Call Secrets of the OR- OR investigations

Once upon a time that really happened, the patient was not waking up the way they should. All the anesthesia gases were off, the reversal agent given at least 10 minutes, but they were not opening their eyes or making any effort to, you know, breathe. Time ticks by, first five minutes, and then 10, and then 15 minutes. The anesthesiologist has been called to the room.

While anesthesia is trying to wake the patient up, you drag the workstation on wheels to the patient’s bedside so you can be an active part of the extubation, but also able to read the chart looking for clues.

There are none.

Time for a group think.

You ask about family history that isn’t in the chart. You remember that there is an enzyme deficiency that delays the clearance of anesthesia. You remember because one of your med-surg patients had it and would call for a certain medication whenever she woke up from anesthesia. You remember her telling you that she had a liver problem in the beginning of this conversation. And not only did she have it but so did her youngest daughter. And the last time there was a very long delay in waking up from anesthesia on one of the cases you’ve worked, it was also an enzyme deficiency. The same one the med-surg patient had.

The anesthesiologist goes out to the surgical waiting room to ask about family history of slow wake ups. This was covered in the pre-op consultation at bedside but this is a check in that what the patient and family said pre-op is correct. This is where they remember that grandfather would talk about the time that it took so long for him to wake up after surgery that when he finally did it was the next day and he was in ICU. But no one else has had a long wake-up. Not that many of them had ever had surgery other than babies.

There is such an enzyme deficiency that causes this. It is called pseudocholinesterase deficiency. This is an enzyme that breaks down anesthetic medications, such as succinylcholine. This is the medication that is often used to paralyze the patient prior to intubation.

Unknown to any of us, and the patient, and the family, this patient had a pseudocholinesterase deficiency. Their liver wasn’t metabolizing the paralytic, which kept them unable to breath on their own.

This is a quandary. There are two paths. The first is to keep the patient intubated in the operating room until enough time has passed to allow them to breath on their own. This is costly as an OR minute is expensive and who knows how long it will take before the patient wakes up. And also it effectively ties up the anesthesia team and leaves OB especially vulnerable in case there is a stat section. The second path is to keep the patient intubated, call for a ventilator to be brought to the PACU, and admit them to the ICU. Not long, just long enough for them to start breathing on their own. This can be anywhere from 2 hours to 12 hours.

The decision is made to move the patient to PACU and the waiting ventilator. If they are not extubatable at 2 hours, then PACU would move the patient to the ICU. Because call back time for the PACU nurse is expensive.

The first thing to do as the OR call nurse is to check the hospital census. This is a picture of what rooms are available. The second thing is to call the supervisor and tell them about the situation and the steps that might need to happen going forward. They promise to save an ICU bed.

The patient is moved to PACU, and attached to the ventilator and the monitors.

The waiting begins.

After the patient is settled in PACU, on a ventilator, you call the surgeon, who has been long gone, to tell them of the situation. Regardless of the working theory it is pseudocholinesterase deficiency, the surgeon still needs to be informed of what is going on. You tell the surgeon of the plan to wait in PACU for 2 hours and then the admission to the ICU if the patient is not yet awake.

You check in the PACU nurses and tell them that you’ve called the surgeon and gotten them up to speed on the situation. If there is nothing else, you will be heading home because OR call back time is expensive and being in the PACU when there are 2 recovery room nurses is expensive.

You remind them that the nursing supervisor is aware, there is a bed being held and the surgeon is aware. They run through the plan again with you of 2 hours intubated in the PACU and then, if not awake enough to extubate, admission to the ICU. They tell you to go home.

On your way out of the PACU you pass the anesthesiologist who is writing a letter to the patient advising them to be tested for pseudocholinesterase deficiency and advising them of the importance of having the family tested to. Because this is a genetic deficiency and is passed down. Like the patient’s grandfather likely passed it down to the rest of the family.

Luckily there is a test for that.

You tell the anesthesiologist that the PACU nurses know the plan and ask if they’ve spoken to the family again. If they have, you are going home.

The anesthesiologist assures you that the family has been spoken to and are waiting to see which path is to be taken.

You head home.

In a rare follow-up, you learn that the patient was able to breath in the PACU after an hour. They were extubated and sent home with family. The entire family was aware that they had to be tested or tell the next hospital and operating room they found themselves at.

This was the best case scenario. If the patient hadn’t been a young, health individual with a possible family history of pseudocholinesterase deficiency, more steps would have been taken in case it was something else. A head CT would have been the next stop to check for a stroke, and labs would have been drawn.

But not this patient. They were able to be extubated and go home with their family. With a heck of a story to tell and homework to do.

Medical non-fiction book review 8/17/25- Beyond Limits: Stories of Third Trimester Abortion Care

Beyond Limits: Stories of Third Trimester Abortion Care by Shelley Sella, MD. Published 2025.

Do I have any idea how this book got on my radar? Nope, none.

But I am not surprised I had it to read. I believe I was perusing the new and notable section of the library. You know, the section where they put all the recently returned and the new and shiny books? Yeah, there.

I am very interested in feminine medical care, especially in these fraught times. Especially when females are under attack by those who should care for us in the governments. Yes, plural. State governments are as complicit as the federal.

But this cannot have escaped Dispatch readers’ attention. Nor the side I am on.

The woman’s.

Always.

This was a quick read. That is not saying it was an easy read. It was definitely not an easy read.

However, I believe it to be an important one.

In these stories, families cared for regardless of their feeling on abortion. That is, until they need one.

In this book, the author is careful to tell all the stories but focuses on the maternal indication, meaning that to be denied an abortion would have substantial negative effects on their life, or the fetal indication, meaning that there is something deathly wrong with the baby. One woman is anti-abortion until she needs one. Another is anti-abortion but understands that this is in the child’s best interest. Unsurprisingly, the second family have the support of their pastor and that of their community.

Dr. Sella points out when the mother has religious beliefs that conflict with abortion, pain, distress, and anxiety are heightened. And she takes steps to lessen all of these. She gives each couple a book about others who have to make the decision of peace for their baby, wanted as they are, loved as they are. It is “A Time to Decide, a Time to Heal: For Parents Making Difficult Decisions about the Babies They Love”. This book is written by Molly A, Minnick, MSW, Kathleen J. Delp, ACSW, and Mary C. Ciotti, MD.

For me this is take away from the entire book. Yes, the baby is dying, but not because of anything the mother did, and not because they aren’t loved and it sucks but the parents will get through this and by undergoing a late 2nd and 3rd trimester abortion, they are giving babies peace and not a life of struggle and pain and death. Or the mother faces certain hardships or death to carry the baby to term.

This doctor and clinic take steps to decrease the mother’s anxiety, with lowered lights, soothing music, and medication as needed to keep the patient less anxious and to decrease the pain. A counselor is also present. This is about supporting the mother who has chosen a better end for their wanted baby. Every person is there for support of the mother.

This book is part history lesson about the abortion care in the U.S. From the 1970s, all the way through the current Dobbs decision. Dr. Sella takes us along on her personal journey and history. Interspersed with the real time four days it takes to complete a third trimester abortion. These chapters focus on four mothers who are at the clinic in search of care.

The author was adamant that she not go to medical school, that she could provide care and counseling away from the bedside. But the doctors were still in charge and she realized that she wanted to support at bedside and give her patients back the power.

She gives the patients scripts to use when talking about why they are no longer pregnant. “The baby was sick and we went for testing. The baby didn’t make it. It’s hard for me to talk about right now.

What struck me as especially compassionate was the discussion she led with the families of what would happen after the now still birthed baby. All of it to make sure the families were as supported as they wanted.

Pictures, both medical of anomalies and commemorative are taken after the stillbirth. These pictures are always taken and kept in the chart, even if the woman says they aren’t wanted. That way they can give them to the family if they change their mind.

Taking pictures of a deceased infant has come a long way in the 25 years I’ve been a nurse. Now there can be photo shoots, and keeping the body in the room on a cold cot for as long as necessary. I have had many conversations with women, patients and friends alike, who have told me they would have like a picture. Or a remembrance of some kind so that others know that this baby was here, and was loved, and died. Because they haven’t forgotten.

Footprints and handprints can be taken. She counsels the families that if the pregnancy is ended closer to term, there will be a birth certificate and a death certificate. The mothers will have the option to view the baby the next day, after they’ve rested and recovered a little. But there is no pressure to do so. Of the four mothers the book is about, only one does so.

In the beginning and through the process, she counsels the families in a group, so that they have support and can feel comfortable sharing their stories.

She leads them through the expected question of will the baby feel any pain. She explains that is why the heart is stopped, through medication, before the delivery can take place. If there is no heartbeat, there can be no pain. Fetal pain is a subject that I have heard a lot about, probably because of the anti-abortion insistence that there is pain for a fetus during an abortion. There is no studies backing that up.

Through the entire book, the author is open to ongoing changes in American law and what these challenges mean to abortion care. And the unceasing anti-abortion backlash, up to an including the release of her personal home address leading to protests in her neighborhood.

Up to and including the murder of her mentor at the hands of an anti-abortion zealot. Inside of his personal church, where he was an usher. What these zealots fail to comprehend is that these are human beings they are calling murderers, and pigs, and more, This is a human being that they killed to satisfy their hate. As if by killing the head of the serpent they would kill the clinic and the need for this level of abortion care.

I think the best way to end was with what one of the fathers said when it was over and they were preparing to leave “Quite frankly, my religion has let me down.”

There are reasons listed in the book as to why these four women are seeking third trimester abortion care. Their babies are ill or the procedure is done to support the mother or the procedure is done to protect the life of the mother and she can now undergo additional cancer care. Dr. Sella ends each procedure four day period with a final meeting with the families.

There are several reasons to have a third trimester abortion. Some are fetal abnormalities incompatible with life. Some are maternal cancers or heart problems. Some are dealt blows by life such as rape or abuse. The reasons are the woman’s alone.

I am a firm believer that personal stories can change mountains and make the explaining of third term abortion need impactful. The personal stories and names, changed though I am sure they are, humanize the patients and give voice to the circumstances that led them to make the decisions they do.

This was one of the best medical non-fiction books that I’ve read. I will be recommending it to all the OB and Labor and Delivery nurses I know.

FFS Friday 8/1/25-F-in Cowards #4

Oh, my god, they pulled up the corpse of Elmo and shot him again.

Shield your eyes, children.

And just like that the path in childhood has been closed to CHILDREN. No more education programs that are not ads for toys or ads for movies or just plain ads.

The Corporation for Public Broadcasting announced today that it has begun shut down procedures. People are being laid off, with the corporation shuttering in January 2026.

The CPB was authorized by Congress in the 1967 Public Broadcasting Act to ensure that everyone, and I mean everyone, has access to non-commercial, high-quality content and telecommunications. They used 70% of their own funding to support more than 1500 locally owned radio and television stations.

This means that the shows and the broadcasts are not trying to sell you anything.

Unlike the rest of the world.

Every minute of every day.

But, alas, this is no more because congress yanked its funding in order to give money to millionaires and billionaires in the form of tax credits.

“But, but you will get a tax credit too!”

pffft, I’ll believe it when I see it.

We certainly did not receive any money during the pandemic and those 2017 “tax cuts”? Our taxes went up. By a lot. Many thousands of dollars a lot.

No, I don’t believe you when you tell me that it was worth it.

Fucking cowards.

Mr. Rogers is very disappointed in you.

I believe Horatio in Hamlet said it best “Now cracks a noble heart. Good night, sweet prince/and flights of angels sing thee to thy rest.”

Or maybe Inigo Montoya when he is advancing on Count Rugen, “Hello, my name is Inigo Montoyo, you killed my father, prepare to die.” Count Rugen pleads for his life in the final duel, offering Inigo all that he wants, money, power jewels anything Inigo wants.

And Inigo, stabbed, bleeding, facing down the man who murdered his father twenty years before, tells him “I want my father back, you son of a bitch.”

Let me tell you, we are all Inigo.

We want our PBS and NPR.

Again, Mr. Rogers is very disappointed in all who voted for this.

Tuesday Top of Mind 7/30/24- childless cat lady here, reporting from the front line

There is a furor of JD Vance denouncing the country as being run by childless cat ladies. There is a lot to unpack here and is my Tuesday top of mind.

It goes beyond the regret that he says that the U.S. is being run “by Democrats, corporate oligarchs and a bunch of childless cat ladies who are miserable at their own lives and the choices that they’ve made and so they want to make the rest of the country miserable, too.”

Point number 1- I feel this is a call back to the spinster horror from the Victorian era and before where a woman needed a man. Otherwise, they would be “on the shelf” and unmarriageable by 23. She was forced to care for her parents until their deaths and after they died forced to live in misery, unwanted. (frowny face here) This is definitely the underpinning of this idea. It is a well-known trope that it was best to be widowed because the widowed woman was thought to be independent and beholden to no man.

Point number 2- I feel this is a projection of the miserableness of those who have children. They see those of us who do not have children as selfish and having all the fun they can’t have themselves. You know, because of the kids. I think this is especially poignant because some people with children want to make the world as miserable as them, mainly when it comes to book bans and drag queen bans. I get it, when you have children they are vulnerable and everything looks like a threat. But is it, though? Or is the threat coming, as it often does, from inside the house?

Point number 3- Who says those of us who don’t have children are miserable? Kind of goes back to point number 2. Projection much?

Point number 4- This lumps all women and men who don’t have kids into the bucket of not having kids because we don’t want them. This might or might not be far from the truth. What about those of us who couldn’t have kids? We are apparently the same as those who don’t want them. One of these things is not like the other.

Point number 5- I think this is about transphobia as well. Trans women do not have the plumbing to create or carry a child. This is through no fault of their own. But why not twist the knife? It says nothing about their willingness to carry a child, if it was physically possible.

Point number 6- Men like this and others who embrace what he is saying are afraid. Afraid of the woman who is not under a man’s thumb. Afraid of a woman who doesn’t need a man. Afraid of a woman who knows what she wants and goes after it.

Much like the abortion bans and the book bans, it is all about control.

They can’t control us.

And they fear what they can’t control.

Therefore, we childless cat ladies, married or not, women who are unable to bear children or not, are to be squeezed into a teeny tiny box of their making. Because they fear what they can’t control.

Fuck that.

My cats and my uterus and my husband would like a word.

I have also seen the childless dog women coming to our defense and that of Kamala Harris, who the slur was originally against. And it is glorious.

You bet I bought that tee shirt.

School Me Saturday 4/20/24- personal end of semester update

On this palindrome Saturday I am going to be digressing from the Alice in Wonderland school series I have been writing and will be writing about myself and my program.

Why?

Because it is nearly the end of the Spring semester and it’s been a hot minute since I did an update.

Two weeks remain in the semester.

That is 2 more times driving to the university for my research assistant job. I did decline to work this summer for the department as I anticipate life is going to get very interesting and busy over the summer.

That is 2 more assignments. One in the qualitative research class and 1 in the measurement class.

As the qualitative, I should have seen the writing on the wall. I do not care for math. Especially the kind of math that is required for quantitative research. Statistics makes me itch a bit. You know? I am leaning into the qualitative sphere. And this is shocking to me.

Talking? To other people? Not really a strength of mine. But here we are.

For the third class, the directed research class, I was thrown off a bit by being sick for 2 months starting in February. I just feel like I got a slow start. But that’s okay. I am chipping away at it. Next week I will be presenting my directed research project, an observation project, to the corporate research council. After that, and after the blessing of the school IRB and the hospital IRB, I will dive into the observations and finish the class.

Thankfully, I am not the first person to have a slow start and there is a process for this.

For the rest of the summer, I will be preparing for and taking my preliminary exams. These are exams that separate the PhD student you from the PhD candidate you. These are also the threshold that must be crossed to begin dissertation work.

The exams are timed, kind of, and meant to be written over two weeks from home, or 3 days at the university. I will stay home, thank you, and write them from here.

After I pass the preliminary exams (I hope) I will start work in earnest on my dissertation project and my dissertation itself. As I understand I will need to have it completed and defended by March if I want to graduate in May. The directed research informs the dissertation project research.

I have had so much support from the university in this journey. And a journey it is. And support from family and friends.

I need a better answer to what are you going to do after graduation?

For the longest time, the answer has been write for publication. I might throw in some teaching in there too.

After the end of this semester, I will be a 3rd year PhD student. If you had told my younger self that I would someday be looking at and surviving a dissertation she would have laughed.

Oh, boy.

Let’s get started.