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.

Best Kept Secrets of the OR- Frequently asked questions that new staff have part 1

Awhile ago I asked everyone I could in the OR to contribute questions that new nurses might have. And I was not disappointed.

During this limited series I am going by each person’s response.

The questions run the gamut from existential to practical.

For this first post in the series I asked myself what would be the questions I expect new nurses to have floating through their heads at least once.

I wrote down two questions that I know I had when I started in the OR.

The OR was different back then. At least for me.

It was a 3 room OR but we only had enough staff for two of the rooms. The big autoclave was only run once a day, maybe. The rest of the time we made do with flashing. That is the immediate use steam sterilization to those who don’t know. Being people who are keen to use acronyms where there has not been a call for one this is shortened to IUSS. Otherwise known as the flash.

Bear in mind that this was over 20 years ago and the policies that are in place now around flashing were not yet written.

It was 2001 and I had fought mightily to get my senior experience in nursing school in the operating room. The school really didn’t want me to do it, they wanted me to be a good little med-surg nurse. Little did they no. But I finally prevailed. And I showed up for my first experience day as an almost graduated ADN nurse. This was it, the final hurdle.

Only to find there were no scrubs in my size available.

As an aside, most ORs provide the scrubs to the workers. Because no one wants to take home dirty scrubs and wash them in your own washing machine. Also because no one wants to bring in home germs (AKA outside germs) into our as clean as possible rooms.

But there were no scrubs in my size available. I wore scrubs that were two sizes too big. I just shrugged and rolled up the sleeves and pants.

My preceptor for the day was a ditzy blond who took me through the admittedly small department and introduced me to the unit secretary, to the cleaner, to the PACU staff, to the boss, to the charge nurse and, finally, to the surgeon who was preparing to start a case.

The surgeon looked down their long nose at me from their superior height and sniffed. To the preceptor they murmured that perhaps I could hug the wall. Or watch from the hallway.

The preceptor just laughed and said that I wouldn’t cause any trouble.

They led me into the room, explaining all the lights and colors and sounds as the scrub tech opened supplies while watching me.

For those who do not know, the OR can be overwhelming at first. It is cold. It is bright. It is loud. I shrank back into my too big scrubs and just watched.

My preceptor positioned me next to the window. Yes, the OR had a window. Mind blowing to me all these years later. They left to interview the patient and check with the anesthesiologist and told me to just watch the scrub tech.

They left the room after warning me not to touch anything blue.

The scrub tech didn’t say one word to me.

My first question to myself, after I was finished being overwhelmed with the noise and the cold and the light, was “Where do I stand?”

After all, I didn’t want to interrupt the scrub tech or the surgeon or the anesthesiologist or the patient.

All these years later, knowing that where do I stand was my first question in the OR, I am careful to reassure any tourists I get in the OR (these are what I call the outsiders in the OR) that if they accidentally touch anything blue we could fix it as long as we know.

I have other rules for the newbies. But that is the first one. Stand where you aren’t going to touch anything blue.

Best Kept Secrets of the OR #24- There is always one

This can apply to many, many things.

There is always that one surgeon who demands perfection, except from the people they like. The one who tirades and demands and threatens but only if you are not their chosen ones. You know, the ones who flatter the surgeon and know which side their bread is buttered on. And then use that access and favoritism to get what they want.

There is always that one team member who rides the clock like it is their business. These are the ones who go home late “because they were doing X”. Even though no one asked them to do X and another person had been assigned to X but the first person perhaps overrode the second person who gladly gave up X. Go home means go home.

There is always the one surgeon who asks for something that they’ve used for twenty years that only came out two years ago. Reacting and dealing with the insanity of this is what keeps us young.

There is always that case that looks like it will run over and that makes you sweat bullets and frantically plan to get the team out on time. You end up calling the call team in only for the case to finish 15 minutes before the end of shift. And now you have the call team there and nothing for them to do.

There is always the one team member that drives you incandescent with rage. That’s it, that’s the end of this instance. There isn’t anything to do about that one team member. We all have our trials. If it makes you feel better you are that team member for someone else.

There is always the one policy that infuriates the department. Until you realize why the policy was created. Hint, it usually has to do with safety, both staff and patient.

There is always the team member who works in the background, quietly. They are not the squeaky ones and they don’t cause the drama. These are the ones that should be cultivated and celebrated. Be aware they may not enjoy much being made of them.

There is always that one patient who you always remember, long after they are gone. It is memories like this that keep you in nursing.

Best Kept Secrets of the OR #22- FAQ of friends

FAQ means frequently asked questions.

Today I got a phone call from a spouse of a friend I hadn’t heard from in years. Damned degrees and the time and attention sink they are!

During the call, they asked me not where I’ve been as I kind of dropped off the radar because of school and the gym closing. Instead, they asked me one of the FAQs all healthcare workers get, who would I see for X problem?

This is one of the most frequent questions that we get. Presumably, us healthcare workers know the best doctors/surgeons and our friends and family want to know.

It is the highest mark of respect that we can give these doctors and surgeons to refer a friend or family member.

This friend called me because I had referred them to the surgeon who replaced their knee a bunch of years ago. Now they wanted information on a sports surgeon. Of course I gave them a couple of names. I ranked them as well, telling them that Dr. X was my favorite.

And then I asked them not to tell Dr. X that they were my favorite.

They laughed and we chatted for a few more minutes but they said were going to call the surgeons as soon as they got off the phone with me.

I rang off, after telling them to give their spouse my best and vowing that I would reach out to them.

Even as we give recommendations as healthcare workers, we have to keep in mind the different personalities and expertise of the different surgeons. After all, the total knee surgeon might not be the best fit when the request is a sports surgeon. Not that the total knee surgeon couldn’t do the sports surgery, but that they might not be the correct fit for the request.

No, I am not talking about the look at your rash/bump/do I think the bone is broken FAQs.

Because ew.

That might not be the kind of relationship we have.

Post-it Sunday 2/9/25- table height

The post-it reads “Height of the OR table is important.”

Height of the OR table is important and can be changed for a variety of scenarios.

When a tall person is intubating the patient, the OR table is high.

When a short person is intubating the patient, the OR table is low.

When a tall surgeon is working, the OR table is high.

When a short surgeon is working, the OR table is low.

You with me?

When a patient is on the fracture table or the CHIK table and the hip is being worked on, the table is high. Not only is that for surgeon comfort, but it is also so the C-arm, which is an x-ray machine, can clear the table in order to take pictures.

When a circulator is prepping a patient’s leg, the table should be low. This is for leverage and also changes the fulcrum of the balance of the weight of the leg. This also improves the circulator’s reach to ensure that all the skin is prepped.

I have always known this was important but I didn’t realize that other specialties do this too. Which is odd, because of course they do. I came to this realization when I was in the dentist’s chair going up and down, depending if it was the dentist or the hygienist working on my mouth.

Talk about your flash of the obvious.

Imagine me not even realizing of course it would be the same, even when they are sitting down.

But the number one thing to take home is that after the patient has been moved to the in-patient bed, the head of the bed should never be raised until it has been moved away from the OR table.

Why?

Because I’ve seen OR tables get tipped, a lot of degrees, by the head of the in-patient bed that is being raised.

Heck, I’ve also heard the cysto table groan as an anesthesiologist was raising the head of the patient bed after we moved the patient. And those tables weigh a ton and are not to be moved.

Breaking news 12/4/24

It is rare that I get to write about kind of breaking news.

Today there were two separate reports about insurance companies.

12/4/24- United Healthcare CEO Andrew Witty was fatally shot by an unknown assailant outside of a hotel in New York City, and the killing was captured on hotel surveillance. The victim was due to host an investor day in a Hilton hotel. The suspect has not been located. United Healthcare is the largest private health insurer in the U.S.

I don’t have a lot to add except that United Health Care had the largest denial of care rate of all the major insurers.

11/14/24- (not sure why this is just gaining traction today)- Anthem Blue Cross Blue Shield announced that it would not be paying anesthesia costs for the entire duration of a surgery in 3 states. The states are Connecticut, New York, and Missouri. Instead, it would only pay for a certain amount of hours of surgery. Presumably, the patients or the hospital, or the anesthesiologist would have to eat the remaining cost of the anesthesia.

Wow.

No idea where this idea came from. Greed, probably. The insurance parent company reported a 24% year-over-year profit increase in June 2024.

No idea how the decisions were made for how long each surgery will be covered. Presumably not by surgeons.

Because a surgeon would know and understand that there are unforeseen things that can happen during surgery that would make it longer. Does the insurance brain trust that came up with this think that surgeons are just making surgeries longer for the hell of it?

To me, 2 1/2 years into a research degree, this smacks of pilot study.

To be expanded to other states when they can.

You know, for the money. Certainly not for the patients.

Post-it Sunday 7/7/24- I’m not that kind of nurse

The gown card reads “Mocking MDs to their faces is funny.”

Yeah, on its surface this gown card is kind of mean.

But MDs are people too. They should be people first.

I remember when I wrote this gown card. The companion note says that “the squeaky wheel gets the flip.” And I wrote the Post-it Sunday dispatch last year on 4/9/23. And you thought I was just picking post-it notes from the cloud.

Nope. I still have a container full of them.

But I should really have left these two together.

I have laughed in a surgeon’s face when they requested a flip. Only to have them go behind my back and TEXT my manager. Who told them of course they could have the flip room. No matter that we didn’t have staff for another room. Or that another room wasn’t even cleaned. No matter that they were at home with their wine and their kids. The squeaky wheel got the flip.

But I got to laugh at a surgeon. So that’s good.

The title of this dispatch is that I am not that kind of nurse.

I was thinking of John Travolta and the movie Michael, where he played the titular angel who leans over to Andie McDowell as she was protesting that he was an angel and he couldn’t do what he was doing. His next line was my favorite in the movie, “I’m not that kind of angel.”

Still cracks me up.

I am not that kind of nurse. I will take under advisement any requests for a flip room.

But the surgeon may not get it.

So don’t go and tattle to someone who isn’t even at the hospital.

Or I’ve got a mop you can sling.

Something lighter today, I think

I will be writing about something lighter today. Saturdays seem to be the only day that I write about the lighter side of things. Today I will be writing about the lighter side of the operating room.

Knock knock.
Who’s there?
Crickets.
Crickets who?
Who let the crickets in the sterile core?

Yeah, don’t quit my night job.

There is a difference between jokes between coworkers and pranks. I have pranks and I think they have no business being in a workplace. Especially not a workplace as serious as the OR.

In California, I worked with a tech who would routinely prank new doctors. I warned them this was not a good look for us, but especially not a good look for them. They continued to put KY in the biogel gloves and cut up gown cards into confetti to fold into their gowns. They did that so there would be an explosion of confetti when the gown was snap unfolded. Hey, someone has to pick that confetti up.

However, one of my favorite dad jokes came from one of my favorite orthopedic surgeons.

What is the last thing that goes through a bug’s mind when he hits the windshield? His teeny tiny butt. His 6 year-old son told him that one.

And then there is the very old joke about how orthopedic surgeons only know one antibiotic. Or how orthopedic surgeons are strong as an ox and twice as dumb.

But my favorite favorite joke was one that a patient told me.

Apparently there has been a car accident right in front of the hospital. Two of the hospital employees are dying and are organ donors. One is a nurse and one is a surgeon. There was a patient on the floor who needed a brain transplant for whatever reason. His wife was asked which brain was best. She said, I don’t know, is it expensive? The transplant doctor said that the surgeons brain was $750 and the nurse brain would be $300. The wife looked at the transplant doctor and asked about the difference in price. The transplant doctor said that it was because the nurse’s brain was used.

Badum-tiss.

I’ll see myself out.

Maybe next time I’ll write about kittens and puppies.

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.