The Thirteen Days of the OR Christmas

Adapted from a Little OR picture book by the same name.

Once there was a snowy Christmas, cold and snowy, snowy and cold. Nothing would be better than staying home under the covers with a good book and a cup of tea. But, of course, the patients still made it to the hospital for their surgeries. J. Ashe, my charge nurse, assigned me to a different room each day. These are the my thirteen days of the OR Christmas.

Bah Humbug.

On the first day of Christmas, my charge nurse gave to me
a surgeon in a good mood.

(Dr. G. Mood declined to be pictured for this book or even named as he doesn’t want to ruin his reputation among the other surgeons)

On the second day of Christmas, my charge nurse gave to me
two shoulder scopes
and a surgeon in a good mood.

(get out the hip waders)

On the third day of Christmas, my charge nurse gave to me
three appys
two shoulder scopes
and a surgeon in a good mood.

(this is not looking good)

On the fourth day of Christmas, my charge nurse gave to me
four cataracts
three appys
two shoulder scopes
and a surgeon in a good mood.

(at least the eyes are quick)

On the fifth day of Christmas my charge nurse gave to me
FIVE C-Sections
four cataracts
three appys
two shoulder scopes
and a surgeon in a good mood.

(babies, hurray!)

On the sixth day of Christmas, my charge nurse gave to me
six bowel resections
FIVE C-Sections
four cataracts
three appys
two shoulder scopes
and a surgeon in a good mood.

(this is not trending well)

On the seventh day of Christmas, my charge nurse gave to me
seven hip revisions
6 bowel resections
FIVE C-Sections
4 cataracts
3 appys
two shoulder scopes
and a surgeon in a good mood.

(well, at least the surgeon is in a good mood)

On the eighth day of Christmas, my charge nurse gave to me
Eight Septoplasties
7 hip revisions
6 bowel resections
FIVE C-Sections
4 cataracts
3 appys
2 shoulder scopes
and a surgeon in a good mood.

(I must’ve been bad this year)

On the ninth day of Christmas, my charge nurse gave to me:
Nine bladder tumors
8 septoplasties
7 hip revisions
6 bowel resections
FIVE C-Sections
4 cataracts
3 appys
2 shoulder scopes
and a surgeon in a good mood.

(Santa, am I getting coal?)

On the tenth day of Christmas, my charge nurse gave to me:
ten fractured ankles
9 bladder tumors
8 septoplasties
7 hip revisions
6 bowel resections
FIVE C-Sections
4 cataracts
3 appys
2 shoulder scopes
and a surgeon in a good mood.

(Okay, who told Santa about that time at the holiday party?)

On the eleventh day of Christmas, my charge nurse gave to me:
Eleven breast reductions
10 fractured ankles
9 bladder tumors
8 septoplasties
7 hip revisions
6 bowel resections
FIVE C-sections
4 cataracts
3 appys
2 shoulder scopes
and a surgeon in a good mood.

(Or the time at the 4th of July picnic?)

On the twelfth day of Christmas, my charge nurse gave to me:
Twelve carpal tunnels
11 breast reductions
10 fractured ankles
9 bladder tumors
8 septoplasties
7 hip revisions
6 bowel resections
FIVE C-Sections
4 cataracts,
3 appys
2 shoulder scopes
and a surgeon in a good mood.

(Make it stop!)

On the thirteenth day of Christmas, my charge nurse gave to me:
the day off.

Yeah, right.

On the thirteenth day of Christmas, charge nurse Jack Ashe got from me:
my resignation
and a California birdie.

Tuesday Top of Mind 12/23/25- SC measles

Unless you’ve been living with your head in sand, or under the blankets, or under a rock, measles is running roughshod over Spartanburg, South Carolina.

Y’all, Spartanburg county is only 76 miles from the county I live in in North Carolina.

All the data has been gleaned from Department of Public Health South Carolina website.

As of the Friday Measles Update, there have been 9 new measles cases in upstate. This brings their total number for THIS outbreak to 144.

This just in (the website hasn’t been updated yet). The newest total that has been reported for this measles outbreak is 153 confirmed cases. This doesn’t count the 249 in

Some children are on their second round of 21 days of quarantine.

In this latest update of confirmed cases, 34 are children under the age of 5, 101 are 5-17 (so school-aged), and 12 are adults and older.

Measles is no joke. It is at the top of the contagious disease list.

The MMR vaccine, which contains the measles, is one of the safest and most reliable vaccines that is in the vaccination playbook. According to the CDC, the MMR vaccine is 97% effective. It remains one of the most effective vaccines for the MOST contagious disease that there is a vaccine for.

What is the disconnect? Never mind, forget I asked that.

The MMR is 2 doses for those over 1 years of age. There is also an MMRV vaccine that also covers chicken pox for children 1-12 years of age.

According to the DPH South Carolina website, there are no scheduled vaccination events in this county. But you can request a visit from the Mobile Health Unit for vaccination.

You know what is worse than the fear that is being mongered around vaccines? Listening to these monsters and deciding that you, as a parent, know best, disregarding the hundreds of years of experience that public health workers have, and not vaccinating your children or yourselves.

Worse than that is actually getting the disease with its risks of death and disability.

But what do I know, I’m just a nurse who cares deeply about other people and their children.

Perhaps I should write a parody about the 21 Days of the Measles Quarantine. That is a Christmas song I don’t want to write/parody.

Or do I? Stand by for that one.

Also your grandparents and your great-grandparents are rolling over in their graves at the thought that the vaccines that they would have killed for are being discounted by spoiled brats who think a social media influencer who just wants likes and clicks knows better than most of the public health nurses and doctors.

Maybe public health has been too effective.

FFS Friday- FDA, blink twice if you are in trouble

Actually, don’t bother blinking.

We in healthcare KNOW that you are in trouble. As you have a bad case of the know nothings in charge of you and your vaccines and your medications.

Some of the Senators could have helped you out but they were too busy bending the knee to a wannabe fascist who is hell bent on wringing all the money they can out of their shitty decisions and actions.

You see, they are in their villain phase.

Where the only thing that matters is the green.

Of course, I write of money, moola, dough, loot, and bucks.

They are too busy stealing from us that they think that making us sick by not extending Affordable Care Act credits for those who need help with the astronomically skyrocketing costs of insurance, shields what they are doing by providing cover fire.

Forget bread and circuses, this administration is about social media lies and villainy.

Why? Because to be the lowest level they can be feels GOOD. To them at least. I would have sent myself to bed without dinner if I acted like they do. Lives are not their playthings. Did no one teach them manners as children? Or even ever told them no?

Today’s latest bullshit is a waving of a “possible” black box warning on the covid vaccine.

Yeah, that one.

The one that has saved millions and millions and millions of lives.

Worldwide.

This black box warning will be slapped on the life saving, lung saving, world saving vaccine by the end of the year, according to reports from CNBC and Reuters and CNN and other news sites.

I think this is a distraction. Of course all the news is covering it.

Of course all the healthcare workers, MDs, RNs, LPNs, CNAs, PAs, and the like are decrying it.

If true, this is big black coal letters the size of Mt. Everest BAD.

This kind of bullshit pulls the wool over the eyes of the people who don’t know any better.

And makes them doubt ALL the vaccines.

Makes them doubt healthcare.

Makes them doubt medicine.

Takes us back to when we were smashing rocks against other rocks and against each other.

I am not sure of their endgame, besides confusion, and lining their own pockets and those of their billionaire handlers.

Or are they spoiled brats who are gleefully pulling the stuffing out of America?

After all, weakening us makes us prey.

Well, I don’t feel like acting like prey. Wanna see my teeth?

We tried to warn you but you didn’t listen.

Tuesday Top of Mind 11/25/25- Just a little prick

Yes, there are multiple meaning to the phrase. No I didn’t click all the links that were shown. Be careful looking up stuff on the internet.

But it does include the time on South Park in 2019 that Cartman didn’t want to get his vaccination shot. Which leads to him almost being thrown out of school (remember those days?), and he uses this to negotiate the exclusive use of the volleyball for the next six months.

Of course, he escapes the doctor trying to give him his shots. Again.

Why do people hate shots and vaccinations?

25% of [ep[;e are terrified of the needles.

Some people are afraid of the pain.

I’ve had many, many, many, many, many vaccines and I can tell you my experience.

Many.

In fact the last 2 I got were the Shingles second shot in October, and the flu shot in October.

Let’s talk about the fear of needles. While tatted with full sleeves and choker.

Sometimes it is an irrational fear.

Sometimes it does hurt.

But the hurt always goes away. The hurt is cause by the inflammation of the immune system response to what it thinks as an invader.

The hurt is a good thing. It means that the immune system is activated and will learn the often inactive microbe that was in the vaccine.

When I was giving covid vaccine shots in 2020 and 2021 many people were afraid of the needle.

But they still rolled up their sleeves.

Often I would administer the shot and the patient would ask when would I give the shot. Only to be amazed that it was already done. For the very fearful, I advised them to close their eyes.

These vaccine clinics often led to the how much is it going to hurt question.

Fair enough question.

I would engage in conversation with these people and ask them if they had ever had a tetanus shot, specifically the Tdap, or a flu shot. When they indicated they had, I would tell them that the covid shot hurt less than the tetanus shot and more than a flu shot. With a point of reference, they would nod and allow me to administer the hot.

There is another reason for mentioning the Tdap.

Babies are dying.

According to an article from CIDRAP from the University of Michigan, three infants have died of pertussis aka whooping cough in Kentucky. They were not vaccinated. This is the loss of herd immunity as overall vaccination rates are 90%, well under the herd immunity threshold of 95%.

There have been 2 dead babies in Texas. For the same reason.

The first thing I looked for in the X location transparency that dropped this week was the location of anti-vaxxer bots.

Okay, first I giggled and then I looked.

There wasn’t a lot of information. Most of it was around the bots in the red hats. There were some bots in blue hats. All are to blame here. But the red hatted bots WAY outnumbered the blue hatted bots and from such interesting locations as Asia and African countries.

This 99% accuracy as touted by X is stunning.

But, like most things these days, take with a grain of salt.

But babies are dying because of the inaction of their parents and doctors, fueled by lies from the department of health and human services secretary. They have a new accomplice in the CDC. Which takes vaccine providers to task by not being able to prove a negative.

But babies are dying and will continue to die because of misinformation and lies that have been passed down like grandmothers’ wedding china.

Just like women who are continuing to die under draconian anti abortion laws.

This is nothing to laugh at.

After all, a vaccination is just a little prick.

School Me Saturday 11/22/25- This just in, a nursing degree (any kind) is not a professional degree

This is more of a Tuesday Top of Mind topic but the intersections with education cannot be ignored.

In a slap in the face heard around the country, the Department of Education dropped guidance that a list of degrees would no longer be considered professional. Do you know how many nurses, registered or not, working in healthcare or not, are in the United States?

4.7 MILLION, according to the American Association of the Colleges of Nursing.

Yeah, you done fucked up and insulted 4.7 million people.

The so called professional degrees that were listed

medicine
pharmacy
dentistry
optometry
podiatry
law
veterinary medicine
osteopathic medicin
clinical psychology

The so called non-professional degrees that were listed

NURSING
physicians assistants
physical therapists
social worker
speech therapy
architects
accountants
educators

I first read about this on Wednesday and the everyone else had read about it and were giving their reactions. I held onto my reactions until today. They are in three sections.

The first is that this downgrade means that there is less money for all of these professions to go to graduate school. The “professional” degrees (see above) can borrow up to $50,000 per year, with a cap of $200,000. The “non-professional” degrees (see above) are limited to $25,000 per year, with a cap of $65,000. Massive difference, right?

They do know there is a nursing shortage, right? And the shortage is exacerbated by the severe shortage of MSN and PhD prepared nurses to serve as nursing school instructors. I fear this would only deepen this shortage.

It’s like only rich people can obtain graduate degrees. I mean people have the option go into crippling private loan debt. Things to consider. I would not recommend private loans for school. I know too many nurses who have been destroyed by them.

The second is that the “non-professional” degrees are, with the exception of the architect, mandated reporters. Being a mandated reporter means that the social workers, the health-care professionals (including nursing, duh), the teachers, the child care providers, and law enforcement are mandates, by law, to report child abuse or neglect. This definition comes from the childwelfare.gov.

I know that most people love their children and would never abuse them, but there are always those that will. And, as a mandated reporter, I have to report it. This is to save children’s lives.

The third section is that the “non-professional” degree workers are mostly women. And those in power love nothing more than to treat women as less than. This has been happening more and more in the last few years.

If women can’t get loans to go to school and the cost is prohibitive, I guess they will have to stay home and have ALL THE BABIES. Even though nurse practitioners and physician assistants make up the bulk of the rural healthcare that is available. According to an interview I saw with Dr. Jennifer Mensik Kennedy, the president of the American Nurses Association (ANA), if there were no NPs or PAs a patient in need of care would have to drive 90 miles for care. Each way.

I am not less than. I am a professional working registered nurse. I am not a doctor or surgeon’s handmaiden.

Ew.

In 5 years we’ve gone from hero at the bedside during covid to non-professional.

I have called or written my representatives and the ANA has an online petition at RNaction.org. You better believe I signed that as soon as I heard about this travesty.

It’s like they want women in the home, having babies, and to cripple higher education. If only we were warned (this is heavy sarcasm)! Oh, wait, we were. This is all in Project 2025.

In simpler terms, to keep women dumb and in the homes so they can have all the babies. After which I guess we die?

Nice try and fuck all the way off!

Tuesday Top of Mind 11/18/25- Robin getting slapped by Batman for saying he needs antibiotics for a cold

Less than a century ago, common illnesses such as appendicitis or pneumonia, or even extremity abscesses were often lethal. That means the infection, that there was no way of stopping, killed the patient.

It was in 1928 that the miracle of the petri dish occurred. Well, some say miracle, I call sloppy lab control. The petri dishes weren’t cleaned before Dr. Alexander Fleming went on vacation. He got back to his lab and the dirty petri dishes to find the newly grown mold that had developed was keeping the bacteria from growing.

Penicillin enters the chat.

But penicillin would worked on many different bacteria. Today we call it broad spectrum.

Then they called it amazing. And wondered what other antibiotics could be found and developed. Sulfa medications soon followed. And then resistances to the antibiotics started appearing.

Really the march to where we are now is fascinating.

There is a really good article. “Antibiotics: past, present and future” by Matthew Hutchings, Andrew Truman, and Barrie Wilkinson. It has good graphs, tables, and illustrations. But it points out the present we are living in and the future we should all fear.

The present that we are all living in is the rise of antimicrobial resistance (AMR).

This is when the causative agents of the infections are no longer susceptible to the antibiotics used to treat them. This means that the drugs no longer work for that infection.

I am not kidding when I call that the scourge of the modern age.

Because when the antibiotics we have are not the right antibiotic to treat an infection we might as well be back where we were 100 years ago. Shit out of luck (SOL).

And dying from appendicitis.

But how did we get here?

From the free and loose prescribing of antibiotics for nearly 100 years.

I have a cold, try these antibiotics. They aren’t the medication for viruses, but hey, it might help.

I feel better, I think I will stop these antibiotics. Yeah, I’ve only taken them for 3 days and it is a 7 day course but I feel better now.

A new friend from another place, let me shake your hand and give you what I might have and pick up what you might have. From the casual contact.

Oh, is that a rescue animal. Can I pet it?

Germs are like people, they want to live. And to do so they mutate and learn to overcome the antibiotics. Worse, yet, they have the ability to learn from other germs that are nearby. Germ A learns to be resistant to antibiotic a because germ B taught it to be so.

It is a huge problem.

This week is Antibiotic Awareness Week, November 18-24. It is meant to raise awareness of appropriate antibiotic and antifungal use. (not for colds, jan!)

Because we are rapidly approaching the cliff where none of the antibiotics will work and limited new antibiotics in the pipeline.

Your mission:

Try rest and fluids for illness first, especially a cold
always finish the course of antibiotics
do not ask for antibiotics for a cold. The reason you feel better is the placebo effect
when your child needs antibiotics for a cold don’t give your leftover ones from last year
listen to the medical professionals about antibiotics

Governments and scientists are working on it. They were slow to wake up to it, and slow to get going, but everyone is aware that this is a problem.

And hope really hard that it is not too late.

Call Secrets of the OR- Keeping up with the Joneses, Dr. Jones that is

Call is my job and has been for nearly 4 years, since December 2021.

In that time, many surgeons have come and gone.

There have also been many different pieces of equipment that may be useful at night that have been introduced to the OR.

There have been many changes to the instrument sets.

There have been many changes to the type and style of suture that are kept on site.

There have been many misguided re-working of the OR core. The general cart specifically.

There’s even been a brand new robot introduced into my OR.

Guess what?

Even with all of these changes I am expected to still know everything.

When a surgeon asks for a certain piece of sterile supply, an AbThera, I am required to know where it is. And when I convince the surgeon that no such thing lives in this OR because it doesn’t match our negative pressure wound machine, I have to be able to trouble shoot Macgyvering or cobbling together a facsimile of available sterile supplies. While we are putting our Frankenstein dressing on, I am required to listen to the surgeon bitch about the department not having such a thing. After all downtown’s hospital has it. The why doesn’t this hospital is sometimes silent, most likely not.

Sigh.

The point of this post is that it takes a lot of time and effort to keep up with the various changes to the operating room. But also not look I’m struggling when I can’t find the exact thing the surgeon is asking for. Kind of like Ginger Rogers dancing all the dances with Fred Astaire; only backward in heels.

I just have to bear in mind that the surgeon and I are united in our desire to provide the best care for the patient currently on the table.

Sometimes that requires a little imagination. And a little homework.

In order to keep up with the Dr. Joneses, I tour the OR when I am there and make note of the changes. Because, you know, no one is going to loop me in.

I read my work email nearly every day, looking for policy changes.

I attend the staff meetings when I am able.

I ask questions.

Just keeping up with the Joneses (department changes) can be a full time job.

Good thing I am built for this position.

Tuesday Top of Mind 10/7/2025- Scammy Scamerton called Trump Rx

Let me get this straight:
The president shakes down the pharmaceutical companies, like a mob boss.
The president simultaneously hikes tariffs on medications brought in to the country to triple digits.
The president then announces Eurka! Drug prices will now be falling, no one has ever seen drug prices fall four digits before!
The president then announces that one of the pharmaceutical companies has bit and will be lowering THEIR drug prices.
The president then delays the triple-digit tariffs to allow for “bargaining” time. This is another name for a shakedown.
The president announces a Trump Rx. This is where you give him all of your very personal information, including diagnoses, and current medications, and upcoming prescriptions. This is so your prescriptions, from this one company, are cheaper.

but think what it will cost you in the future.

You are denied a promotion because you are deemed too fat. At least the president thinks so.

The prescription that you need is only $2 less. But hey, the government can have your privileged information. And it use it to line their own pockets.

The prescription that you need now has you on a governmental list. What is the list for? Shh, spoilers.

The prescription that you need is available at the “most favored nation price”. You see little difference between the the price on Good Rx, and that on Trump Rx.

This is so fucking dangerous. I want to see how the website is built to make sure that any information I give up, willingly remember, is protected. If the information is protected this might be adequate. But that is a very high bar.

I am not sure that I am willing to trust the government, this current iteration of the government, to hold my handbag while I am changing clothes.

Perhaps this announcement was rushed out too soon. Before the website is built as a distraction.

Distraction from what, Kate?

Any number of things. The Republican caused government shut down because they won’t protect American’s medical insurance prices. Perhaps it is the Epstein files that they are death gripping. The rising inflation rate. The rising jobless rate. The lowering opinion of the world about America.

I’m stumped as to the reason.

To be clear, this is SARCASM.

Not the very real fear you should have over handing your personal information to the government to be exploited for cash money. That will go to line billionaires’ pockets. Billionaires like the president who has made over a billion after taking office.

Because you know that there is money to be made somewhere. And not by us, the American public.

Medical non-fiction books review 9/21/25- Chasing Rabbits by Rodolfo Del Toro

I get discounted and free e-book lists daily. I never spend a lot of money, less than $5.00 per week. I was looking over the options this past Wednesday, like you do, when I saw this book. It is Chasing Rabbits by Rodolfo Del Toro and it is my favorite kind of medical non-fiction, a memoir.

And it was 99 cents.

I hit the buy now button and I was surprised that I already owned it. I was embarrassed when the site informed me that I had owned this book since February 2024.

I had never read it. School brain, you know. The book was part of my ginormous TBR pile that grows daily. But I can’t give up books entirely.

As medical memoirs go it is on the shorter side, only 220 pages. A quick read. I had time this weekend and so I decided to read it all in one go.

This story is in three parts. The beginning is what stands for present day, many years after the events of the 2nd part, and the third part picks the story back up from the first part. Rudy the doctor has an unexpectedly light afternoon before a three day weekend and his long-time secretary tells him he received an intriguing invitation from a butler.

This leads to the middle part of the book, which is the meatiest part of the book, and Rudy telling his secretary about this one rotation he had in his 4th year of medical school.

Cue the second part. The first part felt a little disjointed and rushed and I was prepared not to like the doctor. His secretary was great and is well written.

In the middle part, Rudy and his friend Mike are 4th year medical students and their planned clerkship for the last rotation of the year fell through. This was strongly hinted out because Mike’s family was rich and connected with an insurance company. This unexpected snafu was punishment for his father’s actions. I could see this but I wish that the book would have spend a little more time on this.

Because their real last rotation of the year was going to be together. In a children’s oncology ICU. With stable cast of characters, the doctor who oversees the unit, the fellow, a resident, and several nurses. And a pulmonology resident. All the nurses are named and have their own personalities. I love it when that happens. There is also Julia the supermodel who has been set up with Rudy by Mike.

There are three main children whose stories are centered in this section. Tim, the little boy with bone cancer, Megan, the little girl who has leukemia, and Maria, the ward of the state with a lost brother who has

Tim has had his lower leg amputated and a lump had been noted on his femur above his BKA. His parents were understandably concerned and he was in the hospital for a biopsy and treatment if necessary. He was waiting on biopsy results.

Megan is most concerned with being well enough for the trip to Disney land that was being planned for the children. When she is introduced, a nursing student has been assigned to restart her IV. Megan objects because the vein they want to use is unusable. Because she knows her body best she gives a tour of the most often used veins in the forearms. The nurse, not the nursing student, is successful in cannulating the vein that she indicates. This was one of my favorite passages. It is important that we give these kids who know they are sick, who know that it might not end the way everyone wants it to, agency over their body.

As Rudy and Mike leave the room, Dr. Betances is explaining to the nursing instructor that no nursing student will be starting this IV. His reasoning is that the kids have been through hell and do not need the pain from an unsuccessful needle stick. The nursing instructor just wants a body to have her students practice on and protests that the kids need new IVs so often it is a good practice place. I also liked this exchange. Dr. Betances standing up for his fragile patients. But I also disliked the nursing instructor who tantrumed off to tell on Dr. Betances. The nursing instructor does not come off looking good here.

Maria is in the isolation part of the ward because of her end-stage leukemia. She had a good attitude and a great smile. She also had a really good relationship with the main Dr. Betances. There is a back and forth about a business arrangement for having 1 medical student in her care, not 2. This was a great back and forth and you can really feel Maria here. The price of 2 medical students for the rotation is a 64 pack of crayons. As the group leaves to continue rounding, a nurse stays behind to talk to Maria.

In the next little bit, you learn about Billy, her foster brother, who was also at the farm where she was being fostered. But once the foster father died, she was sick and they were separated. He was adopted after that. Maria has been at the hospital for nearly a year. This is where it is explained that the staff takes care of all of Maria’s needs, including the non-medical ones. There are pink curtains, art supplies, and all the things to make a home for the dying little girl.

Rudy offers to talk to his friend the lawyer to search for Billy. This irritates Dr. Betances, like no one had bothered to look for Billy in the past 10 months.

The middle part is concerned with these children and their care. The nurses are caring and competent, the head doctor, Dr. Betances, is caring and giving, and the fellow teaches all that he can to the medical students.

I won’t write anymore about what life and death and bad news and good news happens in the second act. Or the third.

The best I can say is that I cried. And sometimes that is the best recommendation a book can have.

Part 2 more than made up for my perceived rushed feeling from part 1. I can understand after reading the second part, he just wanted to get into the meat of the story. I am a little less forgiving of the super model side plot, but even that has a good payoff and explanation.

You’re going to have to take my word for it.

I will read this again. I might even come to like the first part. But the second part is where the heart of the story is.

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.