Yesterday was the autumnal equinox.

Where we begin the long, slow slide to winter.

And more Covid and flu cases/.

What better than a bit of fall flavor in gingerbread,

This is not ginger cookies.

This is gingerbread.

With clotted cream befitting a truly English book.

One of the scenes in Mary Poppins they have gingerbread.

I find gingerbread comforting.

Especially with clotted cream.

Or whipped cream.

I’m not picky,

And you know what is best?

Gingerbread trifle

Because we need all the comforting we can get as we start the slow march toward winter.

One of the guiding principles of scheduling cases in the evening is fairness.

First one to call is first case scheduled.

I schedule by this.

I live by this.

I have received a lot of negative feedback from doctors about this.

I don’t care.

Last night was rough.

There was an obstetrical emergency that involved bleeding.

There was an already ruptured appendix.

There was a person whose potassium level was 6 due to kidney failure.

The first call was the OB patient.

And bleeding trumps most everything.

The second call was the already ruptured appendix.

The third call was the kidney patient.

The OB caller acted as if I had a team on standby at all times, ready to spring into action.

I don’t.

They were quite put out when I would not grant them an immediate OR and begrudgingly took the soonest time slot.

Which was an hour away.

After one of the rooms dropped.

It takes roughly an hour to get a patient ready.

It takes less time in an emergency.

You know, depending on who is the prepping nurse.

Next the appy doc called.

I gave them a time that was three hours later.

I still had 3 rooms going, and now an OB emergency.

They took the time without a whimper, or a complaint.

After I picked the OB emergency case I had to relieve as the robot scrub.

Because the tech was adamant on getting out bang on time.

No matter the fires going on in the OR core.

When another scrub was available after their case, she came and got me out.

Immediately the phone rang with ANOTHER emergency.

The PA was a little taken aback that they were the 3rd emergency in line.

I looked at the cases continuing to drop.

I looked at the likelihood of the OB case finishing by 1900 (they did).

I looked at the 2030 appy time.

And, although the kidney emergency was the third call, I made the executive decision to jump the appy and schedule the kidney for 1930.

And of course the kidney case was difficult.

What should have been a 15 minute case turned into 75 minutes.

But sometimes you have to rank the cases on how sick the patient is.

The appy patient was sick.

But he was already ruptured.

The kidney patient was not ruptured but his labs were far worse.

So I let the kidney patient go second.

And, even though the appy started 45 minutes late and I didn’t get home until 0200, I am at peace with that decision.

Because taking cases as they come in is the guideline, sometimes you have to look at the kinds of patients they are.

And plan accordingly.

676,059 American Covid dead.

According to the CDC the 1918 Pandemic claimed about 675,000.

Well, we’ve beaten that number!

The deadliest pandemic on record.

Yay us!

I do not have a lot of words about this.

Just that it did not have to be this way.

Yes, the US population was smaller then, so the percentages work in our favor.

No, no one knows exactly how many people died, as records were spotty.

But 1918 did not have our current technological advances.

Also I think it is a no to knowing exactly many current era people have died from covid.

With the lack of communication, the fear about being labeled a covid death.

Sheer obstinancy.

676,000+ people are still 676,000+ who do not get tomorrow.

With the newest estimates that 100,000 more can die by the beginning of 2022.

😦

😢

This is more nerve wracking than I thought.

I have narrowed down the field for PhD schools to two.

Sinclair College of Nursing- part of the Mizzou family, with a personal history, online only.

University of North Carolina Greensboro- local, online and in person classes.

I started the UNCG application today.

It has a LOT of moving parts.

And I have to prove that I live in this state, and have since 2005.

I already submitted that information.

I get it, there’s a big difference between in state and out of state tuition costs.

I am undecided but I have to think about it, make charts.

You know, be me about the process.

Let me tell you, so much as changed in the world since I first started baby steps about applying for college in the mid-1990s.

Not sure if the fact that everything is findable online in an instance is an improvement or not.

Regardless, I am making my inquiries, checking my facts, etc.

So Doctor, well, PhD.

Maybe?

The post-it reads ‘timing is not a science. MD’s don’t follow a proscribed march to finishing cases. In short, shit happens. Please do not count your chickens before they hatch and rob me of a third CRNA and hobble the evening.’

Timing.

That elusive, misunderstood, much maligned view of how long cases are going to take to finish.

I could fill books with what I know about timing.

It is specific to both case, and surgeon

One surgeon may be 33 minutes on a lap appy.

Another may be 90.

It is all dependent on what the abdomen looks like when the scope is first inserted.

It is all dependent on skill level of the surgeon; the meticulousness of the surgeon, the poor, or not, protoplasm of the patient.

It can be dependent on the availability of the anesthesiologist; are they in another unit intubating, or on OB inserting an epidural.

It can be dependent on the OR team and their cohesiveness as a working group; do they have everything they need, including reloads of the stapler?

It can be dependent on the likelihood of the lap appy becoming an open laparotomy; CTs are only as good as who reads them, and sometimes there are surprises.

It can be dependent one who in pre-op is prepping the patient; we all know that one nurse who takes FOREVER!

There are many, many factors that need to be considered and tabulated regarding timing.

Times the number of surgeons, times the kind of cases, times the X factor.

It all goes into the OR charge nurse’s tabulation of time.

Mostly I get it right.

But I’ve been doing this for years.

This is a skill that is hard to teach.

This is a skill that is hard to learn.

However, the charge nurse and the head CRNA need to be in constant communication about needs of the department.

They should not send their third CRNA home at 1600 because no cases have been added.

And the phone rings at 1605 for an emergent case.

And the OR has been hobbled.

There are three teams available.

With 2 CRNAs.

And the emergency will have to wait.

As I was filling out the call shift application I came across a section that I answered in the negative 16 years ago when I applied for the hospital system when we moved to the South.

Of course, it was pen and paper then.

The section asked about military history and if I was active, retired, disabled.

The answer is none of the above.

And that may be why I have been hesitant to claim that I am a veteran after nearly 30 years.

I was in the Air Force Reserve Officer Training Corps while I was in college.

In fact, I had an immense scholarship from the Air Force for a private Jesuit university in the Midwest.

I was a year and a half in, with full intentions of going the distance in my Air Force career.

I was going to be a BSN.

I was going to graduate a lieutenant.

I was in the dorms, enjoying classes, including clinical.

When I fell.

The stairs were ripped up.

I can see how this happened.

Who takes the stairs?

The ROTC people do.

Any chance to exercise, including getting up at 0600 to work out with the Army ROTC.

I did a lot of damage to my labrum on my left shoulder because I was holding onto the railing as I was going down the stairs to the communal television on the first floor.

I had the first of two reconstructive surgeries over Spring break, three weeks later.

I could no longer do push-ups.

And sprinting hurt a hell of a lot.

And I was medically DQ’ed that summer.

This was before 9/11.

This was after Desert Storm.

This was before Afghanistan.

They decided I was too much trouble, I guess.

I was shown the door, stripped of my scholarship, and given a bill for all that had been spent on me.

It took me 10 years to pay off.

I graduated from a community college 5 years later, with my ADN.

After 9/11, when I went to a college fair at the community college I went by the Air Force booth.

They assured me I would be welcomed back.

But that I would have to get my BSN.

And they would not forgive the scholarship repayment monies that I still owed and was chipping away at.

I declined, as I would essentially be enlisting.

And I would not become a lieutenant until I graduated with my BSN.

This was before bridge programs made it so easy.

I didn’t get my BSN for an additional 15 years.

I feel ashamed to claim that I was a veteran.

Was I?

Today is the Air Force’s birthday.

Happy birthday.

I would have made a great officer.

2, 980, 376 minutes.

That is five years and eight months without an immediate use steam sterilization for total joints.

5 years and 8 months saying no to surgeons.

Until this week.

Because the surgeon didn’t want to wait.

A flash takes 13 minutes.

A pre-vac takes 25 minutes.

For an impatient surgeon that didn’t want to wait the additional 12 minutes for a pre-vac cycle, the no flash streak in the OR was broken.

For a surgeon that no one had the balls to say no to, the patient is at increased risk of infection.

For a surgeon that just had to have his way, the patient has to be monitored by infection control for 5 years.

Flashing should solely be done in life or limb situations.

I have been working on decreasing the IUSS in the OR for 7 years.

And they fuck it up in one fail swoop because the precious surgeon didn’t want to wait.

I am so disgusted.

And defeated.

And tired.

But, mostly, I am angry.

(the title is an homage to Seasons of Love from Rent: the musical)

For Cookie Thursday is a Thing this week, I decided to use Harry Potter as inspiration.

Which fits in with the literary month.

If you ask anyone who has read Harry Potter, a child, a teen, or an adult, what would they like to try in that fictional world, the answer is butterbeer.

I have had butterbeer at Universal Studios and it is butterscotch adjacent.

We’ll see what the cookies turn out like.

My normal meeting for the third Thursday of the month was cancelled by the CNO of the market.

Because of the Delta surge, you know.

It is not looking too promising to have a symposium in 7 weeks.

Especially if I have two slots left to fill with speakers.

Yeah, not looking too likely.

Even if it is virtual.

The memo/welcome letter to new doctors worked!

Yesssss!!!

It was toward the end of the shift and I was walking a piece of equipment over to the other OR when the phone rang.

It was a new doctor.

The one I had helped get scrubs the other day.

When he was here I gave him a copy of the welcome letter.

And today he followed the hints.

(happy dance)

I knew it would work!

I cannot stop looking at the death toll.

I look at it daily.

At night.

After I get home from work.

I knew that the death toll was nearly to 660,000 on Sunday.

As in 659,931.

But with the expected weekend lag with reporting I knew that the number would be reached on Monday the 13th.

And it was.

I looked back at other posts to see what had transpired.

The post I did about 650,000 was on September 8th.

5 days, 10,000 dead.

Of course.

However, I think the hospitalizations are lessening at my hospital.

And the hospital system.

You know, just in time for the Labor Day surge we all know is coming is here.

Please practice social distancing.

Please wear a mask.

Although the case volume is down our ICU and IMCU are still full of covid patients.

Be safe.