two most dangerous times in any case, from an anesthesia standpoint, is going to sleep and waking up.

There can be shifts in blood pressure at both occasions. The heart rate can be affected. The respiratory effort has to be engaged as the patient has to breathe on their own after surgery. All of the gas that has been maintaining the general anesthesia is turned off and the patient breaths off the gas, either by the machine, or on their own.

Different CRNAs will turn off the gas and begin the waking up procedure at different times. It all depends on what they are comfortable with. Many times the waking up process starts too soon and the patient starts to emerge from anesthesia at the wrong time. This is usually before the surgeon is finished closing and the surgeon will tell the CRNA that the patient is bucking. Or coughing against the tube. And the CRNA will need to add more medication (likely a paralytic) to the line or reestablish gas to get the patient deep enough to finish closing. This is fraught with peril if the case in question is a hernia, because the entire repair can be ruined with ill-timed coughing and must be redone.

Sometimes the case is quicker than anticipated by the CRNA and medication reversal must be given. There are several medications that can do this. And they all have an associated cost. The other option is to wait for the medication and gas to wear off naturally. This is frowned upon because it can take many minutes and there is always another case to get started. Also, OR time is charged by the 15 minute increment and it costs the patient money to have a slow emergence from anesthesia. It also exposes the patient to the risks of emergence.

The scrub tech puts the dermabond, or skin glue on the skin over the port sites. This is the dressing that the patient will go home with.

During this time, I keep an eye and an ear on the CRNA and the patient as I am doing my end of case work. I catch up on the charting of the times, except for out of room time. I bring in the gurney and untuck the arm, if that is the arm that is closest to the corridor door. I put the gurney next to the bed, adjusting the height as needed, put the slide board on it with a chux pad. I lock the gurney. After I have done this, I stand by the side of the gurney and am ready to assist the CRNA as needed. I have my OR phone in my pocket in case I need to call the anesthesiologist stat. I watch the patient and the CRNA closely, watching the color change of the face, and the monitor numbers. The scrub tech is breaking down her table and stacking instruments.

The CRNA is making final adjustments, checking pupillary position, checking patient’s response. Some will wait until the patient grimaces or opens their eyes to command. The patient will no remember any of this but this is a way to determine readiness for extubation.

Finally the CRNA is satisfied and, suctioning the mouth, deflates the balloon on the endotracheal tube and pulls it out. The entire reason I did not pursue CRNA work is that there is a year in ICU that is mandatory. I have no desire to work in the ICU and I hate respiratory secretions. That is a hard no for me and my nursing kryptonite.

Assessing for responsiveness the CRNA will put a nasal cannula on the patient. And a mask over it. Intubation and emergence are aerosol producing events and if covid has taught us nothing it is to control coughing. Extubation does not always lead to coughing but it most likely does.

If the PACU nurse or anesthesiologist is about I will ask them to grab feet and assisting with transfer back to the gurney. If the patient is over a specific BMI I will insist on this. Otherwise a pillow is placed under the patient’s calves. Or, better yet, a pad from the armboard is, slick side down. It slides better.

The CRNA controls the head and counts us in. The scrub tech log rolls the patient to their side. I always am the puller and I place the chux and slide board under the patient. We allow the patient to roll back to their back and glance at each other. I do a quick check of the locks on the gurney, by tugging on it, and I say to the group “Locked.” The CRNA counts us 1-2-3 and I pull the chux pad on the slider, the scrub tech pushes from the opposite side, and the CRNA brings along the head and shoulders. Presto, the patient is on the center of the gurney and the legs slid over on the upside down armboard pad. When I am the puller the slide board is visible on the other side of the patient, ready to be grabbed my the scrub tech. Sometimes we have to roll the patient a little to get the board out, depending on their size and the skill of the puller. I take the upside armboard pad out from beneath their calves and replace it on the armboard.

Why am I always the puller? I have a body mechanics routine for this. I do not use my back. Never. I have seen many nurses and techs get injured being the puller. I use my glutes and my hamstrings. When I was a CNA in a nursing home I assisted a 400+ patient out of bed every morning by honing this technique. I’ve tried to teach it to others but they prefer to rely on their back muscles, despite repeated warnings not to. Sigh, you can lead a horse to water…

Now that the patient is safely on the gurney, the CRNA assesses their breathing again. I pull up the side rail on the side I am on and grab the chart and the specimen bag, tucking it on the end of the bed. Using the OR phone I call PACU and tell them we are incoming.

The CRNA nods and connects the nasal cannula and to the bottle of O2 that is on the gurney. I unlock the bed and pull it away the OR table. Pulling up the other siderails, we get ready to move out.

The Inflation Baking theme is continuing on for a second month.

But this recipe has 3 tablespoons of butter in it. That’s cool, I think, a normal batch of cookies has 16 tablespoons of butter in it.

Again I pulled out the mini muffin pans and filled each well 3/4 full.

I topped each one with one of three things.

Blueberries.

Raspberry.

Or mini mini chocolate peanut butter cup. These things are maybe a centimeter big. I bought them to use as a chocolate chip substitution.

One muffin pan always sticks. I think I will clean it up and find another use for it. Or donate it.

Covid is surging again. The hospital went from 1-2 patients to 8. All in a couple of weeks.

I’m just over here wearing my mask if I go ANYWHERE.

But, hey, at least there hasn’t been any mass casualty events because someone got mad and decided to take it out on the healthcare system trying desperately to help.

Knock wood.

Our London trip is in 8 weeks.

Sigh.

In the last installment of this series, the medication on the field was discussed. It doesn’t matter what kind of medication it is, it must be labeled.

Now that the appendix has been visualized, stapled, and bagged like a prize steer, the MD’s thoughts turn to closing.

At least mine do. Because there is still a lot of things that have to happen, from my point of view, prior to closure.

And also from the surgeon’s. He has to monitor the staple line for a moment, watching for bleeding. If there had been pus in the pelvis and he called for a suction irrigator that will be used at this time.

But I have already opened the irrigator and hung the warmed bag of saline. I also plugged it into the machine and also spiked the saline. After the suction is turned on, the field is good to go and I can turn my attention back to the chart.

It is at this time that I confirm with the surgeon that Mr. A is going home. If he was staying he would need an inpatient bed at the end of the case. He is going home after PACU and Phase II type tasks. Phase II is the after PACU care. The patient will no longer need the intense recovery room care that keeps their pain under control and their vitals where they need to be. Phase II is the step before discharge. The patient relaxes, drinks a little something, and we make sure their pain is controlled before they are discharged.

I do a visual check through the windows to see if I can see a PACU nurse. With the call gig, the PACU nurse will come by the room when he gets in to check on us.

And, if I’ve timed it right, this is about the time that the PACU nurse should be arriving.

Irrigation is done. The surgeon makes one last visual survey of the abdomen, again inspecting the staple line for bleeding. Finding none and no identifiable issues within the abdominal cavity he starts pulling out trocars, beginning with the one that the scope is through.

The appendix is still not out, the bag’s string is through one of the trocars. The surgeon will “deliver” the bag and appendix through the trocar site. Because of an incident that happened when a bag full of blood and an appendix that tried to make a run for it, the surgeon must palpate the bag, to ensure that there is tissue inside of it. He announces to the room that the appendix is in the bag. Some of this is done in jest, but some in complete seriousness. No one wants to go back in, after closure, to retrieve a specimen. That is known as a sentinel event for the Joint Commission and much hullabaloo surrounds a sentinel event. The less their eye is on us the better.

After the appendix and bag are palpated with announcement, the surgeon pulls out the rest of the trocars and calls for camera off, gas off. For me this is the indication that I should turn on the overheads and the spotlights, turn off the gas, turn off the camera light, and unplug everything from the tower. All within 20 seconds.

There is a rhythm to how I do this. While he is calling for closing stitch, I turn on the overheads, hit the spots as I turn to walk to the tower, turn off the CO2, turn off the camera light, and unplug all the equipment, taking care to cap the camera so that it does not get wet and ruined. Next I walk back to the workstation and hit the closing button. This changes the case color on the caseboards that are in the waiting room and PACU. This indicates that we are closing.

I ask what the name of the specimen is, take control of the specimen after showing the tech the label on the specimen container. After she passes it off to me, she moves smoothly into counting sponges and sharp things. This is our closing count. There will be one more, the skin count in less than 3 minutes, mostly while the surgeon is injecting local medication.

I still have more to do after the specimen is handed off. I do a quick mental check: cords disengaged, machines turned off, tower moved back, ring stand stripped of the basin and the basin drape, ring stand moved back.

Now that the lights are on, I do a visual survey of the ground and pick up anything that has been dropped. The secret to a quick turnover is making sure the room is as picked up and clean as possible. This means that the irrigator is disconnected and the bag of saline left to drip in the sink in the substerile room. I add thickener to whatever fluids are in the suction cannister and take it out as well. Depending on the surgeon, I will disconnect the bovie and turn it off. I have been burned by this before and I make it the last thing I do.

This is the time we do the final count. And the RF wanding of the patient, prior to last stitch. I announce the results of the count and the wanding to the room and go through the post-procedure time out with the surgeon. This time the room agrees that the surgery was X, the specimen is Y, the patient is expected to be discharged, the wand was good, there were no issues during surgery that need to be addressed. A smaller version of the pre-procedure time out.

Today, June 8th, is national timeout day here in the US. And a big deal should be made of it.

When the last stitch is placed and the skin glue applied, I click the wound closed time on the chart and call the PACU for moving help.

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.

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.

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.

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.