This month’s theme is Blast from the Past.

Cookies and Makes that I don’t make very often and haven’t made in ages. Sometimes years.

It has been nearly 6 months since I made the perennial favorite if 90% of the OR: the jalapeno chocolate chip cookie.

This month I had to make do with diced jalapenos.

I put 3 tbs of diced jalapeno in a quarter cup of water and let sit overnight to rehydrate the bits.

It isn’t ideal but it is what I am working with.

The fluid is then added with the eggs during the making of the batter.

Make as usual.

Standard Toll House chocolate chip cookie recipe.

I’ve done it this way a bunch of times.

And the cookies spread out very thin, making for a thin, crispy cookie.

Odd.

New baking soda. Room temperature butter, room temperature egg.

It just goes to show you that you can’t control for every variable.

But I think there is something going on with my oven. The cookies baked very unevenly, one side baking faster than the other. I am familiar with the back of the oven being hotter than the front and I can correct for that with size of the dough balls. But the side versus side unevenness. I have to read more about this.

I love my little oven. It is 16 years old at least. And I get a LOT of use out of it.

Next week I will use the standard-sized oven and see if that makes a difference in even baking of the cookie sheets.

If it isn’t one thing, it is another.

This is the 5th post about Counting Basics.

Rarely.

And, I mean rarely, there is a case that is completed without additional instruments being added.

These can be small: a forcep.

These can be bigger: a retractor.

These can even be bigger: an entire extra tray.

Sometimes a surgeon does not want to pause when an instrument set that they asked for is added.

But take the time when a new set is added to do the count.

Anytime something new is added to the field, it must be counted.

ANYTHING!

ANYTIME!

If the surgeon pushes back, inform them that this will save time in the end because the OR room will not need to take an x-ray because the count was not correct.

I mean, sometimes there is literally zero time to count additions.

That is a very rare case and most likely an emergency. This case we are doing of a lipoma removal is not that case.

Trust us, doc. It is better and safer if we take 30 seconds to count off an additional tray. Especially if the patient isn’t actively dying. Okay? Glad we had this talk, now suction something or bovie something to keep your hands active.

Any additional single instruments need to be added to the count sheet. Or multiple instruments.

Just let us get on with it. I will have your scrub tech back to you momentarily.

The count sheet will be Counting Basics 6.

Yes, the world is on fire.

Earthquakes.

Death.

Destruction.

Snow at the Hollywood Sign.

Unprovoked war justified in a megalomaniac’s mind as getting the old band back together. And by old band I mean the glory days of the empire. You know what I am referring to.

Governors and state governments deciding about women’s bodies.

Not a lot that I personally can do.

I can decrease my carbon footprint. We can be good stewards of our energy consumption and overall commodity consumption. No fast fashion, not that do fashion. Interacting with the neighborhood Buy Nothing group. Reuse, recycle, reduce.

What I do have power over is not participating monetarily in conferences in states that have been egregious about a women’s right to bodily autonomy, and hatred of what they don’t understand, including books.

I am looking at you Texas and Florida. I just won’t engage in conferences at either place. And what’s more I inform the groups holding the conferences why.

In detail.

This I have a small modicum of control over.

Will it do anything?

Probably not.

But I can tell people the reasons I have for not engaging in conferences in these states that do not value women. Admittedly this is made easier by attending the conferences virtually. That way the organization gets the money, not the states.

And maybe I will start something.

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

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

It is an entirely different mindset.

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

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

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

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

It means debris.

In fact, that is a much better word choice.

Evening shift cleans up day shift’s debris.

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

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

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

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

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

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

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

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

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

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

Just be kind to your teammates coming after you.

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

See, shudders.

I’d rather not, thank you.

There is always one of three archetypes

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

You can be all of these at the same time.

I know I can.

I just finished a midsemester project for statistics.

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

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

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

Back to the group make-up.

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

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

I can do math. I know how this works.

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

Nope.

There are 2 groups and 7 singletons.

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

To keep me on track.

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

Because all of this is self-inflicted.

I guess there re some good points about group projects.

I could have shared the misery.

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

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

Or didn’t want to impose.

I will know better next time.

After the presentation-

well

I misunderstood that assignment

Clearly I would have benefited from a partner.

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

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

Yeah.

That happened.

And now I wait to hear what the professor thinks.

The last day to drop the class is next Friday.

Stay tuned.

It might get bumpy from here.

Isn’t hubris fun? Asked no one ever.

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

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

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

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

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

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

I had mini chocolate chips. And I used those.

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

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

There are only 4 ingredients in the recipe.

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

2 cups pancake mix

1 c milk

3 eggs

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

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

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

Now to the nitty gritty of counting: the instruments.

There are a few rules for when to count instruments.

The first is the beginning count.

This is the pre-incision count.

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

Basically, don’t screw it up.

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

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

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

ALL the instruments.

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

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

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

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

What goes in, must come out.

Unless it is meant to remain there.

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

This totals 60 instruments that must be counted.

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

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

This is why the count is so important.

It is a matter of patient safety.

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

I will not revisit that.

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

I can deal.

There is an urgent case.

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

45 minutes.

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

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

Deep breath.

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

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

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

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

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

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

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

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

And they proceeded to test the irrigation. Twice.

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

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

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

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

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

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

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

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

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

Aargh!

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

Joy.

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

That’s it.

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

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

Yes, stewardess. It is a 1980 movie.

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

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

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

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

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

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

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

Grades happen.

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

I’ve never really been into checking my grades.

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

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

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

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

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

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

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

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

And then the MSN.

And now the PhD program.

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

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

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

Nurses doing what is uncomfortable since 1850.