25- Participating in PACU games

When I started the call shift, almost 4 years ago now, I was asked if I could be the second nurse in PACU. Because I liked learning and shit. And so they wouldn’t have to call in their second PACU nurse.

I like learning and shit so I agreed. Every opportunity to learn is a good opportunity in my books.

Not every call nurse does this. I know this.

However it is a good avenue to learn about what happens after the drapes go down.

But what if there is another case? And only the call PACU nurse is there?

Well, you get the details of the second case. You give them the standard time. I have gotten some push back here. “Aren’t you already there?”

Yes, but the second PACU nurse isn’t. The first step is to call the second PACU nurse in.

The next thing you do is call the anesthesia team and give them a heads up. And then you coordinate with the scrub tech to pick the case and prepare the room.

And you schedule the case.

This is when you ask the CRNA to wait in PACU and be the second nurse while you get the patient from the ER. If they cannot (OB), you call the nursing supervisor and ask for them to come down and be the second nurse or send someone from the floor.

I mean you could put in transport but you know that there is limited transport at night. And the OR is never first priority.

It seems like a lot but it really isn’t. It is basically all the steps that you do when a call case is scheduled. Plus a second nurse in the PACU who is caring for their own patient. The second case is just stacked on the first case.

A second nurse has been obtained. You get report from the ER nurse and you go to the ER to pick up the patient. It takes less than 5 minutes usually.

This is where the 2 back to back cases blend into each other. This is normal.

The only thing you have to remember to do is bring the patient and their family member to the other side of the PACU.

Privacy reasons, you know?

The second nurse is dismissed.

You prep patient number 2. This is also familiar to you because you do it every call case. Anesthesia is alerted to the patient in the PACU, the surgeon pops in (if it is the same surgeon, but that doesn’t always happen that way). Consents are signed, pre-op checklist is completed and the Quick Prep that you always use to prep a patient is completed.

And just as you are finishing, the second PACU nurse arrives.

You hand over the patient’s family to the second PACU nurse and they take them to the waiting room. But not before you mention again the instructions to pick up the waiting room phone if it rings.

In truth it takes about 20 minutes to prep on a more standard day. This is just a little wrinkle.

But both PACU nurses are now in PACU, the second patient is in the OR, and the first patient is still waking up.

If the surgeon complains about the thirty to thirty-five minutes it took to get the second patient on the table kindly remind them that back to back call cases at night are not the usual. But next time they could go get the second patient from the ER. Or they could sling a mop and turnover the room.

OR call is all about managing the expectations of the surgeon, the anesthesia team, the scrub tech, and hoping there is a bed. Plus thinking about all the possibilities and ensuring you have what you need to answer them. It is a matter of perspective.

Call Secrets of the OR- What to do when there is a screw up with the call sheets that you tried to head off and a day shifter got called in when they shouldn’t’ve

Well, that’s a run on sentence.

This exact scenario actually happened less than a month ago.

You see, for my 49th birthday my sister had gifted me tickets to see Cary Elwes (the Dread Pirate Roberts aka Farmboy aka Wesley from The Princess Bride) for January of this year. That was when his house burned down in the Los Angeles fires. Understandably the show was cancelled and rescheduled for May. And then that show was cancelled and the money refunded to my sister.

She asked me to pick another show. We ended up going to the Postmodern Jukebox when it was here locally. It was awesome.

But the show was on a Thursday. I calculated how many hours of PTO I would have to use to cover the show and the driving home. Four hours. I asked for 4 hours off. On the calendar that everyone’s time off is posted I made a notation over my name on that day that I only needed coverage until 2300.

I fully intended to take 2300-0700. Like the good little call nurse that I am.

I called the OR in the afternoon to check on the call sheets reflected that I would be on call after 2300. They assured me it was correct and to have a nice time.

My conscience was clear and I went off to enjoy a dinner out at a new to us restaurant and a rollicking good show. Side note, if you are sleeping on these performers stop. Check them out on YouTube right now. My personal recommendation is the House of the Rising Sun.

I was home at 2300, as planned, and reading, also as planned, when the PACU call nurse texted me at 5 to midnight that the nursing supervisor couldn’t get ahold of the call nurse.

But…but I’m the call nurse.

I checked.

I texted the PACU nurse back.

I called the nursing supervisor and got the surgeon’s name and number.

I called the surgeon and arranged for surgery time to be at 0100.

I called the surg tech.

I called the nursing supervisor back and told them that I had spoken the surgeon and gave them the time and that I was on my way in.

I got in to the hospital, changed, and scheduled the case. Just like a normal night call case.

Suddenly the OR core door opened and it was a day shift nurse. Called in to do the same case I was setting up.

whomp, whomp

The best laid plans.

I told them to go home. And that I would handle it and also handle the necessary conversations with the evening nurse I had spoken to.

They went home.

I picked up the patient from the ER and delivered them to the PACU nurse who was there out of time because they had been called by the supervisor before they texted me. Which was the thing that started the cascade of unfortunate events.

We did the case.

I had a long conversation with the new to the job nursing supervisor. I gave them point blank instructions to call me with any problems in the future.

The next day I had a long conversation with the person who had assured me the call sheets were correct. They hadn’t even looked at the call sheets when I called them.

aaaarrrrrrrrghghghghgh!

Next time I want a half shift off, I will call the supervisor myself to check the call sheets.

But kerfuffle aside the patient needed the semi-urgent care and the OR was happy to provide.

Oh, and I also spoke to the new to me surgeon as well and gave them the sitch about call at this hospital. I also encouraged them to call me if they needed to do another night call case in the future.

Call Secrets of the OR #6- Sometimes you get beaten by the buzzer

Look, we are in the business of solving the case, of being the kiss on a boo-boo, of the patient having a problem and we need to fix it, of being the buzzer beater every damned time.

Sometimes that doesn’t happen.

And it sucks.

I had a difficult case a few weeks ago.

The kind of case where the patient is going to sleep and I am holding their hand, telling them that their son told me to tell the patient “I love you from your Danny.” He told me this while I was getting a phone consent with another nurse because the son was frantically waiting for his flight to get to the area and the patient, who was struggling to breathe, smiled.

The kind of case where you are listening to the pulse ox beeping get lower and lower and, without letting go of their hand you turn your head and tell the scrub tech to please let the first arrivers to the pre-op area (0530) to be on stand-by because the patient might need them.

The kind of case where the abdominal blocks are on hold because if the patient goes straight to the unit what’s the point of them?

The kind of case where you call the anesthesiologist back to the pre-op area that is also PACU at 0400 to tell them of the patient’s desired code status.

The kind of case where the anesthesiologist came right back and spoke to the patient and the son on the phone about what needed to happen about the code status during surgery.

The kind of case where there are a thousand different needs from the field, from the anesthesia team, from the front desk calling you for some reason because they want to tell you not to call in the PACU nurse.

The kind of case where before you even are in the room with the patient you look to see where the open beds are, hoping that there is an intensive care bed.

The kind of case where you text the nursing supervisor that you will need an ICU bed as you are on the phone with pharmacy looking for the coumadin antagonist that has been ordered. STAT.

The kind of case where the surgeon asks for an impossible item that does not live in the hospital, despite you mentioning it several times that it has been requested. The surgeon didn’t want to use the off-brand disposable.

The kind of case that when day shift workers, who have shown up by now, are in the room for the sixth time asking how they can help you send them to get gloves and to try to find the piece of equipment that the surgeon is demanding that you know doesn’t live in the hospital.

The kind of case where the surgery is cut short and the surgeon says that the patient will have to come back to the OR in the next day for completion of the surgery after the patient was worked up a bit more (we call that resuscitation). Because the surgeon knew that the patient was too ill to continue surgery, after the offending part had been excised.

The kind of case where you’d love to go home and get back into bed but you’ve a full day planned between meetings for the hospital and a long delayed birthday lunch.

The kind of case where you leave the patient open because of the need for a further surgery shortly. Open but with a wound-vac.

The kind of case where you call and ask the pre-op area to please get the ICU bed from ICU and a transport monitor and the bed that is left for the patient is a regular patient bed. And the transport monitor? It is dead.

The kind of case where it takes so long to pack the patient and their various lines up and get ready to bag the patient all the way to the ICU the ICU bed and monitor make it downstairs. And you help put the patient on it, making sure that all the lines and the foley is untangled and not caught.

The kind of case where you clock out at 0830, an hour and a half after your end of shift.

The kind of case where you tell the front desk, the unit admin, the charge nurse that the ice cream you’d made for the ice cream social that afternoon was in the freezer and every damned person in the lounge and at the desk freezes and says they forgot that it was today. You collect money and go to the grocery store across the street and buy 4 gallons of ice cream, ice cream bars, 3 different types of syrup, canned whipped cream, sprinkles, spoons and bowls for the exact amount that you collected from the guilty coworkers who forgot about the 11th annual ice cream social. It isn’t like this happens every year.

The kind of case where you go home and stare at the wall for awhile. But you have meetings to attend! So you get up and join the meeting.

The kind of case where you never know the outcome because the patient was transferred to a higher acuity hospital and it is against policy to open up charts willy-nilly because you are curious.

Ugly calls will exist.

What matters most is that you were able to comfort the patient as they went to sleep and you were able to pass on the message from their loved one. What matters most is that you were able to manage all of the calls and push and pulls of day shift and the call shift in that moment.

And that there was ice cream.

Call Secrets of the OR #2- The contact list in case of emergency

I’ve been at this call business for a long time.

Well, strike that because I swore to my big belly patient last week that I would stop saying that. I apparently told them that I had been a nurse for a very long time, not once but twice, and they called me out on it the second time. They just wanted me to be more specific.

Ahem.

I’ve been at this call business for nearly 25 years and in that time I’ve had my share of no shows or no answers or, on two occasions, the tech that I was waiting for was in a car accident.

It was odd enough the first time it happened but the second time? Eerie. Made me think of the night call unit secretary that I worked with in California. She trained me and was always there to answer questions, even after I became a nurse. She died driving home after a night shift.

This is why I always, always, always tell people when I have called them in to drive safe.

What do you, as the call nurse, do in event of a no answer/no show/accident?

If you are me, you grab the big red book of numbers. Everyone is in this book: surgeons, PAs, doctors’ offices, anesthesiologists, CRNAs, scrub techs, circulators, management, charge nurses, SPD, and the all of the department numbers for the hospital.

You know, in case you don’t have those memorized.

If you still haven’t gotten a call back or a response to the second call, you start in on the list.

Over time you will get a feel for who is friendly to a three am phone call and who might be interested. If it is a scrub tech you might even call nurses who you KNOW are capable of scrubbing the case.

That’s what I did when the first tech got into the car accident on the way in.

If you don’t get a response or all you get is no thank yous or hung up on, you call the nursing supervisor to keep trying.

If after the case is picked and there have been no nibbles you should consider more scorched earth options. You call management until THEY pick up. And dump the problem into their lap.

While this is going on you also keep preparing for the case. Because the show must go on.

In my twenty years of doing this I have never had outright nos from every single person I have called. Knock on wood. Mostly because I have garnered 17 years of brownie points at my current hospital.

Because they’ve all been there and can commiserate with you.

A very last resort would be transferring the patient to another hospital. This is the very last option because there are going to be delays getting the receiving hospital to accept the patient. There might not be room in their overnight schedule. And surgeons would definitely not appreciate this kind of maneuver.

And you’ll never hear the end of it.

If you are going to be new to call and are scared that this might happen, start gathering your brownie points now. Be nice, consistently nice, and people will have a harder time saying no to you.

There is also the mandatory call list but that is more to cover people during the day. I’ve never used it at night. But it is an option.

Know your friendlies and also know who is more likely to say yes.

That will save you, the patient, and the surgeon a big headache just trying to get the case off the board.

Being nice never cost you anything.

Think of it as banking brownie points for use in an emergency.

Best Kept Secrets of the OR #?- Happy 23rd birthday, surgical time out!

Once upon a time, when I was just a mere baby nurse, new to the ways of the OR, there was a wrong site surgery in the operating room. I was listening to my preceptor talk about the schedule when a more experienced nurse burst out of their room, nearly in tears, babbling about the video tower being on the wrong side of the room.

The video tower is just what it sounds like. Remember those AV carts in high school and middle school? The ones that the teacher would wheel into a room when they wanted to show a video. Do they still do that? I have no idea. It was a video monitor, a light source and a camera box. Sometimes a printer. That is so the surgeon can insert the arthroscopy camera and see what they need to see and, because of the video set up, so can the rest of the room. The early early scopes didn’t have the camera and a surgeon would hold up the scope to their naked eye and no one else could see. We’ve come a long way, baby.

Another detail that non OR people need to know is that the video tower is on the opposite side of the patient than the operative side. For example, a right knee arthroscopy requires that the video tower be on the left side of the patient.

Clear as mud, right? Just go with it.

The case left knee arthroscopy was the first case of the day in that room. The problem was that the last scope of the previous day had been a right knee arthroscopy and the video tower was pushed back to the wall to the left side of the room. The tower for a left knee scope should’ve been on the patient’s right side. And the nurse, not thinking, had just pulled the tower next to the bed and prepped what she assumed was the correct leg. She assumed that the knee arthroscopy that the patient needed was a right one because the tower was on the left side.

It wasn’t until the surgeon was in the knee, looking around and not seeing the anterior cruciate ligament defect that they even asked to see the consent. The operative consent was for the left knee and they were in the right knee.

Early morning, first case of the day. That was when we didn’t set up the rooms for the next day. It was just convenience that led to the video tower being on the incorrect side. It was just bad luck that the nurse and the surgeon and the scrub tech and the anesthesiologist didn’t recognize the error. This is the very definition of Swiss cheese error.

This is the kind of stuff that I came to understand, very quickly, was nightmare producing. It goes against everything healthcare is supposed to be and a patient was temporarily injured. And inconvenienced. The surgeon had to stop the surgery and, accompanied by the charge nurse, go out to speak to family and tell them what happened. And get permission to do the real surgery on the correct leg. I imagine while this was happening the surgery manager was on the phone with the hospital lawyer. But maybe not, it was a simpler time. The family agreed and the patient got the surgery on the correct leg, and three port sites in their other knee as well. As this was before bilateral orthopedic surgery became more commonplace.

This was before the surgical time was developed and introduced. But wrong site surgery was such a bad thing that the National Quality Forum included it in their never events. These are medical error events that should never be. The surgical time out was the solution developed by AORN.

All members of the OR team must stop what they are doing, agree that this is the correct patient, correct laterality, correct equipment, correct surgeon, correct surgery set up, and correct surgery.

The surgical time out is kind of like the 5 rights of medication administration that they taught us in school. Scratch that, the surgical time out IS the 5 rights of operation.

I still remember when the manager gathered us around not too terribly much later and explained that there was a new WHO tool that had to be done on every surgery. Also why it is called the WHO surgical time out in some hospitals that cling very tightly to their traditions.

Whatever it is called, the surgical time out or “pause” has been integral for stopping surgical mistakes. Thousands, if not millions of them, in the 23 years since its adoption.

Taking the time to pause or stop and agree on all the things is the very best we can do for the patient.

Post-it Sunday 9/22/24- how the hospital speaks and tells time

The post-it reads “Military time primer. Alphanumeric.”

I am aware that these are two entirely different things.

However, they are how every hospital that I’ve ever worked at communicates. All five of them. Plus the nursing home.

Military time is used so that there is no question as to what is meant by 2 o’clock. Is that morning or afternoon? And do I know that you think it is morning or afternoon?

Well, in military time, that would be 0200 for the morning. And 1400 for the afternoon.

Times in the hospital are mostly for important things like drug administration times. Or surgery times. Or visiting hours. It is important that we mean the same thing.

The best and easiest way to learn military time is to know that it is based on a 24-hour clock. Just like hours in a day. Midnight is 0000, and noon is 1200. What confuses people is anything after noon. All of a sudden we are adding 12 to the hour. 1 pm becomes 1300, 2 pm becomes 1400, 3 pm becomes 1500, and so forth.

The way I’ve taught many people to remember military time is that if it is after noon, just subtract 12 from the number and get the number they are most likely used to seeing. 13=12 is 1 in the afternoon, and 1600-12 is 4 in the afternoon.

I’ve used military time as far back as I can remember. It is second nature to me and how all of my clocks tell time.

Alphanumeric on the other hand is to ensure that a message is not misconstrued.

For example, if you are on the phone with a doctor and they tell you this important heart medication is TID and you heard BID, that can make a patient sick. TID means three times a day and BID means 2 times a day. How often does the patient need the med you begin to ask the doctor. And they’ve already hung up and will yell if you call them back.

The proper way to convey this information is three times a day versus two times a day.

Alphanumeric also is useful when spelling out names of medications or even names of staff or anyone for that matter. M and N sound a lot alike when you are mumbling them into a phone. As do B and T and D. Mike and November sound markedly different. As do Bravo, Tango, and Delta.

It is all about the easiest way to communicate with others in the hospital. Without the possibility of error.

I learned alphanumeric spelling in the Air Force. Because it is how to military communicates as well. Although they love their acronyms as an additional ease in communication too.

As does the hospital.