25- Call bootcamp

There’s this thing I do with new to the OR nurses or new to our OR nurses. It is called Call Bootcamp and I am the guru.

I’ve been taking all the call for so many years it has become my favorite.

And so I teach the new ones about how not to fear the call.

I call it Call Bootcamp. This is where the new nurse and I meet for about 60-90 minutes and talk about call. I also optimize their Epic situation to make it work better for them everyday. Not just on call.

I’ve done this well before the call shift. I used to buddy call with the new nurses and get them comfortable with call. I’ve done this for at least 10 years.

But I have never been able to justify the little call bootcamp on my clinical ladder. There isn’t a space for education items that are not posters or ANCC credited in person experience. That is my next step but it is a helluva lot of work and I have never dedicated weeks of my life to getting ANCC credits for the work.

The following is an attempt to get credit for the call bootcamps that I run. These are not part of my job description but rather are born from wanting to get a new nurse the best shot at a successful call shift.

1) How did you determine the date, location, and time frames for in-service? How did you communicate information to promote attendance?
This is a rolling in-service for new hires to the OR. These are one on one sessions that are not part of my role. When a nurse is deemed ready to take call for the department, the session is set though the assistant nurse manager. This is not expected in my role.

2) How was the need identified for this educational offering?
Surgery call is specific to the types of cases that you might encounter on call. Each time you are called in follows a pattern. This need was identified in new employees, many who had not taken call before. I was the natural answer to this need as the week call nurse.

3) Resources utilized?
None as I was available because of the call hours. The new nurses are paid for their time. Each call bootcamp takes 60-90 minutes, depending on their experience with call.

4) What is the objective of educating the team member?
The program objective is to familiarize new nurses to the call process at this particular hospital. This is done by a mock run through of a call case. From initial contact with the nursing supervisor, scheduling the case, picking up the patient/arranging for transport, picking the case supplies, doing the pre-op checklist through the Quick Prep tab of the operating room navigator, signing consents, doing the actual call case, when and how to call the recovery room team.

The new nurse and I walk through surgical services and talk specific to the OR things and specific to call things. Highlighted is the overhead call system, and the code button location in the OR. Specifics of code situations in the OR are discussed as well as where to find the department code carts. The silver anesthesia emergency binder is located and gone through with the nurse. In the PACU, the highlights include the Broselow cart, the Malignant Hyperthermia cart, the supply room and what might be needed from there. In the ACU, explanation of the pregnancy testing on all patients per policy and where the kits are, the supply room in the ACU is explained. The availability of the test tubes is discussed and demonstrated. The location of general ACU supplies are demonstrated. Matching Broselow band location is demonstrated, specific to pediatric patients, along with a discussion of how important it is for the responsible parent to have a band on as well. Tips and tricks specific to the call routine are discussed. I want them to be at least familiar with emergency procedures in the OR that can happen on call when there is a skeleton crew.

The Epic platform for each new nurse is optimized for the operating room. Specific to the OR flowsheets are added to the flowsheets (perinatal demise, and hysteroscopic use). Location of the code button hyperlink is explained but not demonstrated.

The Call Preserver notebook is highlighted. This is a step-by-step FAQ of specific OR things- including blood administration, how to schedule a case, how to put in a culture, what information is necessary to book a case, what specific orthopedic instrument sets are on site, how to use the iPads to do the surgical and anesthesia consents, how to run a code, and more. With a section of the supervisor has called me and I’m on call, now what?

The tour ends with the location of the call sheets. These are the pages that list who is on call for the day. In this hospital there is a call sheet for OR, PACU and Endoscopy.

5) Describe the benefits of the education to the unit/department?
Being on call is a scary proposition for new nurses. It is basically a mini shift, alone in the department with only the other call people and surgeon to rely on. This Call Bootcamp sets them up for success by answering their questions in a controlled environment when there isn’t a patient on the table, or a surgeon staring at you. I continue to offer support after the bootcamp by encouraging them to call me with any call question when they are in the middle of a call case if necessary. In the last week, I have received phone calls about specific supply locations, scheduling a case, and where the tonsillar bleed bovie was located.

By making myself available I alleviate their fears. Sometimes I do their first call with them. It is one thing if you are lectured about what to expect, it is another thing to actually do the thing. I iterate and re-iterate that I am always available for questions, should the need arise.

All of this stuff and there still isn’t a place to take credit for it. Shame.

Call secrets of the OR 10/1/25- 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 #5- Designated Call Room

This is it. The big call secret.

It’s not about how to make friends with people you wouldn’t talk to at a party. It isn’t about making nice with others of the opposite political divide. It isn’t about sleep deprivation or a cool, dark place to sleep. It isn’t about keeping all the procedures in your head so that you can pull out the appropriate one and get to work. It isn’t even about being on call.

It is about having a designated call room.

No, I don’t mean a room in the bowels of the hospital to chill in if your call is a twenty-four hour deal.

It is about having a designated operating room for call.

We like to think that all operating rooms are the same. We like to think that all operating rooms are a blank slate, just waiting for us to walk into and start the surgery.

We like to think about the call shifters as being separated from the rest of the OR crew. After all, we are a small cohesive unit. We work well together because we know the mission is to get in, do the case, and get out. No breaks, no water cooler moments, just case and be done.

In our perfect little world, every operating room would be the same. Each room would have exactly what it needs for the most common call cases. It would have a video tower, it would have an auxiliary monitor that shadow casts from the video tower. And it would be hooked up. It would have a full tank of carbon dioxide so that you can inflate the abdomen. It would have an irrigation module so that irrigation can be run into the abdomen. It would have a functional suction tree, with every “branch” that has a suction cannister. It would have the powered coagulator that you need to create access in the abdomen. It might have a tourniquet. The dilation and curettage machine would be in the designated spot. It would also be fully stocked. The irrigation would be warmed to the correct temperature of 104 degrees Fahrenheit and in the anteroom. The warmed blankets would be in the same warmer as the irrigation, steps away from the action.

The perfect little world call room is also close to help if you or the patient needs it.

But we don’t live in a perfect little world.

These operating rooms are workhorses. In the course of a day they can go from an OB-GYN case, to an orthopedic case, to a podiatry case, to a general case, and back again.

You will never be able to enact your will on every operating rooms. Don’t even try.

Because there are humans who inhabit the rooms during the other shifts. And their idea of a perfect operating room will differ from yours. The orthopedic rooms will have a tourniquet but will not have the power coagulator. The OB-GYN room will have most of what you need for a perfect little world call room, plus stirrups. The podiatry room will have a tourniquet and a bump for under the hip.

However, what is possible, is to have a dedicated call operating room that has all the equipment that the perfect little world operating room does. But you know that the dilation and curettage machine is fully stocked and where it should be.

This is imminently possible to have a conversation with your boss, or the boss before that one, or the boss before that one, about why having a dedicated call operating room is important.

Ideally invoking the wrath of a code blue in a surgery is not necessary. Remember what I said about close to help. Having a dedicated operating room allows those who would show descend on you if there was an actual code know where they are going.

I’ve done a code in the far flung cysto room. Now, do you understand why there are directional signs to that cysto room?

Having a dedicated call operating room will make your life so, so, so, much easier.

You won’t have to run around like a chicken, cursing day shift out loud as you search for the irrigation module, or the cord that connects the video tower to the auxiliary tower, or a video tower in the altogether. Or frantically searching operating room by operating room, in every store room, in the other store room, maybe it’s in the cysto room, looking for the dilation and curettage machine.

And that?

Is priceless.

And well worth the brow-beating you have to do to accomplish having a perfect dedicated call operating room.

Post-it Sunday 10/20/14-hoarding

The gown card reads “Hoarding is not a good look and leads to panic.”

Yes, this is an operating room topic that I’ve written about before.

Yes, this is something that is happening in the real world right now because of hurricanes.

Yes, I am a bit late covering this for the hurricanes. Gee, Kate, Helene, and Milton were like TEN days ago. What? I live in North Carolina and I’ve been busy.

To be explicit, I’ve been busy with school, not with horrific water damage.

Hoarding is what happens when the OR fears that there won’t be a piece of equipment, a surgical supply, or a certain instrument(s) available for their case.

Instead of considering the entire picture of the surgery schedule and the fact that the case that needs X isn’t until late afternoon, with plenty of time to turn it over, they take X and hide it.

I am talking about any number of things in the operating room. An irrigation machine, a video tower, everyone’s FAVORITE C-arm, a battery, it can be any number of things. Most egregious is when the room doesn’t even need it for any of their cases but squirrels it away so 1) no one else can have it or 2) they can look like a hero to their doctor who might (emphasis on might) need it.

This is problematic for a variety of reasons.

It breaks trust in the department.

It makes it look like the department urgently needs a supply. It doesn’t, the supply is in a drawer in a room, location known only to the person who put it there. And maybe their work bestie. You now, for days they are not there.

The team members in question are greedy and desperate to be the hero when THEIR surgeon needs X and they abra cadabra produce it.

This is just as big of a problem as it is in the real world.

In the real world, I am talking about toilet paper.

Of course, I am.

The same reasons apply.

People are afraid that they won’t have it in case of emergency. Or what they think is an emergency or because Debbie Down the Street has it and I need it. ‘ll buy it ALL up and I will have it all. I will corner the market in tissue paper.

Just don’t. You have enough toilet paper, water, canned goods, etc. Leave some for people who really need it.

Did covid hoarding teach us nothing?

Best Kept Secrets of the OR #10- sometimes your coworkers are unpleasant

This might have been a better secret after #7 about unpleasant surgeons. I don’t know why I waited until number 10.

No, wait. Yes, I do.

Your coworkers can be as close as family. And, like all family, there are some bad apples.

After all, these are the people that you spend a lot of hours with. Lots of hours in stressful, high impact situations. Situations that are so tense one wrong move, or wrong word can wreck your entire day. Or, at least, the case.

No one said that you would like all of your coworkers. After all, they are not family. Not really. Not even chosen family. More like a gang thrown together under extreme circumstance and it is either learn how to work together or suffer for 8 or 10 or 12 hours.

Sometimes it works and your coworkers become like family.

Sometimes it doesn’t.

And when that happens it is like a black cloud, or a stench that you can’t get out of your nose all day. There are some people you will work with that are so teeth grittingly unpleasant that you fear for your dental work.

Trust me, we ALL have people that when we see them in our room as the team for the day we roll our eyes and think, “Ugh, not [blank] again.” No, seriously trust me. Even on the call shift that I work there are some team members that make me irate for no other reason than their mansplaining and general I’m the man and you are the woman and I know best attitude.

Ahem.

Not my night tech, she’s lovely.

However, to go back to the first secret, it isn’t about what we want. It is about caring for the patients. After all, they are the ones who have had all of their agency stripped from them, their clothes taken, their electronic leash to the world secured, their families shunted off to the waiting room.

The patients are why we grit our teeth and struggle through the shift with the person you would rather not spend all those hours with.

Or any hours with

Post-it Sunday 8/11/24-um, OR nurses should interview the patient BEFORE the CRNA brings them back

The phone note “Are OR nurses going out to see their patients prior to meeting them at the door of the room? Is this not a done thing?”

If so, why not? You get to meet a patient who has probably not had any mind-altering medications (ahem, versed) and can assess many things in a 2-minute conversation. You can allay their fears. And the fears of the family member, who you can also meet. Put a face to the person who is taking care of their loved one behind the double doors.

Most importantly you can quadruple check the NPO status. I have a story for this. Once upon a time, I was the last person to interview a patient. Anesthesiologist, pre-op nurse, CRNA, other pre-op nurse, CNA, surgeon. And she lied to them all. Why she chose to tell me the truth, I don’t know. The patient, who was in her 80s, giggled at me and whispered to me she had had chocolate cake on the ride in to the hospital. Case canceled.

You can establish rapport and assure them that there are humans behind the masks and the aforementioned double doors. There are people involved in their surgery beyond anesthesia and the surgeon.

I chose this topic to be a Post-it Sunday because I have heard that the newer nurses are not going out to interview. Instead, the focus is on starting the chart.

I have heard this from multiple people.

Um, excuse me?

I am deeply unsettled by this report.

This leaves the patient and the nurse and the hospital in a delicate situation. All it takes is the CRNA bringing the wrong patient to the wrong room and introducing them to the RN at the door. Per policy. The patients are sleepy because of Versed when they hit the doors to the OR.

Boom!

Clusterfuck of immense proportions!

Not to mention Lawsuit City!

I must investigate further.

Post-it Sunday 7/14/24-Details will save your ass

The gown card reads “Take credit for what you do. All documentation is important.”

This can be thought of in at least two ways.

Yes, write down everything you do during a surgical case. This is important. The OR documentation is a shell, it is up to you to fill in the details.

ALL the details.

This is to protect you when there is a complication.

All the positioning aids are important to note. It is also important to note what position the patient is in during the surgery. If you have to fudge the lithotomy a bit because of their body limitations, write that. Be as detailed as you can.

I don’t care if you’ve done this case 2000 times, document everything you’ve done.

All the medications are important to note. How will the pharmacy and nurses and doctors who take care of the patient AFTER they leave the OR know the details of what medication was given? Be detailed, not only in the medication dispensed to the field, but the total of the medication delivered to the patient. Don’t forget to include the route. Remember the 5 rules of giving medication to a patient from nursing school? Yeah, right patient, right time, right dose, right medication, right route. I would add another right; the right indication for use. If this medication is being used in a way that is unusual, write it down. Give justification as to why. If there are antibiotics added to bone cement, explain that.

All the dressing details are important, even if they can’t be seen without deconstructing the dressing. An addition of an antibiotic or non-adherent film is important to note. Because the nurse or doctor who will be taking down the dressing has to make sure they have all the pieces. Because some of that turns transparent against a wound.

All the people in the room are important. Not only is it up to the circulator to control the traffic in the room and keep the crowd down to necessary people only, but times are important. People I often see not listed on the chart as being present are the correct product representatives or x-ray techs. The times all the people in the room are present may be useful in the future. Not only for productivity tracking.

All the details of the equipment used are important. This is so we can track the equipment used and also aids in tracking down instrumentation if there is an issue with a later patient where the same equipment is used. It is often necessary to note when the equipment is used on patients.

All the supplies are important. In so many ways. This is important on the back end for ordering and correct billing.

Be as detailed as you want to be while charting. But remember, your charting might save your ass in a deposition during a lawsuit in 5 years, 18 if it involves an infant, or until age of maturity if it involves a child.

Counting Basics #15- opening trays during surgery and refusing to count

There is so much that is done incorrectly in the title sentence. This is from a friend of mine. There was a large, involved open case and the scrub tech was searching for just the right instrument, neither too short, nor too long, nor too stout, nor too fine. Look at Goldilocks over here.

They had the circulator open at least 6 trays searching for this one instrument.

The circulator, who was fairly new, would ask to count all the new trays. The scrub tech refused and said that the instrument was the only thing they were going to take and to just add the instrument to the existing count sheet. They then instructed the circulator to take the tray out of the room.

Facepalm.

Never take a tray out of the room.

Always count the entire tray. Even if you don’t take the tray out of the room, I have caught scrub techs, and even surgeons and PAs rooting through the open tray. The open, uncounted tray.

Of course, they needed an instrument from the tray the scrub tech had dismissed from the room. With no additional trays that had the needed instruments. This led to even more trays being opened and dismissed.

Of course, the count was off and they needed to take a pre-wake-up x-ray to make sure that there were no instruments in the incision site. This leads to a prolonged wake-up from anesthesia because the scrub tech can’t break down the table (this means keep it sterile), or the patient awakened from anesthesia in case there is an instrument or a sponge or a needle that the surgeon needs to go back in for.

Always count the tray.

Never take a tray out of the room.

Never listen to someone who is telling you to do the wrong thing. The wrong thing that you know in your gut is the not correct thing.

It’s okay to call for backup.

Heck, call me and I will yell at them.

Let’s talk sterile consciousness-what it is and what it is not

Sterile consciousness is defined as being acutely aware of potential or actual contamination of the sterile field or object and taking steps to remedy the break.

You want surgeries to be as sterile as possible; as a patient, and as a surgical team member. There is a LOT of work done to keep it so.

A break in sterility happens when there is an inadvertant introduction of something non sterile into the sterile field. This can be a tear in the drapes, this can be a puncture from a blade being opened in the wrong area, this can be stray hair in the sterile instrument tray, or when people where their surgical cap in a messy manner with hair hanging out everywhere.

Many things can break the sterile field.

Today, I want to write about the sterile caskets. These are the hard metal containers that the instrument tray is sterilized and stored in. Some of these caskets have single-use filters that must be replaced in the bottom and the top. This is so steam can penetrate the instruments during the steam sterilization process.

You with me so far?

The filters themselves can be inserted incorrectly. There can be missing filters. There can be punctures in the filters from incorrect storage or from loose instruments in the casket. There can be folds in the filters. All of these instances render them unsterile.

If in doubt, sterility has been compromised and another tray must be opened. Hard and fast rule in any of the ORs I’ve worked in.

During the case opening process, the scrub tech does not continue set up and will stand there holding the instrument tray until the filters in the bottom of the casket can be checked for holes. Don’t wander off during this time, your scrub tech will not appreciate it as they are literally left holding the bag.

This next break in sterility has been reported to me. The scrub tech was holding the instrument tray, waiting impatiently for the circulator to reach into the casket, pull out and inspect the filters. Normal right? Yeah, the scrub tech placed the sterile instrument set BACK INTO THE NO LONGER STERILE CASKET and was picking instruments that they wanted out of the tray. No recognition that the entire instrument tray had been contaminated and must be taken away to be re-processed and protesting when the circulator told them it was now contaminated.

That is what I mean about breaks in sterile consciousness.

Don’t do this.

The OR is complicated.

Post-it Sunday 3/17/24-Recognition can be paralyzing

The post-it reads “Being recognized is hard.”

I didn’t add anything else to the post-it so I can only guess at the meaning.

Being recognized when you aren’t prepared for it is hard. It is paralyzing.

Years ago a patient approached me at the bookstore. I remembered them as being a patient several weeks back. They asked me if I was a nurse. I said that I am. They asked if I was their nurse.

This is where it is paralyzing. At least for this OR nurse.

Most of our patients are asleep. Even if I do the pre-op check-in and check-list with them I am not expecting to be remembered. There is a reason that the only Daisy nominations for the OR people are us recognizing our own.

I remember this patient. I remember that the outcome was not necessarily positive. But I couldn’t come out and say that.

Instead, I said, “Yes. I remember you. How are you doing?”

Taking the pressure off of me as an OR nurse and them as a patient. And recognizing them in return was a good thing. Perhaps they didn’t feel alone after their surgery and especially during. They had a hand to hold and a calming voice as they went to sleep and as they woke up.

I don’t think all OR people are awkward. But enough of us are. I definitely count myself in that number.

Because being recognized out of context can be weird. And paralyzing.

I hope that the patient is continuing to do well. I haven’t seen them in the bookstore in a while.