Picking the surgical case is a personalized topic

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

Call is my favorite, after all.

Call is my life now.

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

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

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

This is mine.

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

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

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

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

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

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

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

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

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

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

But we adapt and move on.

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

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

End of story time.

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

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

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

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

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

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

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

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

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

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

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

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

How to delicately say things to patients and to not give away too much information

How, and what, to say hard things to patients should be a graduate-level class. You know the things I mean.

There is potentially life-altering information that you have that you may be asked point blank your opinion of.

Knowing what is a conversation that should be at a doctor or surgeon level AND also knowing how to get out of giving too much information without the proper context and freaking out the patient would be the final exam.

Practice the following “The specimen for the surgical case is in the lab for testing. Dr. X will know more. They are speaking to your family right now.” Or there is always the cop-out “Dr. Y will be in to speak with you shortly.”

No one likes the second one, not the patient, not the family member, not the surgeon. Not even me when I give that line. Because the patient or the family member knows that I know something and I AM NOT TELLING! And I know that I can’t tell because I give the proper context to tell anything.

Last week I had a patient ask me directly how the surgery had gone when they were in the recovery room. I was not about to give any details that were better off coming from the surgeon. Instead I leaned forward and said earnestly, “We were glad that you decided to seek care today.” They closed their eyes and nodded, content with the explanation.

We were, the surgery would have been much harder if the patient had waited, suffering at home. Instead they decided to come in and seek care. If they had waited, the outcome might not have been favorable.

Sometimes I do pass on information during the intra-operative phone call that we make to inform the family how things are progressing. However I always ask what the surgeon wants me to tell the family.

Saying the wrong thing can absolutely be bad. The family, who is not medical, can take things out of context or misunderstand what is being said. This can lead to repurcussions when the surgeon is yelled at by the family, or goes to the waiting room to find ALL the family, all crying, when the message was interpreted incorrectly.

It is best to be simple with explanations of the surgical kind, or, really, the medical kind. You have training to understand the words and the context. The patient and the family does not.

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

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

Mic drop.

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

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

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

Just smaller.

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

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

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

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

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

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

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

Sometimes you just need to make the incision bigger.

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