When a nurse co-signs a consent they are only witnessing the patient’s signature on the consent. Not that the surgeon has had a conversation with them about the risks and benefits of having or not having surgery. That conversation is in the H&P, signed by the doctor.

People don’t realize that. They think to be the witnessing signature the nurse has seen the risks and benefits conversation, and been privy to the questions the patient and/or their family has asked the doctor.

We do review the procedure as listed with the patient. But that is not what we are witnessing.

We are only witnessing that it is their signature on the signature line, Or that of their family member in the case of the patient who is unable to sign for themselves due to sedation or lack of mental capacity.

Consent is a complicated subject. And is different depending on where you are practicing.

And one that is not well understood. Even by the ones witnessing the signature of the patient on the legal document.

No abbreviations can be listed. Although I know what a lap is, not everyone does. To avoid confusion the word lap must be spelled out laparoscopy. The writing of lap appy on the consent is not to be done. What should be written is laparoscopic appendectomy.

Laterality is another big one. If there are 2 of a body part, it must be described in the consent with a descriptor, usually right, left, or bilateral.

As discussed before, the reasons for the rules is because someone, somewhere did not follow the rules and something happened that cause harm to a patient.

It is a common misconception that the Hippocratic Oath, recited by all doctors, contains the words do no harm. That part was removed when there was a new translation written in 1948. Some medical schools have their own interpretation of the oath as part of the graduation swearing in ceremony for new doctors.

The phrase do no harm is what many of the doctors and nurses that I have worked with cite as reasons to take action, or not take action, as the case may be. This issue is a sticky one that some people allow to color their actions, especially in medically necessary, but ethically dubious situations.

And then there are the patients who are unable to sign their own consents. This may be for a variety of reasons: age of the individual, mental capacity, decisional capacity, or the ability to make their own decisions, not being conscious, loss of ability to sign among others.

And then the big one: emergencies. This is a situation that arises where not to act or have surgery, would be detrimental and lethal to the patient. In other words, to save the patient’s life. But, oh no! There is no family that is easily reachable by phone. In this situation, 2 doctors may sign. But if one of the doctors is the surgeon, this may lead to ethical questions.

In the operating room, our work is driven by consents. It makes sense that we be as knowledgeable as possible.

Consent law is different in every state. Read up on yours. The life you save or impact may be a patients.

Not a post-it today, but a Facebook memory.

My husband and I had just moved into a different house. As I remember it, we didn’t have cable. But perhaps we had local channels only. Because my husband distinctly remembers watching the second tower fly into the South tower of the World Trade Center. This would have been at 0902 EST. We were living in Sonoma, and it would have been 0602 PST. Our memories do not match on this one.

What does match is that my mother in law called and woke us just as it was getting light outside. To tell us about the terrorist attack. To tell us to turn on the television.

The second plane hit the South Tower just after we talked to her.

And the plane that hit the Pentagon shortly thereafter.

Time does stop.

It feels otherworldly.

The closest thing that current day me can compare it to is the first month of the Covid-19 Pandemic.

But that day and those weeks felt never ending, and compressed at the same time.

I listened to the local NPR radio station while I unpacked boxes.

And my husband went to work.

After I finished the boxes I wandered over to the hospital, to see if they needed any hands.

This was when we lived a block and a half away from the hospital.

I was new to my RN license and I wanted to help.

I was convinced that there would be an influx of patients with chest pain.

I don’t know why I thought that.

Perhaps that the pain of an attack on US soil would prompt it.

These 21 years later have seen war, and more war.

And now domestic terrorism.

Mass shootings weekly.

Nowhere feels safe.

Where does it end?

Everywhere you look someone is trying to sell continuing education classes. Or bundles of classes. Easy ways to get the continuing education that keeping current on your nursing license requires.

Every where!

I know that some of this is algorithm based. And if you expressed interest, or signed up, or even paused too long on an ad you will get inundated.

Most of these are looking to provide a service for a fee. Or provide the CEUs for a fee.

But it doesn’t have to be that way.

There are many places that have free hours. They just might be a bit time intensive.

The hospital corporation that I work for has compiled a list of free CEU sites on the health library home page.

I’ve been collecting sites, not only for myself, but for others, including the medical library, for years. And frequently people ask for sites, often in a hurry because their renewal is in three weeks. Or less.

I have no problem paying for CEUs. Unique hours are often found here. These can be especially useful on a very short lead time.

The free sites are everywhere though. I keep a running list still that I give out.

The first place to start is the state Board of Nursing. Often, they will have CEUs on their site. There may some hoops to jump.

I would definitely suggest beginning there. At a quick glance, even the neighboring states have free CEs on the website.

In today’s digital world, CEUs can be found just about anywhere. For free, or not. It is up to each individual nurse’s preference.

Go ahead and learn.

But be careful.

Education can be addicting.

The theme for this month is baker’s choice. And this baker choses to make a fan favorite for the department.

Why?

Because what is Cookie Thursday is a Thing other than a morale builder for the department?

And this is the single most requested cookie from the department.

Today I used fresh jalapenos from my garden.

As always, no idea the Scoville scale on them.

This means the heat of the cookie may be uneven.

The cookie drawer was mobbed even before I left the breakroom.

I continued on my hospital based errands and took my clinical ladder to the person who uploads it to the committee that reviews them.

And while I was there, I had a bag of cookies. And I offered them the bag. I had kept this bag out just for this purpose. And they kept one.

Then I gave what was left of the bag to IMCU, or the step-down unit. And told them that

1. these cookies had jalapenos and to warn everyone who took a cookie
2. that the cookies came from the OR, well, more specifically me

I had started distributing small batches to departments as part of Cookie Thursday is a Thing earlier in the year. And then inflation reared its price busting head and I had to pause. Going forward I think I will add another department monthly, not weekly as planned.

Because homemade cookies make people’s day a bit better.

And that might as well be the subtitle for Cookie Thursday is a Thing, right after ‘It is Not Yet Friday, and We are Sad’.

According to the Merriam Webster Dictionary dissect is to separate into pieces: expose the several parts for scientific examination. Medical students do it in cadaver lab. Other kinds of students, all the way down to elementary school perform dissections on different things to learn.

As always, the OR is a bit different.

To a surgeon dissection means clearing the way to get to a body part that needs to come out or be repaired. This is important because body parts do not hang in the body, ripe for the plucking, or fixing. The body is an entire living structure. And sometimes the only way to get to the body part that needs to be repaired or removed is to machete a path down to it.

This is known as dissection.

And there are many types.

There is sharp dissection. This is using a blade, or a pair of scissors or a saw to get through skin, or muscle, or bone. These are all sharp things, hence the name.

There is fine dissection. This is using the tip of something, usually forceps, to tease a path through to the body part. This is useful for getting past delicate structures to get to a piece of the brain, or to get to a nerve bundle that needs to be repaired.

There is hydrodissection which is using streams of water or other fluids to gently part the tissues to achieve the objective. Cataract surgeons use this, and so do gynocologists when they want to save the fallopian tube by removing the ectopic pregnancy that is threatening the patient’s life.

There is blunt dissection where the surgeon uses their fingers to open the field. This can be done in cesarean sections when the abdomen is pulled apart by surgeons tugging on it to expose the uterus. Or when a surgeon sticks their finger in an incision and sweeps along the path they want to take, only using their fingers.

There is electrical dissection which is when a hot blade that is heated up by electricity is used to cut away what is obscuring the path. This is electrocautery, also known as a bovie. And it is very useful to make precise incisions into a body part when a sharp blade will not do.

And then there is the legal dissection that happens after a sentinel event. This isn’t on a body part, or even a patient. This is done on behalf of the patient, to find the root cause of the error that led to harm.

Many different ways to expose what needs to be exposed so that the ectomy, which is the removal of something, or a repair of the exposed part.

With all these different ways to expose something, the circulator has to know and anticipate what is needed. A surgeon would only use a different method if their preferred method was unavailable.

Although, as circulators, we are not wielding the knife, or the bovie, or the fluid we still have to be aware of the risks of all of them. And where they are in the case of an open belly. The knife blade and bovie tip are countable.

Why?

Because something happened somewhere and led to a root cause analysis.

That is often why we do things.

Because someone, somewhere messed up. And we should heed the warnings and not go down their path.

It has been just over 10 weeks since Roe v Wade was overturned in the Dobbs decision. And the news about abortion and desperation in some states keep getting darker and more sinister.

I mean it was bad enough to be informed that a woman’s worth is only based on what she can create and carry in her body. You can extrapolate and say that a woman’s worth is only her womb. That she has no decision power of what is carried within her womb, or when. To carry the idea to its conclusion women without a womb because of surgery or genetics and women who have hit menopause are worthless. Not the girls who have not yet started their periods yet; they still have value because of the potential yield bearing of the womb that is still under construction and not ready for use.

Insert eye roll here.

In other news, a 16-year-old in Florida was denied an abortion because the court felt she was too immature for an abortion. Wait… too immature for an abortion but mature enough to raise a child? Or did the state want to take the child upon delivery and give it someone more mature (worthy)? This is Handmaid’s Tale level bullshit.

insert eye roll here.

A man in Texas decided that abortion care in states where it is illegal could be a good business model. A for profit business model. He outfitted a boat in federal waters off the coast of Texas with necessary medical equipment, healthcare professionals, and doctors and started providing abortions to those left without care in Texas and surrounding states. This is a novel approach, and, so far, he is not charging exorbitant fees. But even he says can you believe this is what it has come to? The level of secrecy and subterfuge for these women. There are sonogram codes, they have to leave their phones behind on shore, they are motored out to the boat for treatment. It is absurd. Not that someone saw an opportunity, but that these women have to go through this for medical care on their own bodies they no longer have a say over in their state.

In neighboring Louisiana, a mother has been told that her fetus has a death sentence outside of the womb. The fetus is growing without the top of the head. This is not compatible with life and is termed acrania and is not one of the narrow reasons that someone decided were the reasons for an abortion. If we were to name every single thing that was terminal for a fetus, we would be here for a long time. And still circumstances would arise where the body decided on a new fatal flaw.

Another eye roll; can I see my brain yet?

And the political person out west who does not understand why the woman even needs to be involved. After all, everyone knows that there is no connection between a fetus and a woman. Or the always popular just reimplant the ectopic pregnancy crowd. Say it with me; this is not a thing, this has never been a thing, this will never be a thing in a human body. And how do you propose to study this? Torture those that will die?

Women die from ruptured ectopic pregnancies. And now the state and the court are involved in deciding who gets care for this true medical emergency. A woman with an ectopic pregnancy was sent home to “wait it out” because there was still “cardiac activity” and the hospital could not do the surgery. On a non-viable pregnancy. That can be lethal to the woman.

My head hurts.

In a ray of hope some teens are running their own sex ed. Because the adults in their lives have failed them and failed to provide accurate information that is not abstinence. Which is withholding critical health information from children so they can make well-informed decisions about their body. Because abstinence only sex education does not work, as has been shown time and time again. We can only hope that they are using correct information, because the adults sure aren’t. The teens in Tennessee who are the subject of a Washington Post article are. And sharing with other teens who want to know. Because if you know, you can protect yourself in this scary time.

These laws are terrifying to doctors and hospitals because they are so capricious. And in many of them, the doctor or the hospital can be held liable and go to jail. And probably lose their license to practice medicine. This is how it is impacting hospitals and healthcare workers. Even if this is a practitioner in a state that has not enacted laws. Even nurses I know from these states feel that it is coming, and they say abortion hasn’t been outlawed in their state YET.

But what society does not take into consideration is that they are torturing the child that has fetal abnormalities, mostly fatal. No conversation has been had about that. Women who would have otherwise had an abortion just to decrease suffering in their child and can no longer do so. Where is that conversation? Some of these children are born into a world where all they know is pain and suffering. Who is speaking up or advocating for them? Or advocating for their parents who know that their child is suffering a needless, cruel fate?

It remains and has always been about control and the old white men who fear losing it.

The gown card reads ‘Tell me the patient is dehydrated without telling me the patient is dehydrated. There is a kidney stone/appendicitis.’

Both are true stories.

Dehydration leads to stagnant urine making in the kidneys, which leads to kidney stones forming more readily. Which leads to said stones migrating from the tight fit renal pelvis in the kidney, to the very, very, very tight fit in the ureter, to the roomier accommodations in the bladder, to the very tight fit in the urethra to the outside world.

This is painful to the extreme. There is a reason that kidney stone pain is compared to childbirth. Ask my sister, she’s had both. And she texted “It is more painful that childbirth. Excruciating 10 out of 10 pain.”

Of course, being of the same genetic stock as I am, she worked the next day. And mowed the lawn.

I’m so proud. And it was absolutely what I would have done.

And what season is dehydration most prevalent? Summer!

Drink the fluids, folks. The next kidney with a stone could be yours. Not that dehydration is the only cause, but it can be a big one. Genetics may play a role. Some people are known ‘stoners’.

Yeah, we make that joke in the OR on repeat patients with repeat stones.

What are the symptoms of a kidney stone?

It, of course, is different for everyone. But many people have low back pain.

But, Kate, doesn’t everyone?

Yes, but this is mid to low back pain (depending on stone location) that actually is exacerbated by movement. There is also the difficulty in urination, blood in the toilet bowl. And let’s not talk about what happens if there is an associated kidney infection. This can lead to sepsis, can lead to an ICU stay or even death. It is nothing to fool around with.

Appendicitis can also be linked to dehydration. Appendicitis can be caused by a piece of poop that gets stuck in the neck of the bottle. The appendix only has one opening, like a bottle. And, like dropping Mentos into Diet Coke, the pressure is what leads to pain, nausea and vomiting, and ultimately surgery. And dehydrating poop makes it sticky, which makes it more likely to stopper up the bottle.

Drink your fluids. Push them often on family members. The best fluid is water. Although there is a folk remedy for kidney stones which is cheap beer. This leads to a host of other problems. such as impairment and tickets and, ultimately, the loss of your license if you choose to drive. Don’t do that.

Just drink your water.

Because urosepsis due to kidney infection due to a stopped-up ureter due to a kidney stone can kill you. Appendicitis can also be lethal.

Enjoy your summer, but don’t die.

Okay.

New theme for Saturdays.

Since Funsies Fridays has been changed to Saturday. Not that I think I am that funny. Or organized enough to continue Fridays when I have class all day every Friday. I am not that organized. Trust me.

And I know that I am not the only nurse who is in school, or thinking about school, or preparing to think about school. The why is different for every other nurse but the 10 nurses in my PhD cohort said they were doing the program to aid the public in the very real problem of health disparity. This could be disparity of race, of gender, of sexual orientation, and more. It all fits.

And then there was me who said I wanted to do the program so I could do research specifically in the operating room. This is very seldom studied area of the hospital. Most studies and research are done from the doctor point of view. Well, buttercup, the surgeons are nothing without the support of the operating room staff. Just like the OR staff is nothing without surgeons to operate. We go skipping the halls hand in hand.

Even if a nurse isn’t actively pursuing a degree, they are pursuing education in the form of CEUs. These are continuing education units. There is ALWAYS something new to learn. And all that knowledge goes back into improving health outcomes for our patients. And it is required to maintain licensure from the state. The hours required will vary depending on the state.

And CEUs are required to maintain certification. The CNOR that I hold requires 135 CEUs every time I recertify, which is every 5 years. The nurse anesthetist requires 100 hours every 4 years. There are other certifications, but this is what I know and am familiar with.

The point is that nurses, especially certified ones, are an educated bunch. And we are always learning.

Some nurses only do what is required for licensure upkeep. And that is okay. Not everyone is as education crazy as I am. But continuing education hours still need to be maintained. And the board of nursing can audit a nurse at any time. It is not worth it to fake it. In California, you had to list the CEUs on the renewal form. Ditto for my CNOR recertification.

Are there cheats? Absolutely, but there are only hurting their patients and themselves.

At the end of Philosophy yesterday, I made a general announcement that there will be a 2-day symposium on reversing the chronic disease crisis in America. I thought this would be useful to many of my cohort. There was interest, just in that little group, and my professor asked me to send the information to her and she would post it on the graduate degree page.

That’s the thing with education and nurses. Someone is always interested in learning more. This has been lost a bit during the pandemic. And it is time to get it back.

You know, if you want to.

Cookie Thursday is a Thing has a new theme for September. The days are marginally getting cooler, kids are back in school, I’m back in school. I’ve not baked a cookie for cookie’s sake for 4 months! That is way too long.

First, we had inflation baking in May. This was in reaction to the inflation, especially around food and I baked vintage recipes from the 1930s. No butter or eggs was the main thing. The impossible cakes that I turned into cookies.

It was so popular, and inflation was so overwhelming, and I still had so many inflation baking recipes that the theme repeated in June. And I learned a lot.

And then the Dobbs decision came down from the Supreme Court. This kind of branded women as being worth only what our uteri could produce. And told us that we had less than no value. And If You Want Women to be in the 18th Century so Badly… July theme was created. Cookies and bakes from the 18th century. Learned some more interesting things. I love looking things up. Am I still mad as hell about this. You better fucking believe it. Me and more than half the country.

And August. August is hot here in the South. Too hot to put on the oven. For seven years this month has traditionally been no heat month and I don’t turn on the oven at all. And it is the month of the Back to School Ice Cream Social that the entire department is supposed to participate in. Good idea in theory, and when I was there every day I could exhort and prod people to participate. Yeah.

It is now September and I want to have fun with Cookie Thursday is a Thing. And bake things that I’ve been missing over the last 4 months. It’s going to be a blast. I just hope the cost of butter comes down. Cookie Thursday has always been done on my own dime.

First up in this 5 Thursday month is one of the original recipes I created for Cookie Thursday is a Thing- the watermelon cooler. Lemon cooler is a cookie that exists, and lime cooler, but I thought, what about watermelon. There is not a fruit that screams summer to me more than watermelon. Which both is and isn’t a subtle flavor that plays well. But watermelon itself does not mesh well with cookies as it is much too wet.

Trader Joe’s had a watermelon jelly. This made a good starting point. And I looked for a watermelon extract; I mean something has to be in all the watermelon candies. And it exists! And watermelon itself is very juicy, perhaps I can use a couple of tablespoons of it in the recipe. And I didn’t want a tremendously sweet cookie as some watermelon candies tend to be. A mix of powdered sugar and cane sugar solved that.

And the watermelon cooler recipe was born. Not too sweet, not too overwhelming a watermelon flavor because that can be bad.

At the very bottom of the gown card I put the recipe on is a note. Try with feta.

Well.

Interesting.

There was a salad that made the rounds last year of watermelon and feta with a bit of balsamic dressing. It is amazing. If you’ve never had it, go and make some right now!

I knew I wanted to at least try feta in the watermelon dough. But not the entire batch, just a cookie sheet worth of cookies.

I baked four cookie sheets of cookies, carefully reserving some for this little experiment.

To the reserved dough, which was about 1.5 c of dough, I added 1/8 c of feta. Can’t wait to see how this turns out.

Experimentation is the name of the game with Cookie Thursday is a Thing.

Will report back later.

Yes, I can’t believe we are still talking about covid.

It is still lethal, killing about 400 people A DAY!

I read an article where the death rate was stubbornly flat. This means that the number of people who are dying is staying consistent, day after day.

We want the number of dying a day to go down. It’s not going up, yet. That is something. But I, and all healthcare professionals, would prefer it going down. Trend lines are big in healthcare circles, and it is hard to affect a flat one.

We still don’t know how many people are infected due to the decrease in testing, and, if you are testing, the decrease in reporting of positive cases.

The perception of the pandemic is beginning to grind down. Masks aren’t required in most schools as children go back to school. Most of the population does not mask up in public, even if the local rate is red.

Free testing kits from the US government ends on Friday. England ended their free program on April 1st. Many states have ended their states of emergency for covid. The United States government extended the federal state of emergency recently until October 13, 2022.

Because it remains a serious threat to us.

I wish I could people to realize the extent of it. I get it. People are sick of covid. I’ve said it before; we are ALL sick of covid.

There is going to be a new booster shot entering the arena very soon, possible as next week soon. Maybe.

Breaking news: Omicron variants have their own booster! This is important because it remains the most prevalent variant out there, with others knocking on the door to be let in. And the covid vaccines have been proven to lose effectiveness over time.

For those of the population under 55 and not deemed vulnerable enough the wait has been long. Especially as BA.5 rages. I know my husband will be among the first in line to get it. He tried very hard to get one before we went overseas but was rebuffed. Apparently, they were wasting boosters instead of putting them in willing arms.

Covid is not over, all the wishing on a falling star, or the first star you see at night, or on a wishing well will not make it so.

I cannot stress this enough. Covid is not over, and we are heading into the colder months where infections ramp up. Thousands are dying every week. All that potential snuffed out.

Wash your hands. Wear your mask if the threat level is high where you are. This will change often, keep an eye on it.

Get your booster, the life you save may be your own.