As I wait for August because all the exciting things happen or begin in August, I have been doing a lot of continuing education. I mean I have to keep the learning muscles up and ready for school. I get different CEUs from different sources. Or. sometimes, I don’t get CEUs but they are important talks to attend.

Including different avenues from the hospital. This past month I did a research symposium where I learned a lot. And my advisor for university was the key note speaker. And at the end of last month I did a class on the Pause. This was not the surgical time out. This refers to the moment of silence among the healthcare workers after an unsuccessful code blue and the patient dies.

Because we are not going to win them all.

This is an intentional pause.

It is done to acknowledge the patient who has just died. Because they were a person with hopes and dreams and desires in life. And they had every expectation of going forward with that life.

Until they couldn’t.

It is also done to acknowledge the healthcare team who were working to save them. And all their individual effort during the code.

And couldn’t.

The Pause is an international practice. And was started in 2009 by Johnathan Bartels, an emergency room nurse. And has spread since, even to television shows. I think this is something that has always been done, to some extent, but now it has a name. And naming things is influential.

This is a way to acknowledge that with all of our medications, and tools, and machines, this person who had value was unable to be saved. It is a moment to recognize that something momentous has happened. And while momentous things happen every shift, especially in the ER, this was the patient’s momentous thing. And it was also a thing that happened to the healthcare workers.

To me, the pause is a moment to recognize that this has happened, to realize that there will be changes in the survivors lives, and to realize that were will be a change in my own life. Because every death impacts the healthcare worker. The pause allows healthcare workers to realize that something has happened, to acknowledge that it happened, and to set it aside to help the next patient.

This 1 hour webinar was powerful. And made me think about the times I have pronounced a patient dead while working in med surg. And all the times that perhaps went unacknowledged in the last two years as patients died alone in their beds. Except for the healthcare workers who were there. And they just kept giving care to their next patient after pausing to reflect, very briefly, on the one who just died.

I hope that understanding that someone was there when they couldn’t be gives comfort to the families.

All last week I waited with bated breath watching for the FDA to finally approve the covid vaccine for children ages 6 months to 5 years. I have friends who have been waiting for this for as long as their babies have been born.

The approval finally came down on Thursday.

And the CDC followed up on Saturday and voted unanimously to grant emergency status.

Yes, it is true that kids don’t get as sick as adults. But it is still potentially lethal to children, as at least 450 kids under 6 have died.

I know people who have been in virtual lockdown as there is a member of the household who cannot get the vaccine and cannot send their child to pre-school or school in case they bring the virus home to their family member.

Is vaccinating their child a choice every parent will make? No.

Should they consider the options and not listen to histrionics who claim that the vaccine magnetizes your child or you, or has a tracking chip in it? Yes.

People like these who have politicized the vaccine roll out because it suits them and go on to poison others with their warped thinking are the reason covid is still a thing. And still evolving. And people are still dying.

There are new variants I’ve been watching in the UK-BA.4 and BA.5. This variant seems to be able to somewhat dodge the antibodies from vaccination and infection. But if we keep going like we are down this path of variants there will be a variant that can completely ignore the antibody status, regardless of how it is obtained.

And then we will be right back where we started. A virus with no vaccine that can teach your body to attack the virus.

And the hamster wheel would begin again.

Don’t make us go back in time.

Get your vaccine.

Vaccinate your children.

This is the only palatable way of ending this.

And if I have to plan my trip to the UK again for the 5th time, we will have words. And they will not be nice ones.

The post-it reads, ‘if you act like prey, you will be treated like prey’.

We have all seen or heard of the attacking surgeon, have we not?

The one who paces.

The one who complains when their case is late.

The one who complains when their case is early, why didn’t we tell them.

The one who complains about the team in their room.

The one who complains about the team from two weeks ago.

The one who complains that the scissors are dull.

The one who complains that the light source is not bright enough.

The one who complains about the room being too hot.

The one who complains about the room being too cold.

Okay. I was only kidding with that last one. The room can NEVER be cold enough for some surgeons.

Complaints aren’t attacks, although they can feel like them sometimes. And some surgeons live to complain. This makes their room unpleasant to be in. But they are not frightening.

But some of the OR staff may find them intimidating or frightening. And some staff may refuse to go in their room because of this.

This is the wrong approach.

If staff acts like prey-timid, questioning, afraid to speak up. This signals to the surgeon that the staff are not confident in their skills. Which makes them doubt the staff. Which makes them do all of the complaining above.

If a surgeon is acting like a jerk. Tell them. Tell them exactly what you find objectionable about their behavior.

In my experience, they will back off, if not apologize.

And if they don’t back off, report to management.

Do not act timid in front of them.

If any of the staff would like to borrow some backbone call me and we’ll talk through it.

At the end, everyone in the room just wants what is best for the patient. And if their behavior is causing the patient not to be safe because the staff in the room is too intimidated to speak up, tell them to knock it off. Or find someone who will.

The post-it reads ‘using scripts with patients’.

This is something that healthcare has been doing for years. And not just at my hospital.

Scripting is when you use words that you did not write, even if you mean them.

Healthcare providers as a whole are not eloquent. We use jargon too much. We forget to dumb it down for non healthcare people. Not that non healthcare people, aka patients, are dumb, but they don’t know the lingo. And they sometimes feel they are drowning in the alphabet soup that healthcare uses as a shorthand to get a lot of information across to someone who knows and can interpret the lingo. So ixnay on the lingo in front of patients and families.

Sometimes the patients think they know the lingo. This can lead to misinterpretation of the facts when they try to be hip and cool like the healthcare personnel. And cause a headache for the healthcare provider trying to be clear and concise when they are speaking to a non healthcare type person.

The worst kinds of scripts are the ones that are tailored to the patient surveys they receive after care. These scripts use the exact words of the survey questions in order to trigger a memory when it comes time to fill out the surveys. These are not bad on their own merits but feels like cheating. In fact the hospital has told us not to use exact wording from the survey questions. It seems that patients are figuring out that is what’s going on and leading to a mild backlash. They know they are being programmed, in a way, to respond to a certain question in the manner the provider would like. And if there is anything that has been made absolutely clear in the last couple of years, patients do not like to be told what to do. Even if it will save their lives or someone else’s.

Scripting is in fact a programming language that is used to interpret and execute one command at a time. Kind of like healthcare worker trying to get through to their patient the importance of this one little thing. Like the dangers of smoking. Of taking their medication as prescribed. Or avoiding covid.

When I tell you that the patient is an LOL, NAD, CAD, DNR, that may mean nothing. Or it may mean that the patient is an elderly woman, in no apparent distress, with cardiac arterial disease who is a do not resuscitate. Or, where it is dangerous and misinterpreted, when the family decides that all of that means we do not care about the patient, that she should just die. And instead it means that we will treat the patient, take care of her ills, until the time that her heart stops. Because there is a lot of things that can be done until then to make her comfortable.

I’m not sure how I got on to the alphabet soup from scripting conversations that healthcare providers have with patients that mimic the survey questions they will fill out after their care but here we are.

If you get a survey, fill it out. Be honest.

Healthcare entities use these surveys to fine tune care. But don’t let a bad day or a bad experience that is outside of the care provided, such as you got cut off by a driver leaving the hospital, color the survey.

The call case is nearly complete. The surgeon has dropped, which means he has finished and probably left the room to put post-op orders in and speak to the wife.

The two most dangerous times in any case, from an anesthesia standpoint, is going to sleep and waking up.

There can be shifts in blood pressure at both occasions. The heart rate can be affected. The respiratory effort has to be engaged as the patient has to breathe on their own after surgery. All of the gas that has been maintaining the general anesthesia is turned off and the patient breaths off the gas, either by the machine, or on their own.

Different CRNAs will turn off the gas and begin the waking up procedure at different times. It all depends on what they are comfortable with. Many times the waking up process starts too soon and the patient starts to emerge from anesthesia at the wrong time. This is usually before the surgeon is finished closing and the surgeon will tell the CRNA that the patient is bucking. Or coughing against the tube. And the CRNA will need to add more medication (likely a paralytic) to the line or reestablish gas to get the patient deep enough to finish closing. This is fraught with peril if the case in question is a hernia, because the entire repair can be ruined with ill-timed coughing and must be redone.

Sometimes the case is quicker than anticipated by the CRNA and medication reversal must be given. There are several medications that can do this. And they all have an associated cost. The other option is to wait for the medication and gas to wear off naturally. This is frowned upon because it can take many minutes and there is always another case to get started. Also, OR time is charged by the 15 minute increment and it costs the patient money to have a slow emergence from anesthesia. It also exposes the patient to the risks of emergence.

The scrub tech puts the dermabond, or skin glue on the skin over the port sites. This is the dressing that the patient will go home with.

During this time, I keep an eye and an ear on the CRNA and the patient as I am doing my end of case work. I catch up on the charting of the times, except for out of room time. I bring in the gurney and untuck the arm, if that is the arm that is closest to the corridor door. I put the gurney next to the bed, adjusting the height as needed, put the slide board on it with a chux pad. I lock the gurney. After I have done this, I stand by the side of the gurney and am ready to assist the CRNA as needed. I have my OR phone in my pocket in case I need to call the anesthesiologist stat. I watch the patient and the CRNA closely, watching the color change of the face, and the monitor numbers. The scrub tech is breaking down her table and stacking instruments.

The CRNA is making final adjustments, checking pupillary position, checking patient’s response. Some will wait until the patient grimaces or opens their eyes to command. The patient will no remember any of this but this is a way to determine readiness for extubation.

Finally the CRNA is satisfied and, suctioning the mouth, deflates the balloon on the endotracheal tube and pulls it out. The entire reason I did not pursue CRNA work is that there is a year in ICU that is mandatory. I have no desire to work in the ICU and I hate respiratory secretions. That is a hard no for me and my nursing kryptonite.

Assessing for responsiveness the CRNA will put a nasal cannula on the patient. And a mask over it. Intubation and emergence are aerosol producing events and if covid has taught us nothing it is to control coughing. Extubation does not always lead to coughing but it most likely does.

If the PACU nurse or anesthesiologist is about I will ask them to grab feet and assisting with transfer back to the gurney. If the patient is over a specific BMI I will insist on this. Otherwise a pillow is placed under the patient’s calves. Or, better yet, a pad from the armboard is, slick side down. It slides better.

The CRNA controls the head and counts us in. The scrub tech log rolls the patient to their side. I always am the puller and I place the chux and slide board under the patient. We allow the patient to roll back to their back and glance at each other. I do a quick check of the locks on the gurney, by tugging on it, and I say to the group “Locked.” The CRNA counts us 1-2-3 and I pull the chux pad on the slider, the scrub tech pushes from the opposite side, and the CRNA brings along the head and shoulders. Presto, the patient is on the center of the gurney and the legs slid over on the upside down armboard pad. When I am the puller the slide board is visible on the other side of the patient, ready to be grabbed my the scrub tech. Sometimes we have to roll the patient a little to get the board out, depending on their size and the skill of the puller. I take the upside armboard pad out from beneath their calves and replace it on the armboard.

Why am I always the puller? I have a body mechanics routine for this. I do not use my back. Never. I have seen many nurses and techs get injured being the puller. I use my glutes and my hamstrings. When I was a CNA in a nursing home I assisted a 400+ patient out of bed every morning by honing this technique. I’ve tried to teach it to others but they prefer to rely on their back muscles, despite repeated warnings not to. Sigh, you can lead a horse to water…

Now that the patient is safely on the gurney, the CRNA assesses their breathing again. I pull up the side rail on the side I am on and grab the chart and the specimen bag, tucking it on the end of the bed. Using the OR phone I call PACU and tell them we are incoming.

The CRNA nods and connects the nasal cannula and to the bottle of O2 that is on the gurney. I unlock the bed and pull it away the OR table. Pulling up the other siderails, we get ready to move out.

The Inflation Baking theme is continuing on for a second month.

But this recipe has 3 tablespoons of butter in it. That’s cool, I think, a normal batch of cookies has 16 tablespoons of butter in it.

Again I pulled out the mini muffin pans and filled each well 3/4 full.

I topped each one with one of three things.

Blueberries.

Raspberry.

Or mini mini chocolate peanut butter cup. These things are maybe a centimeter big. I bought them to use as a chocolate chip substitution.

One muffin pan always sticks. I think I will clean it up and find another use for it. Or donate it.

Covid is surging again. The hospital went from 1-2 patients to 8. All in a couple of weeks.

I’m just over here wearing my mask if I go ANYWHERE.

But, hey, at least there hasn’t been any mass casualty events because someone got mad and decided to take it out on the healthcare system trying desperately to help.

Knock wood.

Our London trip is in 8 weeks.

Sigh.