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.