When we last left the OR, the surgeon was searching for visualization on the appendix.

Hark, he has found it!

I open the stapler and the load as requested. After, I take a visual and auditory survey of the room. Anesthesia seems content, there are no alarms, they have enough IV fluid.

There has been no call for the irrigator. This means that the warm normal saline that is used to irrigate the abdomen through the laparoscopic trocar sites can stay in the warmer. I never pull the warm saline before it is asked for. Some nurses hang it on the IV pole prior to surgery; but not every surgeon uses irrigation. Instead, I head for the other warmer, between the operating rooms, and pull out a bottle of warm saline. If the bag had been used, I would have asked the scrub tech to squirt some in the graduated pitcher that is used as a sterile containment device prior to handing it off to the surgeon.

Not only is there a cost to the patient every time I open and chart a different fluid, there is a cost to the environment from plastic packaging. There is enough of that in the OR already.

This is the time I consider opening and pouring the local medication into a cup on the field. There will be local medication injected by the surgeon during the case. Some inject prior to incisions and you have to remember which surgeon is which so that the scrub tech has it prepared for them and when.

This surgeon is the inject prior to closure type of surgeon. The medication was pulled before the start of case as part of my case prep. All I have to do is confirm the desired medication with the surgeon, open and pour into the prepared cup the scrub tech has left available at the edge of her table. This is when I also discuss expiration dates, or show the bottle to the scrub tech.

All medications poured on the field needs to labeled. There is no way around this. What if the scrub tech faints and a replacement scrub tech appears from no where and has no idea which medication is on the field? I joke but it has happened. It is policy that the medication is labeled with what it is, concentration, expiration date and time (if applicable). I pour the marcaine 0.5%, expiration March 2023 into the specimen cup. And confirm the details with the scrub tech, as they label it.

When the scrub tech hands it to the surgeon, they will confirm with them what is being handed off. Rarely, this is when the surgeon will change their minds and ask for a different medication. But this is a rare occurrence.

All medication given to the field must be labeled. Have I made that clear?

But what if it isn’t medication that you are dispensing to the field? What if it is a betadine, or hydrogen peroxide? You know, stuff that shouldn’t be injected? This is why labeling is so important. As is the use of the opaque cups that are in the basin pack.

Labeling the medication is important. And safe for the patient.

On Thursday my boss texted all the call nurses: endo, PACU, and OR. And wanted to arrange a meeting with us all.

I said I was absolutely available for when she wanted to meet. As did the other two nurses.

Immediately, I got texts questioning what this was about. Immediately, everyone’s mind went to they are shutting down the project. And we are not ready for the project to be shut down. If they shut down the call project the nurses and techs will have to take the bulk of the call back.

I tried to reassure everyone that the boss did not include the tech in the meeting or the texts. And I felt the job class we are in now was safe. How long is it safe for? Who knows? I do know that the regular staff are enjoying the minimal call that they are taking. Of course, it is more than they were taking because I am no longer taking extra call. But people are being told when they interview that this project exists.

The other two were no assuaged. I knew I would have to bring out the big guns. I immediately texted the boss and told her that the others were panicking, a little. Nothing good ever comes from waiting to drop the hammer.

Anticipation is the worst.

She rushed to reassure everyone. She had no idea that we would take it as imminent danger.

But we are nurses, always on the lookout for danger and problems; the vital sign machine tone change, the increase in heart rate, the precipitous decrease in heart rate. We are always on the alert. And that is why anticipation is the worst, waiting for the hammer to fall.

I know it is human nature to try to shield people from unpleasant news. Just tell me. And just tell the other call nurses too. Because whatever is conjured in our heads cannot be worse than actuality.

It is just like when I took the NCLEX. I had to drive to the testing center, about thirty minutes away. There was more shopping centers in that city than in the town that I lived in. I took the whole day off, anticipating going shopping after the test. Well, the test shut down after 75 questions. There can be anywhere between 75-265 questions. They are weighted to judge the person taking the test’s over all knowledge and problem solving. And the minimum was 75. If the test shut off there, you either did really well, or spectacularly bad. Of course, I thought I had bombed and the test shut off in reflective shame for me. I wouldn’t get the results for 2 weeks. Now you are told almost immediately if you passed or not.

I did not go shopping as planned. I was too unsettled by having the test end after 75 questions.

I had to wait. And, as discussed, anticipation is the worst.

Luckily I got my results back in 3 days, not 2 weeks. And I passed! The hammer did not squish me like a bug. But I am always on the look for it.

And frankly this program is saving the department money, at least in my paycheck. If I no longer work all the hours that are, I no longer get paid at that level. I wonder if I can spin that?

The post-it states ‘Healthcare has ceased to see the patient as a person. It has devolved into there is a problem I need to fix it.’

Eleven years ago there began a spate of simple cartoons on YouTube. They were from Xtranormal.

This is a website that you could build a cartoon around a script that you had written and it would be turned into a cartoon.

I have to confess I toyed with the idea of writing a script for the site.

But the cartoon Orthopedics vs Anesthesia is perfection.

And a prime example of the blinders that healthcare workers, including surgeons and nurses, sometimes develop.

In the skit, an orthopedic surgeon is telling an anesthesia provider about his patient in the ED. He begins the conversation by saying there is a fracture and he needs to fix it. When asked to tell anesthesia more, he surgeon repeats that there is a fracture and he needs to fix it.

The conversation goes downhill when anesthesia presses the surgeon to tell them more about the patient.

The surgeon doesn’t understand why he is being pressed for more information. As far as orthopedics is concerned there is a fracture and he needs to fix it.

There is some fourth wall breaking by the anesthesiologist when she looks at you, the audience, dumbfounded.

And the anesthesiologist drags more information from the surgeon. Piece by piece, when all they wanted to know is who the patient was.

The surgeon tells the anesthesiologist that the fracture is in the ED. And that the fracture belongs to a bone, the femur, and it is displaced, which means that is badly fractured.

The anesthesiologist is getting more frustrated, visibly so.

She comes out and asks who the patient is. And the surgeon tells her the patient is a 97 year old female. From a nursing home, with no comorbidities as she is otherwise well, and she is fasted. To him the fracture that belongs to this patient needs to be repaired.

After a pause, he continues that the patient is well, except for her temperature of 29 degrees Centigrade, which is roughly 84 degrees Fahrenheit, and a pH of 6.8. A normal blood pH is 7.35-7.45. Lower than that means that the patient is acidotic. And a pH of 6.8 is incompatible with life. So she is not otherwise well. And her temperature is way off as well, as a normal temperature in humans is 97-99. The anesthesiologist is dumbfounded.

But wait, the surgeon continues that the patient has a condition that he is unfamiliar. And he mispronounces asystole. This is when the heart ceases to beat, in other words death. The anesthesiologist’s mouth drops open. She can’t believe what she is hearing.

The surgeon rushes to console, telling her that he is very skilled with hammers and drills and didn’t tell her about the asystole to begin with as he doesn’t want her to refuse the anesthetize the patient. And fixing the fracture that he is fixated on won’t take too long because of how skilled he is.

The anesthesiologist tells him that CPR would be more useful to the patient. You know, to save her life. And he says that they have finished with that. Meaning the patient is dead. He tells anesthesia that there will be minimal blood loss. This enrages the anesthesiologist because of course there will be no blood loss because there is no cardiac output. He presses on telling her that he needs to fix the fracture and tells her she’s being obstructive in not letting him do the case. And if she breaks her hand by punching a brick wall, he will fix it.

This skit is meant to be funny. And it is. We all know surgeons like this.

This orthopedic surgeon is hyper-focused, only looking at a very small piece of the picture that is the patient as presented. Yes, there is a fracture. And that fracture would need to be fixed at some point. But there is more to the patient and to her entire healthcare picture than the fracture. Which is the point of the skit.

The anesthesiologist is looking at the entire picture and seeing that this is not a surgery that can be done at this time. The patient no longer has need for the surgery. You can feel her frustration at the surgeon as she declines his request for a case.

As healthcare providers we need to be less focused on the piece of the patient puzzle that we can fix, and more aware of the patient puzzle as a whole.

This post-it was written during a class I took about awareness of the whole patient, not just what can be fixed in the immediate future. And I made a note to reference the YouTube video.

And if you haven’t seen the skit, it is on YouTube. Just search for Orthopedics vs Anesthesia.

When we last left our OR call team during the lap appy, surgery had just begun.

To recap, it has been 45 minutes since the page. In that time the RN and the scrub tech drove to the hospital, got dressed in scrubs, picked the case. The scrub tech opened and set up the case. The RN grabbed a unit phone, went and picked up the patient from ED, and started the pre-op work. Anesthesia came and did their part. The surgeon came and explained the risks and benefits of surgery to the patient. The RN witnessed the patient signing the consent for surgery, and anesthesia. The first time, the pre-procedure time out was done, the H&P had been put in by the surgeon, the patient and his wife said see you later, and anesthesia took the patient to the room. The RN walked the wife to the waiting room, explaining what was going to happen next, and stressing the importance of answering the waiting room phone call, and returned to the room. The scrub tech and RN put the sequential stockings on the patient, made sure his seatbelt was secure. And anesthesia put the patient to sleep. The scrub tech used Avagard to cleanse her hands and put on the sterile gown and gloves. The RN clipped the hair on the abdomen, prepared the skin of the abdomen with chloraprep, and while that was drying, put am electronic grounding pad on the patient. The surgeon used Avagard to cleanse his hands and the scrub tech put on his sterile gown and gloves. The RN moved the tower into position after spinning the surgeon. While the surgeon waited with blue towels to square off the incision, the scrub tech and RN counted soft goods such as sponges, blade, needles, fog reduction liquid, and instruments. By now the 3 minute wait time has expired and the RN gives the surgeon the okay to drape. The scrub tech hands off the camera, light cord, CO2 tubing, bovie, and Enseal to the corresponding sides of the table where the RN plugs them in. The RN puts the consents on the prep table where she can see them during the pre-incision pause, the pre-incision pause is done and the fire risk pause is done. All is in agreement. The scrub tech hands off the blade and the surgeon makes incision.

Are you tired yet? This is a lot of accomplish in 45 minutes. And the case has just started!

I turn on the radio after incision to whatever I know the MD listens to, or what is listed on his preference card if I don’t know it.

The cut down incision is made at the umbilicus (belly button) and the initial trocar is introduced. This is usually the largest one.

The surgeon calls for the CO2 to be turned on. On full. This means 30 liters per minute, to an abdominal pressure of 15 mm Hg.

The surgeon scans the abdomen with the scope, looking for adhesions, looking at the liver, looking into the pelvis. He then asks for the blade and the next trocars, which are placed.

The lap appy can not begin in earnest.

The surgeon trains his scope at the site that the appendix is anatomically; the junction of the small bowel and the colon. With luck the appendix is sitting there on top of the bowel coils, ready for its closeup. Sometimes the appendix is buried under the coils of bowel, sometimes it is retroperitoneal, or behind the colon. It just depends on the patients anatomy. And whether or not there is purulent material or pus, depends on how bad the appendix is. As a surgeon put it this week, sometimes the patient can have appendicitis for a week with no rupture, or 6 hours with rupture. It depends on how mad it is. Sometimes the appendix has ruptured and begun to wall itself off in an abscess construct. This is not good because after 3 weeks or so this walling off will break down and the patient will be even sicker. Sometimes the appendix has ruptured so badly that the appendix is not evident because it has burst like a balloon. I’ve only seen a few of these in my 21 years of OR.

While the surgeon is searching for the appendix my job as the circulator is just beginning. There are many things that I, as the circulator, need to be doing. The next thing that the field will be asking for is the stapler, with a load. I do a quick scan to make sure they are in the room and the retrieval bag is on the sterile field. I also do a check that there are more than 1 reload, in case the appendix is larger than the usual stapler and a reload is required. I do a quick glance at the bag of LR that the CRNA is using, to make sure that they have enough fluid still in the bag for the rest of the case. All the while, I am listening to the beeps that the monitors make.

Much of this is not done on instinct, but done on experience. If the patient were to go bad, and the CRNA to begin noticing trouble with the patient, these monitor beep changes are often the first things. Or there is a lot of movement, behind the drapes, of the CRNA. A flurry of movement can indicate the CRNA is pulling meds to counteract a vital sign reading. If that is the case, I move to where I can see the monitors and pull out my phone to contact the anesthesiologist if required.

If I am fairly certain that I have everything they need, I begin to chart. Charting is always the least of my worries. What is happening in real time is more important. And I have a secret weapon, a macro that I created for the surgeon, for the case. This will fill in a lot of the holes that I need to chart. But that will be part 7.

Pimento cheese?

That isn’t a cookie, you say.

True. But it is one of my go to potluck staples.

And today is an orthopedic surgeon’s last surgical day before his retirement.

And there is a potluck. Any excuse for a potluck in the OR.

We like to eat. I have always said that the OR is an army that marches on its stomach.

Instead of making cookies this week I decided to make pimento cheese instead. The party was near the time I bring cookies. And the eating of the cookies go down when there is a party. I brought something to the potluck instead.

The number one requested savory that I make for potluck is the pimento cheese.

This is a food stuff that I embraced upon moving to the south.

It is simple; only four ingredients. But so good. I give out the recipe every potluck.

8 oz finely shredded sharp cheddar

1/2 small jar of pimentos

12-15 shakes of Tobasco sauce- this can be done to taste

2-4 tbs mayonnaise- this can be done to taste. I do not like a goopy cheese

Serve with crackers.

So long and thanks for the fish, doc.

We’ll see you in a couple of months when the idea of retirement becomes boring.

To those who think that pimento cheese cannot be put in cookies, to date I have used pimento cheese in

1. baked pimento cheese crisps which is baked circles of the cheese as prepared
2. pimento cheese thumbprints with triple pepper jelly
3. cheese straws
4. pimento cheese shortbread
5. pimento cheese cheezits

I was going to write part 6 of what does it mean to be called in.

But this is more important.

19 children are dead.

Yesterday, May 24, 2022, a gunman walked into an elementary school that was near his high school, walked into a classroom, and killed many of the students and teachers who were in it.

The suspect was subsequently killed by responding officers.

19 children are dead.

2 adults are dead. I presume these were the teachers.

Is there an idea about motive?

No.

Does there need to be though?

I try very hard not to make Dispatches from the Evening Shift political.

The OR doesn’t care about my political leanings.

My political leanings do not color the quality of nursing care that I give my patients, no matter how I feel about their stances. If I even know what they are. It’s not something that comes up during a pre-op conversation.

I am upfront about not having children.

Does this mean I can’t be horrified and shattered by what happened in this elementary school? I have nieces and nephews that I love.

I can have an opinion on the events that took place yesterday in Texas.

And my opinion is valid.

I have been hesitant to say anything as I know that will lead to me feeling dismissed about my feelings of outrage and grief.

Kind of like my feelings about the Covid pandemic and those who choose not to get vaccinated to shorten this pandemic or protect others. Or people who won’t wear a mask in public because they don’t want to. And these feelings getting dismissed because they don’t want to apparently supersedes my desire to care about the welfare of others. But sure.

Because I am not a parent. Because I am not a mother. Because my husband and I aren’t parents.

And how would I know what these parents feel?

I don’t. But I have a good imagination. And because I’m human and don’t want to cause people to suffer, that’s how.

In the hospital we drill for an active shooter. In case someone gets a wild hair and their gun and decides that their need for vengeance, or to feel powerful, is greater than others need to survive. And my nephew throws out in casual conversation when his school has an active shooter drill.

It is so very sad that society has come to this.

In the plain language codes that my hospital system has adopted, active shooter is the scariest.

I went to the eye doctor today. My yearly appointment/screening is usually in October but there is exciting things happening starting in August. I want new glasses for London and for university.

Prior to entering the office I noted that there were 2 signs indicating that mask wearing is required on the doors. There were also plexiglass dividers at the receptionist and another sign, with a box of masks saying, again, that masks were required. Everyone in the office was masked.

I checked in at took the paperwork to the chairs to fill out.

Normally I go to the first appointment of the day, usually 0800, and there were more people than I’ve been around in the office. All masked. But I made the decision to get my exam early, even if my normal doctor is out until August.

Two other patients followed me in. One, a woman, was masked. The other, a man with his 7 year old, was not. The receptionist asked him pointedly if he had a mask. Because masks are required, as evidenced by the three signs that he had to pass to get to the desk.

Caught, he mumbled, “Oh, I did not realize we were still doing that.”

I am not sure what he thought after passing the three signs, and reading one aloud to his kid. Did he think that the receptionist was going to smile and tell him never mind?

Unsmilingly she passed him a paper mask. Didn’t give one to the kid, but whatever. He sheepishly put it on and took his paperwork to the chairs to fill out.

Let us unpack that a bit.

The eye doctor is examining your eyes.

Which are separated from your mouth by your nose. Both of these are prime droplet spreading suspects. And, I’m not sure if he knows this, we are in the middle of another surge. And a very devastating milestone just passed. 000

Because the pandemic is not over just because most Americans want to go back to their lives.

Insert eye roll.

Yes, wear your damned mask to protect the eye doctor and their staff.

No, don’t pout when the receptionist gives you that soundless look and passes you a mask from the box of masks on the desk.

Be a good role-model for your kid.

The rest of my appointment went by.

I chose new glasses that will be ready in about a month.

Well ahead of the events in August.

After I paid, half listening to the same man saying loudly that he preferred blue or brown glasses, I chose a lollipop to take home.

Because I was a good patient and not snarky.

The post-it reads ‘if we didn’t have gallows humor, we wouldn’t have any at all.’

This is very true. There is little to laugh at in health care. There is little to laugh at in witnessing suffering. Sometimes there is something that we can do to alleviate the suffering, oftentimes not.

You could say gallows humor is in response to life-threatening, disastrous, and terrifying situations. And the Merriam Webster did that as that is a direct quote from the dictionary.

In healthcare much of what is witnessed by us is life-threatening, disastrous, and terrifying. To the patients, and to us who are striving to ease all of those conditions for the patient.

Yes, we make inappropriate jokes, but I say it is in response to what we are witnessing. A bit of whistling past the graveyard to give ourselves courage in fighting what the patient is going through. We don’t have the privilege to act as if we are afraid or unable to fight the current battle.

And for pete’s sake, don’t let the patient see you sweat.

Or your coworkers. There is an art to keeping cool under fire.

A prime example of this is my response to a post on Facebook. This is a group of women who are not medical. Like, at all. And one made a post about how her husband was home from the hospital after undergoing a colectomy. At the end she made fun of the fact that he wanted to keep the removed colon. Why? Who knows. My response was that I tell people all the time that the lab has to have whatever is removed for testing. And that the weirdest thing that someone had wanted to keep was toes removed for gangrene. I wrote back that we could have a what is the weirdest thing ever sent/seen in the lab but I did not want to gross the group out. Some of the women got it, I am sure that some were icked out by the comment. Me? I thought the entire exchange was funny.

The pause, or time-out has just been done and the incision has been made.

For a lap appy this is no time to chart and rest on your laurels. Or on your phone, if you’re that type. We all know them.

Everything may be hooked up and ready to go but you, as the circulator, has to be prepared to dim the lights, turn on the camera light, and turn on the gas.

During a lap appy, carbon dioxide or CO2, fills the abdomen and expands the open area between the abdominal wall and musculature and the internal organs. Doing this allows the surgeon to direct the camera in different directions and see different things. The surgeon has be mindful of the angles in placing his trocars. The trocars are the working channels for the instruments. Basically a tube with a sharp end that is introduced through the skin and muscles into the abdominal cavity. There is an art to placing the trocars in. There has to be enough force to go through the muscle layer, but not enough force to damage the organs. It is a fine balance, especially on a skinny person. What most of the surgeons that I’ve worked with do is place the largest trocar at the belly button, take a peek with the camera to make sure they are through the muscle, and call for CO2. This will begin to expand the cavity and make the other smaller trocars easier to place.

I have a story here. In my first hospital in CA, when laparoscopic surgery was first beginning, a surgeon who had been through classes with pigs was putting in the opening trocar. He was unsure of how much resistance the abdominal wall would give so he took this bladed trocar and shoved it in as hard as he could because that was what he understood. You know what is immediately underneath the belly button? All along the back of the peritoneal cavity, underneath the colon and small bowel?

The vena cava.

This is the largest vein the body. It carries all the blood from the periphery back to the heart where it can be re-oxygenated and pumped back out to the body. Yeah. The surgeon knew enough not to pull the trocar back out, and luckily a vascular surgeon was nearby to open and cross-clamp the vena cava so the patient wouldn’t bleed to death. That lap case turned into an open case real quick. But that was years and years ago.

But for this lap appy and patient A, the large 12 mm trocar was introduced without issue. A quick visual was obtained and the surgeon called for CO2. Me being who I am, was standing next to the tower and turned on the flow of CO2. The machine can be tricky, sometimes you have to hit it twice because the first time only turns on the potential for airflow. A pro tip is to wait for the numbers to begin to go up. These numbers refer to the amount of CO2 given. If the numbers are not going up, the trocar is not in the abdomen and must be withdrawn and the cut down began again. Depending on the size of the patient, and the fluffiness of their subq this can happen.

Finally the CO2 numbers are ticking up. This is a good time to do two things at once. Ask the surgeon if the screen is in a good position and check how many bars the CO2 has on the machine. This indicates how much CO2 is in the tank.

If the screen is in a good place, leave it be.

If there are more than 2 bars on the machine, you are probably in a good position. If there is 1 bar, be prepared to change it. This should be part of your pre-case setup but everyone does things a bit different. I always check the bars when I am turning on the video tower, others do not. There should be a spare, unopened tank on the tower. If you have a suspicion that you will run out of CO2, make sure you have a spare and a tank key to switch them out.

You’ve started gas and the abdomen is filling nicely. The next thing that needs to be turned on is the light cord for the camera. Otherwise it is going to be mighty dark in the abdomen. I will discuss the make-up of the light cord at a different time. It is fascinating.

For laparoscopic cases you need lights, camera plugged in, and action by the surgeon.

Sorry, couldn’t resist.

By now the 5 mm working trocars that the laparoscopic instruments can fit down have been inserted. Depending on what kind of case this is there can be 2-3 5mm trocars. Most surgeons use 2.

Take this opportunity to turn off the room lights. This refers to the overhead lights and are controlled by switches by the door.

And dim the spots, or surgical lights as they are very bright.

One can be turned off completely and the other can be dimmed so that the scrub tech has a small amount of light over their back table.

This is now the time to ensure that the auxiliary monitor that the scrub tech uses is in a good position and they can see what the surgeon sees.

With luck the appendix is sitting in plain view on top of the small bowel coils. Otherwise the surgeon might have to go fishing.

Inflation baking continues this week with the sad cakelets. By cakelet I mean an entire batch of a cake re-imagined and baked in the mini muffin tins. A little cake.

One of the most intriguing cakes I’ve had in a while is the sad cake. This was brought to my attention by one of my favorite pre-op nurses.

Apparently it is so named because you are sad it is gone after you’ve eaten it.

And this is true.

She always saved me a bit if she ever baked one and brought it in. Otherwise the locusts that we work with would have eaten it.

It involves 4 eggs, 1 pound of brown sugar, 2 c of Bisquick, 2 cups chopped nuts, and a splash of vanilla.

Looking at the ingredients I thought that there was no way that 4 eggs would be enough liquids for the entire cake. But it is. And this is what earns it a week in the inflation baking month. It is no less impossible than the other cakes I have been making.

This is a dense, flavorful mini cake.

There is no reason this cake is this good, except for the pound(!) of sugar.

So often my recipes and Cookie Thursday is a Thing arises from the can I bake that into cookies question. And yes, yes I can.

Next time I will add more nuts. And, ooh, should I roast the nuts first.

Yeah, this is how the creative baking juices get going.

And there is a frosting. Of course there is. I’ve been clear on my feelings on making frosting. Which are usually negative. But they have been tempered by the decision to serve the frosting on the side. This way people can use as much, or as little frosting as they want.