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.

Call secrets of the OR #1- Know call time is not your own

Instead of Best Kept Secrets of the OR I thought instead to start a new subset of Wednesday. This is going to be Call Sets of the OR.

I got the idea last night when I had a surgeon, a CRNA, and the surgical tech all tell me that the case we were about to start would horribly. I reminded them that we could not know that and I believed in the power of positive thinking. That thinking and speaking negatively might just create the very negative reality for us and the patient.

No wonder they called me Pollyanna Puke on the floor.

But that is another call topic for another time.

The very first call secret is one that I know that a lot of my fellow operating room people fail at.

And that is knowing that the hours you are on call is not your own. By that I mean that the hours are not yours to do with as you wish and you might get called in during that time. But if you are called in, you are unpleasant and drag your feet on everything.

That is no way to create a positive experience for the patient.

Look, having to undergo semi-urgent or emergency surgery, because that is what the call case make-up should be, is no walk in the park for them. The patient has to be NPO, dressed in tissue paper, have an IV, and have anesthesia. This might be run of the mill for us but maybe they’ve never had surgery before and they are scared out of their wits.

Or maybe they’ve had surgery before but it was years ago when they were a kid and all they remember is being cold and dressed in tissue paper and surrounded by people in funny blue clothes that are not their mommy or daddy and being held down and having to breath in a yucky gas and then nothing until they wake up in a too bright room with yet more strangers and their wrist or their ears or their tummy hurts. And so they are scared out of their wits.

It is rare to have a patient who is laissez-faire about having surgery.

The patients are who the call nurse needs to be thinking about while they are on call. And how to make their experience smooth and efficient.

It is a mind shift for sure.

Make it less I HAVE to go in and more I GET to go in.

Do I know how to make the mind shift? No. The only thing that I know is that the brain is kind of like a muscle. You have to work on changing your own mindset.

Frankly, it can take some time, and repeated calls.

Ultimately we don’t take call for ourselves. Some of us might take call for the extra pay, or to pay back a favor to a coworker, or so that a coworker will owe you a favor. A lot of people take call because it is mandatory. Those are the calls that I took, back when I was the evening charge nurse and scooping up all the calls. Because the person whose call it was didn’t want it.

So don’t make plans. Your call hours are not your own. At the very most make vague plans. And realize that a call from the supervisor can and will change them in an instant.

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.