When we last left Patient A, the case was about to begin. And the pause happens before incision, sometimes immediately prior.

The pause refers to an intentional pause in the activity of the case and everyone in the room focuses their attention on the patient and touches briefly on what has brought him to our OR.

The pause or time-out, as it is sometimes referred to, was started in 2003. Initially this was intended to ensure that the correct patient, correct procedure, and correct site were identified by all the team members in the room.

In his book the Checklist Manifesto, author and general surgeon Atul Gawande, explores the reasons behind the creation of this kind of checklist. I whole heartedly recommend this book, and Complications, his first book. They should both be required reading for healthcare professionals. Along with House of God by Samuel Shem but that is another post.

The idea was borrowed from airlines; they have a checklist for everything aviation.

This was where the pause or time-out began. The entire room has to agree to the correct patient, the correct procedure, and the correct site. I have memories of rolling this out to the OR in CA. Some surgeons didn’t care to mark the patient to indicate laterality. Until there was a wrong site surgery in our operating room and then they couldn’t get on the bandwagon fast enough. Too bad it took a tragedy to get some people to do what has been proven to increase safety.

The time-out has been expanding ever since.

There is a pre-procedure pause with the nurse who did the initial assessment and pre-op work with the patient. This involves much of the same elements of a pre-surgical pause. Correct patient as evidenced by name and birthdate, correct procedure as evidenced by the consent, correct site as evidenced by the laterality being marked, if there is a laterality. And the completion of a history and physical has been added. Also added is the appropriate antibiotic. I imagine that the next to be added to the pause will be a pregnancy test, if applicable. The medications that anesthesia uses are powerful and can be fetotoxic. That means dangerous to the fetus. And this is a discussion that some of us have added to our communication with the CRNA and anesthesiologist.

The pre-procedure time-out is also done with the nurse, the CRNA, and the anesthesiologist prior to any anesthesia procedure. This includes blocking of limbs, blocking of the abdomen during a TAP block. This refers to the Transverse Abdominis Plane as an exploratory laparotomy incision pain block. Also included is the spinal block. If the anesthesiologist is blocking a shoulder for example they should also mark the correct shoulder, in addition to the surgeon.

The pre-surgical time-out includes the same information as the pre-procedure time-out with the addition of the presence or availability of the correct instruments and implants, for an orthopedic case, the introduction of all people in the room, including sale representatives, and a discussion of the fire risk of the surgery. Some surgeons throw in a time estimation for the case, and with the exception of an orthopedic surgeon I am thinking of who does marvelous pauses, are invariably wrong.

The last part of the time out is the expected issues that may crop up during the surgery. This is usually patient condition related and may included discussions of the need for a higher level of care such as the intensive care unit.

The OR team uses this time-out to convey many pieces of information. This is all to keep the patient safe while they are in our care.

It has always been my grand desire to be a published author.

For my ENTIRE life.

You know, where someone actually pays me.

To that end I have sent off a letter introducing myself and by bona fides to all the AORN publications. I guess you could call it a query letter. I am querying if they need an article freelancer. But one who has broad knowledge and experience in the operating room.

Because, you know, I have all this free time now.

It’s a start.

I have also been signing up for all the free sites I can for recommendations on how to start at freelancing. Also a start.

And I have also been exploring the free offerings from the library. I have been to 2 gardening classes, a book club, and a writing club.

The last was yesterday.

Me, being who I am, was 15 minutes early. Clutching the first chapter in my zombie book and peering into the near empty classroom. Okay, let’s do this.

I had no expectations about the group, as this was the first one I had ever been to. Apparently it was a read a chapter aloud and discuss strengths and weaknesses. And I should have brought 5 copies of the chapter so people could read along. Now I know.

There ended being 4 other writers in the group. And the moderator.

I read the first chapter I had brought.

I wrote it several years ago, prior to the pandemic, and my MSN.

And, let me tell you, post pandemic it hits a little differently.

The lab where our main character works is developing a biological weapon around the zombie flu. In this universe the zombie flu is caused by a virus, that is carried in saliva. And 100% infectious and 100% fatal.

I need an elevator speech for it. A quick 30 second synopsis. What I have so far is that the scientist working on weaponizing the zombie flu accidentally infects himself, despite the lab protocols. He has to get to what he hopes is the cure across the country, accompanied by his ER doctor girlfriend. He is getting sicker, and sicker, and closer to full zombie. This is a high stakes race across the country at night, pursued by the man who wants to kill him, to prevent an outbreak.

After I had strong positive feedback from the group I pulled up the rest of the chapters I had written. And re-read them until 0200 this morning. I don’t think it is half bad, but it is a book that clearly needs to be finished. I have the beginning, the middle is plotted, and the ending.

It is called Calling in Dead.

The title came to me when I was waiting for the core elevator in the middle of the night, about to search for something that the case that was underway needed. This was the 3rd add on, it was the 0400, I had been at work since 1030 the morning before and I was tired. I looked at my reflection in the dull silver doors and said that I needed to call in sick the next day, hell I needed to call in dead.

The title is still awesome.

Well, we’ve crossed the one million dead mark.

That is one MILLION.

That is just under the 2020 population for San Jose, California.

To write that I am appalled on behalf of people I don’t even know would be too pale an example.

This is what we in the healthcare field were afraid of. Why we pounded and continue to pound the idea of simple measures to keep the population safe; wear a mask in crowded areas, maintain social distancing, wash your damned hands.

But no.

That appears to be too simple for some people. They would rather see the world burn that to do something simple to help another person.

This is all over the media. And before you poo-poo the media I mean it is all over the media, in all the trusted places that I’ve been reading from for years. Not the echo chambers that are ignoring the numbers, and have been all along.

The media exists to hold up a mirror to society. And this society is looking pretty sad right now. Oh, you’re tired of covid and want to live life as if it doesn’t exist? The one million dead do not have that choice. Society has taken it away from them.

I read a report yesterday about how many unnecessary dead there are. NPR reported on the Brown Public Health Report that was recently released about the number of unnecessary dead in each state. To put it another way, this is the number of people that would have survived if complete vaccination had taken place. If everyone had rolled up their sleeves and accepted the vaccine.

That number that would have survived if there had been more complete acceptance of vaccination? Nearly 319,000.

Would there have been some losses? Yes, because we know that covid is a killer. But nearly a third less.

And the death rate, that had been stable for a number of weeks, is beginning to rise again.

There are no more words.

Reference: Of 1 million COVID deaths, how many could have been averted with vaccines? : Shots – Health News : NPR

This Cookie Thursday is a Thing I intended to make impossible carrot cake. To go along with my theme for the month of Inflation baking.

I did not.

This morning was the quarter 1 awards for my hospital.

Normally the shared governance council votes on all of the award nominations in the next month after the quarter’s end. And we hold the celebration near the end of the month. We hold quarter 1 specifically in May. During Nurses week, and Hospital Week.

No, they are not the same week on the calendar. But they are similar, off by one day. Aggravating. But we Nurses can share our week. Sure,

In my head this is the big awards celebration for the year. I know I have it conflated but yes, yes it is.

We celebrate nurses through the Daisy Award, and the Professional Practice Model Award.

But healthcare is not just about the nurses. There are CNAs and techs. The award we have for them is the Rose award.

And the ancillary staff, who are not nurses or nursing related, such as dietary, admins, radiology, environmental and more, deserve their own award. The award is the Sunshine Award because they bring sunshine to our professional lives.

For a treat we had had nominations and winners from all four awards. This has not been the case for several years. The Professional Practice Model award has gone un-nominated before. Not that there are no nurses who embody the nursing theory the hospital follows, but that the nomination form is complex, and the sections to write on are so small, only 4 lines.

Shared governance has been working for years to get the nominations online. And the Daisy ones are kind of online but it is difficult to get people to fill them out.

And then there is the current staffing difficulties of healthcare. I began the awards ceremony today by telling the crowd that there had been 30 nominations for the quarter. And that this was half of the nominations we had had in the past but more on that in a bit. And of the 30 nominations, 14 had to be discarded because they no longer work for the hospital, or even the system. This is almost half.

How many of those nurses would have remained at the hospital if given a bit of encouragement?

I told the council that we were going to start something new.

After I gather all the nominations, and decipher the handwriting, I am going to email the managers monthly that they had a nomination. And the person would be celebrated at the next awards celebration in the month after the end of the quarter. With instructions to tell the person that they are amazing. And the nominators and the council sees them.

I reminded all the people at the celebration, all socially distanced, to nominate, nominate, nominate. All the staff at the hospital deserve to know that they are seen. That someone knows they are doing an amazing job and nominated them for an award.

I hope this helps.

Traditionally, the Daisy celebration always has Cinnabons. The nearest Cinnabon is in the next town over and I picked them up yesterday. When I was told that the only ones available were 6 pack of large ones, I told the counter girls that I wanted 2.

I panicked, and I overbought. One usually feeds the awards ceremony. I am not sure why I said 2 boxes. I brought the remaining box of 6, cut up small, to the OR for Cookie Thursday.

Happy Hospital Week.

Happy Nurses Week.

When we last left the patient, and the call team, the patient had just gone under anesthesia.

This is when I call the PACU nurse in.

Some might say that it is too soon, I would not. Depending on the surgeon, the case might only be 20 minutes long, plus wake-up time, equals 30 minute response time. For this particular surgeon, call PACU in sooner than later, otherwise you will be chilling in PACU, not knowing the next steps, until they get there.

As I am calling the PACU nurse in, I am pulling back the top blanket to expose the abdomen and preparing to tuck the left arm. As part of my preparations, I have pulled out 1 egg crate ulnar pad, and the clipper and clipper head, plus tape.

After I hang up with the PACU nurse, I tuck the left arm snuggly against his side, placing the egg crate under the elbow, and tucking the overhang of the draw sheet, thereby securing it. I pull off the armboard at this time.

I nearly forgot the electrode grounding pad. I grab it from my desk and go back to the patient’s side.

Depending on who it is, the surgeon may clip the abdomen and remove the hair with the tape. Again, depending on the surgeon, this may be all on me.

With the patient’s abdomen freshly clipped and the hair removed with the tape, I open the chloraprep stick in a sterile manner. Chloraprep is to antiseptically prepare the skin. It is a combination of alcohol and chlorahexadine. And it is bright orange, so that it stands out against pale skin and you can see what area has been prepped. . I have read of a blue chloraprep but that is not available in my system. I leave the stick’s packaging open, making it easy to grab.

I pull on sterile gloves and open and activate the stick. I am waiting for the solution to saturate the sponge on the end of the stick. Once it has, I scrub the abdomen at the umbilicus, or belly button for 10 seconds in a back and forth manner. I “paint” the abdomen with the rest of the solution. From nipples to pubic bone to bed on both sides. You always want to prep more area than you think you need. After all, in the OR, exposure is everything.

But, you may ask, why am I prepping without putting on the grounding pad? Because the chloroprep has alcohol in it and needs to dry, thoroughly, prior to draping. Three minutes total is dry time. It is part of our documentation.

But, Kate, you didn’t put on the grounding pad that you pulled out a little while ago. While waiting for the chloroprep to dry, I apply the grounding pad. As long as I am seen to be doing something, surgeons don’t try to hurry me up, as if I can make time move faster. At least, they don’t try much.

I am known to be strict about this. Alcohol is part of the fire triad as fuel and is very flammable. I do not want any drape fires in my OR, thank you.

As a delaying tactic I often do not tie the surgeon’s gown until the grounding pad has been applied.

I tie the surgeon’s gown at his neck and his waist. And then he will “dance” with either me or the scrub tech to completely surround him sterilely with the gown. Fun fact, anyone who is gowned and gloved for the OR is only considered sterile from two inches above the elbow to the stockinette cuff, which is covered by the gloves. And on the front to the level of the bed.

Finally, the seconds drag on and it has been 3 minutes, despite my ignoring the visual whining/pleading from the surgeon. Often I use this time to talk movies, or sports, or books; whatever I know the surgeon enjoys. This often takes up the entire time.

Draping can begin. It begins with blue towels delineating the operative field. The squaring off. Sometimes the corners of the towels are secured with penetrating towel clips, it is why the instruments are named that.

Direct communication that would feel coded happens between the surgeon and the scrub tech. Stickies or sticker on indicates to the scrub tech if the surgeon wants the stickers left on the fenestrated drape. The scrub tech complies, on or off, and places the window of the drape squarely on the operative field. Once this is placed it is not to be moved. The drape is unfolded, like a flower, to cover the patient entirely. There should be a decent hang off of drape on the sides and end of the bed and enough drape to create a wall by their head. Anesthesia does that bit, securing the wall with their non sterile clips.

The mayo stand, which has been prepared and draped out by the scrub tech, is brought into position at the patient’s side or over the patient. Some of this depends on the surgeon’s preference.

Once the mayo is situated, the surgeon and the scrub tech begin throwing off lines. There are several: the light cord, the camera cord, the CO2 cord, the bovie cord, the smoke evacuator cord, because bovie use creates smoke and smoke is bad, and the secondary electrical unit cord for the ligasure or the harmonic. Both of these machines are made to cut tissue or burn it to control bleeding or to ensure the surgeon can see what he is doing.

I plug all of these cords in. Three on the bovie side, 3 on the tower side. As these are on opposite sides of the patient I need to move quickly, but safely. As I go by the spots, or the overheads, I turn them on. These will allow the surgeon to see what he is doing and it is focused light.

The surgeon asks for the knife. I stop them and remind them of the pause. This will be talked about in the next section. We pause, everyone in the room stopping what they are doing and confirming the surgery, the supplies are sterile and accounted for, the antibiotic has been given. So many things.

You’ll see in What Does it Mean to be Called in Part 4.

The scrub tech hands the surgeon the knife and incision is made.

Happy nurses week for 2022

The American Nurses Association theme for this week is Nurses Make a Difference. This is to celebrate the impact of all nurses on healthcare and patients; no matter they work in a hospital, or a doctor’s office, or are practicing on their own as a nurse practitioner.

As a group we have lived through some dark times in the last two years.

In 2020, the ANA theme was Year of the Nurse.

And with nurses that I know this hit with a resounding thud.

What we do is very important. We strive for hospital change. We care for patients and ourselves, all at the same time. And, as a group, we are tired and sick of being the scapegoat for systemic problems that arrive that we have tried to fix. In short, we are tired of being the squeaky wheel, of trying to bring up issues and being told to stay in our lane.

Now insurance companies are trying to charge back on premiums to account for rising nursing wages. This is just like when the powers that be, such as Congress, tried to indict travel nursing, and nursing in general, for wage hikes. This is because nurses were leaving the bedside and becoming travel nurses. Remember that?

This was in February.

A nurse is being sentenced on Thursday, 5/12/22. On Florence Nightingale’s birthday. If that is not an attack on nursing, I don’t know what is. She was found guilty in March of criminally negligent homicide for a medication error that led to a patient’s death. She was found liable in the systemic problems of a new medication machine relay with the electronic health record. She was found liable for a medication that should never have been in the area she was in.

Much has been written about the Versed, a sedative, versus the Vecuronium, a paralytic, mistake. And mistakes were made on her part. Oh, yeah. And the policy was stupid to not mandate her monitoring the patient after administration. But to elevate this to a criminal matter with conviction is to chill the reporting structure of the entire medical field. Nurses that I know have told me that they will no longer report errors, even errors as minor as a near miss that did not reach the patient. Because they fear reprisal and prosecution. Surgeons I work with have brought up their concerns about the reporting that they know is not going on. And they have referenced the tragedy happening at Vanderbilt Hospital for nurses.

A patient died. There was medical error that may have contributed to her death. The science, including the medical examiner, has thrown doubt on this. The nurse has been convicted of criminally negligent homicide.

Nurses are mad and quitting in waves over this, as we feel the system that we work in no longer has our back. And those who are left have to keep it together. For the patients.

There is a Nurses March in Washington DC on Thursday, May 12. There is another march happening in Nashville, Tennessee, on behalf of RaDonda Vaught on Friday, May 13.

Happy Nurses Week, everyone. Now get back to work.

This is the feeling that I am getting. You?

The post-it reads ‘charting is a secondary job.’

This is very true.

Although the old saw that says if you didn’t chart it, you didn’t do it, you have nothing to chart without doing.

Too often people are enthralled with charting.

Charting must be done.

Charting must be done right now.

They are missing the forest. They are so focused on the trees that make up charting.

The charting should be the last step in your care for the patient.

The patient is in need of care. You provide it, then you chart it.

This is what charting as a nurse is; there is an action we have to document it.

The electronic health record has made it better and worse. The EHR boils down the entire encounter to check boxes and a narrative comment section that allows for observations that don’t fit in the check boxes. Because patients are individuals and are not all going to be check boxable.

Too often, the nurse wants to chart. Above all else. And the OR field or anesthesia is left wanting because the nurse is so bent on finishing the charting, regardless of attempts to sway them from the chart.

There is time enough to do both care for the patient and the field, and chart. But charting should not be a nurse’s primary concern.

The patient is.

In our previous episode I was called in, and I prepped a patient for surgery.

Almost.

There are no consents signed.

Because the surgeon has not met the patient.

The double doors to PACU swing open and the surgeon, dressed in street clothes, walks in.

I am using he as a descriptor because that’s how I described the surgeon in the previous post. Nothing is meant by this. I’ve worked with many fine FEMALE surgeons.

He makes a bee-line for the patient and introduces himself.

With a half an ear I listen in while I am getting a clipboard for the signing of the consents.

Pro-tip: It is better to sign against something. And, as an ER patient, there is no hard chart. All I have are patient stickers.

After meeting the patient, the surgeon wanders off to do the history and physical. This is a must have for surgery. He has to attest in the H&P that he has gone over all risks and benefits of the surgery with the patient. This is where the informed part of informed consent comes from. The surgeon has informed the patient of the risks and benefits and alternatives the surgery. All I am doing when I co-sign a consent is that the patient signed it.

I review the consents with the patient. The anesthesia consent, and the surgical consent. I always encourage people to read the consents. I have read the consents, every line, to patients. The part I highlight, always, is that any tissue removed, in this case the appendix, has to go to lab for testing. I usually make a joke here that the patient cannot take it home for experiments.

The patient laughs and they sign the consent.

I follow up with a story of a patient that wanted to take a substantial body part home and smoke it.

Ew.

Other people are avid fishermen.

Double ew.

Regardless this appendix that we are about to take out has to go to the lab.

The patient signs both consents. I co-sign both consents.

I ask if there is any last minute questions. I’ll answer anything. One time a kid asked me why the sky was blue. And was shocked when I had an answer.

I nod at the CRNA and show them both signed consents.

Logging back into the EHR, because you know it has timed out, I go to the part of the chart that deals with the timeouts.

A timeout is a pause that ensures that we have everything prior to surgery. Patient identifiers (name and birthdate), H&P, pregnancy test if applicable, antibiotic, it is all discussed here between myself and the CRNA and the patient. We both take another look at the consents that I just signed with the patient and it is time to go back.

I encourage signs of affection between the family member and the patient. This is the last time they will see each other before surgery is completed. The family member is always stressed. The patient has had a mickey from the CRNA. By that I mean the CRNA has given the patient sedation for the trip back. After consents, because legal reasons. But they are stressed too.

I wave at the double doors leading to the OR hallway and indicate that the OR itself is beyond those doors and visible from where the family member and I are standing.

As the CRNA and the patient go through the double doors to the OR, I indicate that the family member should follow me and I will take them to the waiting room. They follow me out of PACU.

As we are walking down this long corridor toward the surgical waiting room, I reassure the family member. Remember, they are stressed. I discuss, again, how they will be in the waiting room and if the phone that I am about to show them rings, they are to answer it. It will be me, for them.

I tell every single family member about the phone call that they are going to get. I tell them I have a 65% answer rate. I reassure them if they can’t get to the phone before it rings over to the answering machine I will call back.

By this time I have badged us into the waiting room. I talk up the charging station and invite them to charge their phone as it has all the cords. Years ago when cell phones were become popular, I kept charge cords at the desk to lend to families. Finally, administration listened when I told them that it was imperative that a charging station be installed. Yay for them listening.

I briefly show them around the rest of the room and am specific which phone will ring. I lift the phone up and make sure the ring is audible. I reiterate that this will be the phone that will ring. After I go back to their loved one, it may take me a few minutes to call but I will call.

I hand them the remote for the television and tell them that the restrooms are down the hall on the right.

Last reassurance that we will take very good care of the patient is given. I walk back to proper pre-op area, pulling my phone out of my pocket. I need to call the on call PACU nurse before the patient goes to sleep. That way they will be in the hospital when the patient comes out of the OR.

I walk back into the OR. By this time, the patient is on the OR table and the gurney is in the hallway.

After reassuring the patient their family member is tucked back in the waiting room and I will be giving them updates, and the surgeon will see them after the surgery, I do a visual survey that all is in readiness.

I chat with the patient as the CRNA and anesthesiologist prepare to put him under anesthesia. During this, I and the tech are doing many things.

Mr. A gets sequential stockings on his legs to help the blood return to his heart while he is in our care, the SCD machine is turned on, the seatbelt is applied, the armboards are put on the bed, the patient’s arms extended and secured. Warm blankets are refreshed. The temperature in the room has dropped 5 degrees again.

Sometimes during the whirlwind that is the preparation to go to sleep, I tell the patient that we used to ask people to count backwards from 10. And often they nod, familiar with the concept. They are shocked when I tell that this will not be happening. They look perplexed, and I inform them instead that they will be counting backwards from 100 by 7. I don’t always do this, but patient sometimes do better with a task. This is a task.

And it is time to start induction of anesthesia. The anesthesiologist and I take up posts at the opposite sides of the bed and prepare to assist as we can.

And the medication is started. I remind them to count backwards from 100 by 7. Often they only get to 86.

Lidocaine first. Because propofol is an irritate. Then the propofol, the so called milk of anesthesia, the Michael Jackson medication. Jokes are sometimes made. And then the paralytic.

Medication always wins.

The theme for the month is going to be inflation baking. I was going to call it inflation cookies, but what I am baking is based on recipes from the Great Depression and WWII.

Because inflation is real. It is not caused by our government, it is caused by the US coming out of a pandemic. In my core I think this was always going to happen. It is happening world wide. And the war in Ukraine is not helping matters; in fact it is harming matters because much of the world depends on food from Ukraine.

These recipes that I will be doing for the next month have no butter. Which is the most expensive ingredient in Cookie Thursday. There are no eggs. And now that there has been an ongoing outbreak of bird flu that has been impacting eggs and egg production, this recipe double fits into the theme.

I am aware that today is Cinco de Mayo. Which is mostly a made up holiday in the US. To that end I made spice mine cakes. People ask why I didn’t make flan; some things are best left to the masters and that is not me in the department.

The recipe calls for frosting. Well, the recipes call for an 8 inch cake pan, and I needed to make small servings of the cake, enough for the department. I will be serving the frosting on the side. I hate working with frosting anyways.

When I pulled out the mini muffin pans to bake the cookies, I was surprised, not surprised that I have 3!

The filled mini muffin pans when into a 350 degree oven and I decreased the baking time. Because decreased mass = less baking time.

People the world over are being impacted by inflation, myself included. I hope this theme resonates with my coworkers and impacts and sparks giving.