Best Kept Secrets of the OR #12- What is on back order now?

Your OR life will be spent tracking down instruments and supplies. Some of these supplies are of the urgent nature. This may be a disposable piece that goes to an equipment to a package of sterile towels. This may be the suture that is needed after you, or the surgeon, puts a giant hole in someone to fix their problem.

We have supplies that are by themselves. We will call these one thing.

We have supplies that might come in a pair. We will call these two thing.

We have red supply. We will call these red thing.

We have blue supply. We will call these blue thing.

Now that I am done Dr. Seuss-ing up the post (I hope you got it), we have lots of supplies.

Like lots of supplies.

So many supplies.

You never think we’d run out amount of supplies.

But the thing is that each surgery needs these supplies.

99.999999% of surgeries require supplies. I made that number up but the vast majority of cases need supplies.

These are special supplies that need to come sterile. You know, so that we don’t kill the patient by using a supply that will send them into sepsis. And we might not have the capability to render them sterile on site.

The point is the OR is a supply heavy place. And the supplies need to be sterile.

I would hazard a guess that the OR is the most heavily supplied place in the hospital.

You know what other place is heavily supplied and supplies the rest of the hospital.

The pharmacy.

100% of patients in the hospital require medications at some point during their time with us.

Many of those patients require some form of IV therapy. This is fluids/medications that are delivered to a patient via an intravenous catheter. Straight into the blood stream. And these fluids/medications need to be sterile as well. Same reason.

Hurricanes Helene and Milton did a number on two factories that supply IV fluids. One in Western North Carolina and one in Florida. Guess where many hospitals/surgery centers/doctor’s offices/free standing ERs get their fluids? From these factories.

Immediatly after the hurricanes my hospital put out the bat signal to all of its employees reassuring them that the corporation had IV fluids to continue to operate and reminding us to conserve IV fluids and bags.

The hurricanes were not even been a month ago and some surgeries are being cancelled due to lack of IV fluids.

This is disappointing to patients and providers alike.

Let me tell you about the model that hospitals et al. get their supplies through. It is called just in time ordering. The hospitals et al. can’t have millions of dollars of supplies on their shelves, including IV fluids. For one thing, that is a LOT of money to have in backstock. For another, especially when it comes to IV fluids and medications, there is an expiration date where the sterility of the packaging or the stuff inside the packaging can no longer be guaranteed.

Many hospitals et al. are in trouble with IV fluid supply levels. We in the business call this kind of thing back order. As in we need the supply/IV fluid and the supplier would like to give us the thing but is unable to because of glitches like hurricanes. We’ve had a LOT of backorder for as long as I’ve been a nurse and I don’t see that changing.

Is this model sound? Maybe. Does it hit the fan when it there is a bump? Absolutely.

Does it put patients at risk? Yep.

Best Kept Secrets of the OR #9- It’s okay to argue with the anesthesiologist

In my first nursing school, straight out of high school, soaking wet behind the ears, doctors still had a mystique about them. This was definitely true in the Midwest, where I went to nursing school.

These weren’t the days of standing when the doctor entered the room, of giving up your seat or your pen when required.

However, the doctor, usually a man, commanded respect, just by the virtue of their degree.

Well, over 30 years later I know better.

Doctors are just human. Sometimes they make iffy decisions with the aim of getting off the floor sooner. Sometimes they are good allies against surgeons who want to cut to cut, not to save a life.

It is absolutely okay to push back on them.

Just like it is absolutely okay to push back on the surgeon, or the charge nurse, or the CRNA.

This is part and parcel of protecting the patient.

After all, as the circulator, you are the wall between the patient’s well-being and the rest of the team.

But, be a wall that has some flexibility in it. And don’t be afraid to call them on their bullshit.

They won’t like it in the short term, and you might get written up, but you will know that you did the best for the patient that you could in the moment.

For example, there was a critically ill patient that we worked on in the middle of the night years ago. This patient was in bad shape, tanking blood pressure, holding on to their carbon dioxide, and getting more delusional with it, sky-high heart and breathing rate. The kind of patient you just know, in the pit of your stomach, is circling the drain. Urosepsis in a big, bad way. The anesthesiologist was so focused on getting the numbers that they wanted for the pre-op they were standing in the way of actually helping the patient. I told them that the only way to start helping this patient was to let the urologist put a stent up the ureter and if we delayed any longer for a BS reason, they might not survive that. The anesthesiologist, taken aback, stared at me for a moment. After all, who was I to demand that they treat the patient, no matter the number. They opened their mouth to yell at me and glanced at the patient, who was deteriorating by the minute. Swallowing whatever vile thing they were about to spew they gestured to the CRNA and asked what was taking so long.

Eye roll here.

But confronting them at that moment was the correct course of action. It allowed us to get the patient to the room that much faster, to go to sleep that much more smoothly, and to get the stent placed that much quicker. We did take the patient directly to ICU, still intubated, after the 10-minute case. The patient was exhausted and would probably get sicker before they got better. Two days later, I was dropping another patient off in the ICU and I saw the uroseptic patient and their family in a room. They were looking so much better that they didn’t even look like the same person, who had been gray-faced, panting, and moaning in pain and delirium 58 hours before. When I stopped in the room, of course, they didn’t recognize me, but the spouse did.

This is an example when speaking sharply to the anesthesiologist was worth it. The shock of me being a patient advocate and telling them that the only way to cure the patient was to stop dicking around chasing the perfect number really worked in the patient’s favor.

Don’t be afraid to call an anesthesiologist an ass, or a surgeon for that matter. My job was the safe, TIMELY procedure for the patient.

And I stand by it.

Post-it Sunday 9/15/24- Sour grapes

The gown card reads “Sour grapes, trashing nominations because they can.”

I have no idea if this is an actual thing.

However, I have my suspicions.

The nominations for the nursing awards that I am in charge of are down.

Like, a lot.

So much so that I made an announcement at the end of the last awards ceremony that we did in August that the nominations were down and please encourage people to nominate the hospital staff. If there is a position, we probably have an award for it.

The answer is to take the nominations online.

Sounds simple.

It is anything but.

Where would the nominations be housed? Is this mythical place easily accessible? And is it not able to be hacked?

These are the questions we as a council are reckoning with.

Also, where would someone access the nominations to nominate people?

Because not everyone is tech-savvy.

The corporate-level shared governance tried to do this a few years ago. The same problems came up then, too. Not everyone has access to the computer app. Not everyone has access to the nominations to collect them and collate them for consideration.

I am waiting for pushback about the cursive nominations. Because we have those too.

I’ll just keep collecting nominations, collating them with the massive assistance from the administrative assistant attached to the group, and tallying up the votes.

The only way out is through. This is why I am still in charge of this council because no one has stepped forward to take my place. And after shepherding it through the covid pandemic and keeping it alive with two other nurses, I will not let it die. It is too important to celebrate hospital staff.

And, frankly, we need all the wins we can take.

Post-it Sunday 6/9/24- Don’t be fooled

The gown card reads “Don’t act like you think I’m a moron and I won’t act like you think I’m a moron.”

Look the people who work in the OR and are nurses and doctors are very smart. They have to be. We deal with the intricate workings of the human body. We have to know every part of it, and the mechanism of action of each of it. Not only that, but we have to know all about medications and their actions on every portion of the body.

There is a reason for such a steep learning curve for new OR nurses and techs. There’s a lot to learn. Not only that, you have to learn to anticipate what the surgeon wants. There is a reason that I reassure lap appy patients that if the surgeon falls out (passes out) during surgery the tech and I could band together to finish their surgery while we wait for assistance. It makes them laugh and relax. I once told a surgeon that I tell people this and they laughed and said after 23 years they would hope so.

The point is don’t discount anyone’s intelligence. No one; from the orderly to the circulating nurse.

There is also a soupcon or even a heaping cup of misogyny in there.

There is a prevailing “wisdom” that nurses are nurses because they aren’t smart enough to be doctors. I usually don’t respond to that. Who else is going to carry out the orders and question them when they are inappropriate? Many a life has been saved by a nurse refusing an order as written. Many a license to practice medicine has been saved by the same thing.

Some of us don’t want to be medical doctors and never have wanted to be one. Someone has to watch out for the patients and protect them from everyone else.

Let’s make a deal, you and I.

Don’t act like you think I’m a moron, and I won’t act like I think you are one.

Okay?

I’m glad we’ve had this talk.

Oh, and leave the patronization at the door, will you.

It just clutters up the workspace.

Counting Basics #16- stray sponges and instruments

I’ve discussed 15 other types of counting basics. From what is counted, sponges, needles, and others to what happens if there is a miscount. Today I am going to write about the stray sponges and instruments.

One would hope that when a room is opened and prepared for a surgery that there are no stray sponges and instruments. In fact, the patient is depending on the counts being an accurate snapshot of all the countables.

A stray instrument is a not counted instrument. A stray instrument is also an instrument that is just hanging out on the computer desk, or in the marker tray under the white board. Or even used to hang the irrigation fluids. Or in the computer desk drawer.

This instrument is NOT included in the count.

Some of my coworkers call them the bonus instruments.

I call them a liability.

This goes for the sponges that are not included in the count but are just hanging out on the equipment boom, or on the shelves above the computer desk.

Some of this is to be saved for the worker in the room. I know I am of the thrifty sort and put aside sponges that have been passed off and not included in the count. For use at home.

But…

These stray sponges are not to be left in the room for the next surgery.

I’ll type it slowly. This is a liability!

Last week, after I took over for the day shift nurse and completed the surgery, and did the RF wanding (remember that?) prior to the closing of the incision. Like I’m supposed to. Well, when we were taking down the drapes, a raytec was taped over the foley catheter. Why? I don’t know!

But the scrub tech and I both looked at it, knowing full well I had RF wanded the patient not fifteen minutes before. I don’t know how they felt, but I felt sick.

This raytec was definitely not included in the count. We had done a relief count, and a closing count and a skin incision count and all 10 of the raytecs were accountable then.

Mystery sponge.

I will be discussing this with the nurse I relieved. And the manager.

My brain goes straight to the possibilities. None of them good. I cannot be alone in this.

These are new RF machines and apparently they are not as sensitive as the previous ones. I will be testing them this evening when I go into work.

No matter how you describe it, this is scary. And thoughtless. And leaves the previous nurse and tech as open to a lawsuit as myself and the evening tech.

Word to the wise, DON’T DO THIS!

And take the stray sponges and instruments out of the room prior to the surgery. Or count them. I don’t care which. But they have to accounted for. Our patients are vulnerable and they are depending on us to do the right thing.

Being accepting of stray instruments is not the right thing.

Ever.

Post-it Sunday 5-26-27- Outlook not so good, ask again later

The gown card reads “Surgery is not without its risks.”

My favorite thing is when people assume that surgery will solve everything.

Or should I say least favorite thing?

I get it. People want surgery to be an answer. Strike that. People want surgery to be THE answer.

My second least favorite OR thing is when people discount the c-section as not surgery.

Bitch, we opened up your belly like a can opener to get the baby out.

Understand?

I mean, we put it back together and stitched it up real nice. But the point is that someone was inside your abdomen, rooting around. There are all sorts of risks in this.

And people just answer no, no surgeries when asked in pre-op about previous surgeries. Only to casually drop that all four of their babies were born via section.

Um. That is major abdominal surgery. With a great prize at the end. But major abdominal surgery nonetheless.

But back to the least favorite thing with patients assuming that surgery is the answer to all their problems. Nope, not even a little.

There will be the risk of anesthesia. The risk of death. The risk of infection. The risk that the surgery might not even solve the problem that the patient is having. The risk that surgery itself will lead to another list of problems because of the risk of anesthesia, the risk of infection, or even the risk of it not being the appropriate surgery for their problem.

Why?

Because often to cut (do surgery) is to definitively find out what the problem is. Even if the problem was not the one that the patient and the surgeon thought they had.

Because your skin and insides are not transparent and until the surgeon gets a direct view of the problem, there is always the possibility of a missed diagnosis. Because although surgeons are excellent at their job (ahem, for the most part), they are not prognosticators.

This means they don’t have a crystal ball.

All they can do is their best.

And all the OR team can do is support them.

This is how you get the best outcomes for patients.

There is no magic 8-ball in surgery.

Imagine if there was.

Picking the surgical case is a personalized topic

I’ve been an OR nurse for over 20 years. My career has been in three hospitals, many different shifts, and many, many, many call shifts.

Call is my favorite, after all.

Call is my life now.

I’ve been picking cases, and this is getting case supplies together, for a long time. There have been thousands of cases that I’ve picked.

I like to pick cases and I think it is soothing.

Most people who I’ve talked to about picking cases have developed their own process.

This is mine.

I use the elevator to go to the case make-up area in the basement. This is where the supplies are kept. When we were designing the basement for case-picking I was adamant that the room had to be organized in terms of picking a case. This means you start in one corner of the room with the basics. These are the supplies that every case needs. A back table cover, drapes for the surgery (this is dependent on what kind of surgery you are picking for), gowns for the surgeon and scrub tech, and a basin set. This is the absolute bare minimum for a case.

I crank up Down with the Sickness by Disturbed and start in that corner.

These days or nights, I pick a LOT of general cases, a few ob-gyn cases, and very few orthopedic cases. But the process is the same.

Starting with the basics- back table cover, basin set that is appropriate for the surgery (there are 2 basin sets), gowns for the surgeon, and drapes for THIS surgery.

Next, I pick out gloves for the surgeon. This is the next area in the basement. This is also where I get the prep kit if this is an ob-gyn case.

And then it is time to select the bovie tips that are needed, if any, and the suction tips that are needed, if any. You see what I mean about being highly customizable? I refer to this section as the basic sharps- knife blades, syringes, extra sponges (raytex or lap), bovie tips, bovie grounding pad. These are all within 2 large shelving units. These are the end of the basics, the bare minimum for every case.

If you turn around, there are the dressings on another cart. These are highly case-specific.

Then you go to the particular section of the case make-up that is determined by the case you are picking for. Orthopedic stuff is with orthopedic stuff, laparoscopic stuff is with laparoscopic stuff, ob-gyn stuff is with ob-gyn stuff, and so on.

There is a section tacked on the end of the ob-gyn section that is the hot items. I don’t mean stolen, I mean electro-cautery items used for laparoscopic or open surgeries.

Here I pause to look at the exact card to see what I am missing. I do not go line by line with the card. There are many reasons, but mostly because what is on each line is not alphabetical like I told them would be good. Instead, supplies are listed by how where it is in the WAREHOUSE! Tell me, in what universe does that make sense?

But we adapt and move on.

It would surprise exactly no one when I say that surgeons have many opinions on the supplies. Some surgeons are really concerned with costs, some are not. Some surgeons, well, most surgeons, just want what they want. They will complain mightily if corporate does not want to buy them what they want and instead give them a comparable supply.

I head upstairs to the instrument room. It used to be next to the case make-up area but has since been moved back upstairs. I pull the instruments that are needed for the case.

End of story time.

Down with the Sickness is four minutes and thirty-nine seconds long. It never takes me the entire song, including elevator rides, to pick a call case. But I’ve done this a long time and I have most of the cards memorized.

I train a lot of people in my job, or, I did, and I offered to do a case-picking BootCamp, like the Call Bootcamp that I do. No go.

Everyone is going to develop their own style. But a grounding in the basics would have been useful to new people.

Cookie Thursday 2/15/24-cracker toffee with chocolate on top

To recap the theme of the month is Tracie’s Favorites. This is sadly the last Thursday that Tracie will be at the hospital and the fourth cookie on her favorite list is cracker toffee with chocolate on top. This is also called Christmas Crack, or Cracker Crack but I like Cracker Toffee with Chocolate on Top as a name.

Let me tell you a little about Tracie. She’s whip-smart and has seen some shit in her life and is one of the most caring nurses I know. And she’s leaving us. Insert sad face here.

She let me poach her from the pre-op staff. There was a patient with an injury and a surgeon who wanted to fix the patient but the patient had had pizza about 2 hours before. It is the same old story, surgeon didn’t want to wait, patient needed surgery but it wasn’t urgent enough to compel anesthesia, or the surgeon didn’t declare it an emergency. It’s been a long time, details are a bit fuzzy. It was decided that the patient could have surgery IF it was local anesthesia only.

Well, on call there is only the OR nurse as the only nurse in the department. A local only needs 2 nurses, a monitor nurse to monitor the patient’s vital signs and talk to them and keep them calm and a circulator to do all the OR things. I took a chance and called one of the recovery room nurses on the off chance she would want to be the monitor nurse so we could help this patient.

Tracie agreed to be the monitor nurse. I think it was the exposure to the OR, talking to the patient while keeping them calm, and watching the surgery over the drapes that hooked her into the OR. After that case, she talked to the manager about training her as an OR nurse. I am very glad she did. One summer there were 9 babies born to the OR staff over the course of 4 months. This meant that there were 9 people out on maternity leave, staggered over that time. She and I tag-teamed and did ALL the call for the summer. I took the night call and she took the day call. It was grueling but we got through it.

She has been my best cheerleader in my academic endeavors. I went back to school for my BSN, and she said what about getting your MSN and teaching. I had already been thinking about it and she helped me make the decision. When I said I was thinking of going back to school for my PhD she thought I was crazy at first and has been supporting me in this decision the entire time. Through the onerous PhD application process, the interviews, the recommendation letters, through it all.

I’ve heard about her life and her husband and her kids for years. Basically watched the kids grow up through her stories and pictures. Talked at length about her retirement plans in 2025. And we talked and supported each other through the freaking pandemic. She and I both worked the entire time, because someone has to be the OR staff in emergencies.

Tracie, there will never be another OR nurse like you. It is exciting for you that this is your last week in the OR at this hospital but also sad for us, no matter what certain people say. Let’s just say there is a reason that she is leaving the department and the hospital and I don’t blame her.

Nursing is tops again for being trustworthy. But…

According to the 2023 Gallup Honesty and Ethics Poll, nurses remain the most trustworthy profession for Americans. Yay, us! I mean, I’m not surprised, are you? This is the 22nd year as the top dog out of the 23 professions ranked.

Nurses are the hardest working, patient facing group of professionals out there. We are at the hospital, at the bedside, 24/7/52. This means 24 hours a day, seven days a week, and 52 weeks a year there is a nurse at a bedside. There are also certified nurse assistants to assist in the work, environmental services to keep everything clean and hygienic, plant engineering to keep all systems like HVAC running, IT professionals on standby to help with software problems in the electronic health record, admission and records people to keep the records straight and admit as needed, dietary people to keep the kitchen running and the patients fed, and pharmacists and pharmacy techs to keep the medications correct and flowing.

Honestly, healthcare takes a village. We all worked together to get the world through a pandemic!

I am not surprised that nursing is at the top again when rated on honestly and ethics.

But…

Here it comes.

But… the ratings, although nursing is at the top, have drifted from their peak. Yes, the peak was in 2020. We all know what happened in 2020.

All the ratings are lower, except for those at the other end of the spectrum, their ratings either worsened or were the same. These are the members of Congress, senators, car salespeople and advertisers and they were all viewed by Americans as the least ethical. I mean, when you at the bottom, is there anywhere to fall?

Surprisingly, yes.

I am sure there will be additional research as to WHY there is an almost across the board decrease in perception of trustworthiniess and ethics. I have a pretty good idea. Don’t you?

Anyway, nurses are on top again as the most trustworthy and ethical profession, members of congress and senators are at the bottom. Fascinating read.

Reference

Brenan, M. & Jones, J.M. (2024, January 22). The ethics ratings of nearly all professions down in U.S. Gallup. DOI.Ethics Ratings of Nearly All Professions Down in U.S. (gallup.com)

Post-it Sunday 1/21/24-Make it bigger!

The gown card reads “Dear Doctors, JUST MAKE THE INCISION BIGGER!!!”

Mic drop.

I don’t know who needs to hear this but, yeah, struggling for 20 minutes because you made the incision a quarter inch smaller than normal.

What do you get out of it? Bragging rights in the doctor’s lounge? A free all-expense paid golf trip at the next conference? The love and devotion of your patients?

The push in the OR is toward smaller and smaller. Smaller incisions, smaller case times, smaller.

Just smaller.

And, yeah, that should be shorter case times but it didn’t fit the theme, you know?

I see you struggling with the smaller incisions that you make.

Yeah, patients may like a smaller incision, but how much smaller can you go? And still have the proper exposure to have to do what you are operating to do? Patients probably will be happier with a regular-sized incision and a smaller hospital bill. Because you ramp up their time under anesthesia and therefore the cost of the procedure while you struggle with exposure

I know that you know the incision is smaller. But the patient is not going to know. The incision can only stretch so much.

We were doing a case in the middle of the night. Of course, it was the middle of the night, you work nights, Kate! But the surgeon was struggling with taking out the specimen from the incision size and I mean, struggling! Thirty minutes they struggled and sweated and fought to get the specimen out, me watching from the sidelines, the sterile scrub tech helping them. Finally, they gave up and started pulling the specimen out in pieces. I asked gently if a slightly bigger incision would’ve been helpful. They sighed and said it would’ve been easier. I asked if the patient was going to notice that their incision was mm longer if they had gone for the bigger incision. They said no.

I said nothing else. I think the point had been made.

Two weeks later we had a nearly identical case, same team, same surgeon. When they had localized the specimen they asked for the knife and said to me “See, I can learn.” They made the incision slightly bigger and were able to only work on getting the specimen out for 6 minutes.

Sometimes you just need to make the incision bigger.

It isn’t a slight on the surgeon; just the facts.