Wednesday, June 15, 2011

Third Chapter

Carl and Karen
In which a journey into the underground uncorks some memories
  Carl was circulating in a neuro case with Dr. North. Dee came into the room quietly and sidled up to Carl. “I’m supposed to get you out. Chicky wants to see you in her office, so give me report on the situation here.” After giving Dee report, Carl headed out of the OR wondering what he was in the doghouse for this time. He could not think of anything he had done or said to any of the surgeons or supervisors that would give offense, that being the usual reason for him to be summoned. When he arrived at the office door he knocked twice and without waiting for a reply, as was his habit, he entered. He was surprised to see Karen there, as Karen was not one of the people Chicky usually brought to her office.

  Chicky was standing behind her desk, looking a bit pale. “Dr. Murphy”, the trauma chief, “just called me. There has been a serious accident in the subway. You two are the best and most experienced I’ve got. I want you to round up the trauma bags and meet Dr. Murphy at the trauma rooms down near the ER, stat”. Minutes later Carl and Karen were in the trauma center, humping the two large olive green bags. Murph (Dr. Murphy) waved them into an ambulance that was idling just outside the trauma entrance. They clambered into the ambulance, and Murph laid out the situation as he knew it. “Somehow, two subway trains have collided near one of the main junctions leading into City Center Station. Early reports are of a large number of casualties, many trapped in wreckage. A surgical team may be needed. I expect we may have to do cut downs to establish IV access, maybe some stabilization of fractures, clear airway obstructions, stop hemorrhage, and whatever we will be doing will most likely involve those who are trapped in wreckage. It will be cold, dark and in very tight quarters. I have the drug bag, and I see you have the bag with our personal gear, and the bag with our supplies and instrument sets. We better get into those jump suits and hardhats.”

  The ambulance was waved through a police barricade, and a fireman directed them to the curb near a subway entrance. As they climbed out of the ambulance the fireman further directed them to the lobby of a bank. He introduced himself “I am Frank Orpheus, I will be your liaison with the command center. That is your staging area; hang in there till we get further instructions.” Frank then turned his face out of the wind to listen to his two way radio. The three medicos entered the lobby and claimed three chairs in one of the corners, amid the faux marble and rented planters. These planters made our team feel at home as they were the same as the ones the Rent-Some-Greenery company supplied to the hospital. “All that is missing are the aquariums that the hospital gets for the patient rooms from the same outfit” observed Carl. Murph reached into his breast pocket and pulled out a pack of cigarettes. “Hey Murph” Karen grinned “I thought you gave those up last year!” “I’m making an exception for today. Anybody want one?” Murph gestured with the pack. Carl and Karen both declined. Carl gestured expansively with his hands, “So here we are, hurry up and wait.” Yeah” added Karen, “Just like the Army, “did I ever tell you guys about our welcome into Saudi Arabia in Desert Storm last year?”Murph and Carl both shook their heads, surprised expressions on their faces, as they knew Karen had never talked about the experience, and had brushed off all enquiries with banal generalities.

  Karen’s unit had flown in to Saudi Arabia aboard a C-130 Hercules from an airbase in Germany. That was following a flight from Dover Air force Base in Delaware. The accommodations in the C-130, also called a Hercules, or in GI speak, a Herky-Bird, were Spartan at best. The interior of the plane was one large unheated space, with benches along the sides and pallets of cargo covered in plastic sheeting and anchored with Nylon web nets to the floor of the aircraft. Individuals sprawled on the benches and on top of the cargo, bundled up in layers of clothing and flight jumpsuits against the cold. Some ate MRE’s, the food which had supplanted the infamous C-rations which had been the mainstay of field cuisine since WWII, right up until a couple of years ago. While you could not say they were popular, they certainly were an improvement over their predecessor. Still the troops maintained that MRE stood for “Meals Rejected by Ethiopians”. As quickly as the Herky-Bird landed, the palates were loaded onto trucks, the personnel into trucks and a couple of conscripted commuter buses, decorated in colorful Arabic script and graphics of green palm trees, and rushed off into the featureless desert landscape. Several hours later all was unceremoniously deposited in a place indistinguishable from any of the rest of the territory they had travelled through.

  The Unit was well drilled in setting up their field hospital, a task that had been practiced on many reserve duty weekends. By sunset the hospital was set up and functional, with one minor problem. The pallets with the tents that would serve as living quarters were AWOL. The desert being roasting hot during the day and freezing cold at night, a determination was made after two nights that desperate measures were in order. The only thing that had kept Karen going was the whiskey, forbidden to the service people by the Saudi’s.  Carl had sent the whiskey to Karen in a care pakage. He had gone to the store, chosen two quart bottles of mouthwash of an appropriate amber color. Carl drained the mouthwash out through small holes he made in the bottom of the plastic bottles, washed them out, filled them with Jack Daniels, and resealed the holes. The shrink wrap seals around the caps were thus intact. Karen nearly choked when she took a swig after brushing her teeth.

  Karen and one of her sergeants hitched a ride to a depot along the road south towards the airstrips and what passed for civilization. The depot was like unto a truck stop along an interstate back home, offering fuel, refreshment and toilet facilities for the drivers and transitory personnel mostly headed north toward the Iraqi frontier. The intrepid duo hung out until they spotted a large flatbed truck loaded with lumber and other construction materials. They watched as the driver and his companion entered the toilet area. Karen nodded to her sergeant, who mounted the cab of the truck, and drove off north ward. Karen waited outside the toilet area and detained the hapless crew of the truck, asking questions about where they were from and otherwise diverting their attention for a good half hour, GI’s always being an easy mark for the charms of the  fairer sex. Karen gave them some ration coupons and encouraged them to get some chow, and exclaiming that her transport had arrived, climbed onto a departing north bound bus. The two GIs never noticed her lack of luggage. Carl and Murph chuckled appreciatively. “Good on you!” Carl exclaimed.

  Murph opened up. “You might not know it to look at me, but I haven’t always been a civilian. I was in the Air Force for two years, but during peacetime unlike you combat vets.” Karen observed that “You surprise me; you don’t have a GI issue halo floating above your head.” “I traded mine for a cup of coffee and a dime” retorted Murph. “My best buddy on the base was an OB-Gyn named Esposito, but he went by the nickname ‘Skip’’…..

  Skip stumbled out of the base hospital into the bright sunlight of a beautiful morning. The brilliant sun was low on the horizon, stabbing into his bleary eyes between buildings. Skip had been on the go for thirty seven hours in a row, representing ten hours of scheduled surgery, four vaginal deliveries and two emergency C-Sections. Military bases were notorious for tough duty for OB-Gyns as they had a population, active duty and dependants, almost entirely of peak childbearing age. Skip often remarked that he would like to have a bronzed insufflator mounted on a pedestal in front of the hospital, the insufflator an essential device for performing laparoscopic tubal ligations, each of which reduced Skip’s late night hours appreciably. Given his ordeal, Skip’s uniform was in an advanced state of disarray, jacket over his shoulder, shirt tail half out, tie untied, dark unshaved stubble on his cheeks and chin. Just at that moment, as Skip was taking his bearings, an Air Force Blue Staff Car with flags flying from the front fenders pulled up to the curb. Skip watched in unfocused wonder as the driver energetically leaped out of the staff car, and with a flourish, opened the rear passenger compartment door. A crisply uniformed man emerged, along with a clipboard bearing minion. Skip’s eyes registered the three sparkling stars on the shoulders, and something deep within his consciousness screamed an alarmed “Oh Shit!” His lanky frame drew itself to attention, his arm rose into a crisp salute, the jacket that had been over his shoulder falling to the ground. Three stars could only be General Davis, the Wing Commander, and absolute potentate over three bases that comprised the 48th Tactical Fighter Wing. The General advanced slowly, his gaze fastened on Skip as if he was seeing something so out of place as to be inconceivable. He stopped a pace away and directly in front of Skip. One, two, three beats passed and then the torrent started, with “the kind of example you are setting”, building to “what a disgrace to the uniform”, to “Just giving in to the commies and hippies”, on and on with rising voice up to “the beginning of the end of western civilization” and concluding with “what have you got to say for yourself?” Skip deliberately and calmly reached into his rear pants pocket, withdrew his wallet, raising it up to his face as he flipped the wallet open. “Scotty, beam me up” he spoke into the wallet, then flipped it shut, replaced it into his rear pocket. Then he walked away, dignity intact, leaving the General locked in place, frozen into disbelief at what he had just witnessed. Karen and Carl roared with laughter.

  At that moment, Frank, guide to the underworld, complete with crackling radio, approached. “Time to move out” he said, “I will fill you in on the way”. The situation he outlined was that there was an older woman trapped in the twisted metal of the wreckage. The EMTs thought that she might be going out faster than the progress of freeing her, and that a speedy amputation of her leg might be the only way to save her life. The team crossed the street and entered a subway entrance, and descended to the passenger platform which was crowded with firemen and EMTs taking advantage of the bright lighting to sort their gear and prepare to move out.

They jumped down from the platform to the tracks below which seemed felted with an even coating of greasy black dust. They made their way into the darkening tunnel lit at intervals by naked light bulbs with their own coating of the omnipresent thick grime. Following Frank, they became aware of the narrow tunnel emerging into a larger space, the grime frosted bulbs making islands of light in the intervals between the blackness. “This is where the subway and commuter train tunnels are beginning to converge upon city center station” Frank offered by way of explanation. Silhouettes girders that supported the ceiling, and of toppled and wrecked cars began to be visible, spot lit in places by work lights and the arcs of sparks from metal cutting saws. They were led into the maze of wreckage, and led to the side of what could be recognized as a commuter train car. Two firemen were working with a circular saw, just finishing an opening in the stainless steel side of the car.  A square of the metal about a foot and a half square hit the tracks below with a clang. A woman’s knee was visible framed in the opening. Murph directed Karen to get in the car to monitor the woman and administer a fast acting anesthetic and narcotic. Karen took a smaller package from their bags, and followed their guide around the wreck to enter the car. Without comment, Carl sorted through the bags and assembled a Gigli saw, betadine antiseptic, and esmark rubber bandage, a package of sterile surgical towels and sponges, and a large number twenty-one scalpel. He quickly doused the exposed knee with the betadine, opened the packages to make a small makeshift sterile field, Murph donned sterile gloves and handed another pair to Carl. Murph drew the rubber esmark bandage, a roll of rubber about four inches wide and four feet long, around the leg just above the knee, being careful not to get snagged on the sharp metal of the opening into the car. Then he tightened the tourniquet he had fashioned from the esmark and secured it with a Kelly clamp. Carl prepared the Gigli saw, thin wire with serrated teeth along its length, by attaching small handles to either end.

  Inside the car, Karen rapidly placed the probe of a pulse oximeter on the woman’s ear lobe. Only the woman’s head and shoulders were visible from the confining mass of twisted seats and other wreckage. She noted with satisfaction that the EMTs had managed to get a blood pressure cuff around one upper arm, and had got a large bore IV into the woman’s neck. The woman seemed delirious and did not respond to Karen’s ministrations. The readout of the pulse oximeter showed Karen a very rapid pulse, a high rate of respirations and the BP cuff an alarmingly low pressure, the classic signs of shock. She called out the vital signs to Murph who made the tough decision: Do it now, do it quick. He gave the order to Karen to administer Propofol and Fentanyl. Anticipating this order, Karen had removed the syringes from her kit. She opened the IV drip wide and injected the Fentanyl, a powerful narcotic analgesic, and then the Propofol, a rapidly metabolized anesthetic. Propofol is metabolized so rapidly that it must be titrated, meaning that it is given in a continuous trickle after anesthesia has been established. Karen flicked the woman’s eyelashes and noted the lack of a protective reflex response (an eye blink), a sign that anesthesia had been established. “GO!”  She called out.

  Outside, Frank held two work lamps over the heads of Murph and Carl, lighting the narrow opening and the woman’s leg with brilliant light. Murph cut deep with the scalpel, just above the knee, making an encircling incision around the leg. Carl worked with a clamp and retractor to expose the depth of the incision to Murphs’ view. Murph repeated the encircling motion with the scalpel cutting right down to the femur (thigh bone). Carl spotted the exposed tubular end of a large vessel and snapped on a Kelly clamp, sealing it. Murph passed the end of the Gigli saw around the exposed bone, grasped the handles and began sawing back and forth. Frank was astonished at the sped the Gigli saw made through the bone, eight back and forth’s and the bone parted. “Go!” Murph shouted.

  Inside the car, Karen had moved aside and two EMTs heaved on the woman’s shoulders while supporting her head and neck, dragging her onto a stretcher. Grasping the handles they exited the ruined car, where a third EMT slapped sterile gauze over the stump and held it in place as they made for the exit and a waiting ambulance. “Go with God” Murph intoned, Karen reflexively applying the “Amen”. “Dustoff Complete” said Carl. Frank gave Carl a long look, and after listening to a static filled exchange on his radio, led them back through the maze to the refuge of the passenger platform, where they were met with steaming cups of coffee.
  Frank extended a fist towards Carl, who met it with a knuckle bump, followed by a complicated series of shakes, slaps, bumps, snaps and slides that had Karen and Murph staring in fascination for the nearly one minute it took to complete. What they were witnessing was a “Dap”, a ritualized greeting practiced by enlisted troops during the Vietnam War. It was actually possible for the initiated to recognize the specific unit of another from a dap. “You were a screaming eagle” Carl said to Frank, referring to the Hundred and first Airborne Division. “Company E, first battalion, 506th PIR” said Frank. “45th Medical Company Medivac” replied Carl. Murph and Karen regarded the two Vietnam vets with a quiet respect, as they all sat down among the coils of electric cord, work lights and boxes of rescue gear. Steam rose from the paper cups of coffee. “I didn’t know you flew Dustoffs, Carl” Karen said. “Let me tell you about dustoffs” Carl replied…..

   When Carl reported to the 45th Medical Company, Air Ambulance Detachment, there was a celebration going on. Carl had been met by Tommy Jones, the crew chief of the chopper Carl was assigned to. Everybody called Tommy “Gremlin”. Tommy’s distinguishing feature was a pair of prominent ears. In fact he bore a strong resemblance to a character in a Bugs Bunny cartoon from the forties. Bugs is up in the air in a WWII era airplane with a gremlin doing his best to disable the aircraft. The gremlin had a pair of ears that looked like the tail fins of the airplane, and identical to Tommy’s, hence his nick name.

  Gremlin introduced Carl around as his new “band aid”. A medivac chopper had a permanent crew of a crew chief and a 91-B, the occupation code for a medic, which generically became a “band aid” in GI patois. The Crew Chief basically owned the chopper, being responsible for its upkeep and maintenance. The pilot and copilot that completed a crew rotated to different choppers every day. The pilot functioned as the mission commander, making the decisions and giving the orders. He also handled the radio communications and navigation. The copilot actually flew the chopper.

  The reason for the celebration was that the unit had received new choppers; UH-1H models to replace their UH-1B models. The proper designation for the UH series was the Iroquois, but everybody called them Hueys. The “H” model had a longer body with a bigger cabin. It could accommodate six patients, three on litters, and three sitting as opposed to two, maybe three in the “B” model. The “H” also had longer blades and a much more powerful engine. This gave it a lot more lift which was what pleased the crews so much, enabling them to get in and get out much more quickly. The first crews in country had been alarmed to find that the high temperatures of the Vietnamese climate caused the air to act as if it was thinner, as in a high altitude situation, resulting in greatly reduced lift. The quick in and out or “dustoff” was the preferred method of operation. The Hueys could also use the hoist to lower a sling, litter or jungle penetrator, a method which exposed the hovering chopper, making them an easy target. The hoists also were heavy and tended to make the chopper slightly off balance to the side they were mounted on. If the crews had their way, the hoists would be removed and replaced with an M-60 machine gun. It may come as a surprise to many readers who expect medics to be unarmed non-combatants, but it is a fact by the Geneva Convention that medics are routinely armed, as while they may not engage in direct combat, they are expected to defend their patients as necessary. Carl was qualified with the M-16 rifle, .45 automatic pistol and M-60 machine gun. He always carried the .45. There were two M-16s in brackets in the cabin of the chopper along with bandoliers of ammunition. The crew chief was also armed. The pilot and copilot carried .45s and CAR-15s, a short barreled, short stocked carbine version of the M-16, were on the bulkhead that separated the cockpit from the cabin of the chopper.


   The cabin of the chopper was shaped like a “U” with a fat bottom. The fat bottom of the U was the bulkhead that separated the cockpit from the cabin and the two thin arms of the U stretched rearward, embracing the walls of the mechanical space. There were two seats made of aluminum tubing and a canvas sling, like a lawn chair designed by a cubist artist, facing rearwards on the bulkhead. They faced brackets that secured standard litters, one on the floor, a second 24” higher and a third 24” over the second. A fourth litter could be placed across the canvass sling seats as needed; otherwise they were the seats for Gremlin and Bandaid. Two more bench type seats, one on each side, were on the arms of the U, facing the doors on either side.The walls and ceiling were covered by quilted pads of “olive drab” the ubiquitous uninspiring color of the army. The next morning, Carl, who had during the course of the previous evenings party evolved from being the generic “band aid” to the proper noun “Bandaid”, met with Gremlin and the assigned pilot and copilot of the day down on the flight line. The pilot was Chief Warrant Officer “Sonny” Rodriquez, a quiet spoken, short dark man from Albuquerque, New Mexico. The copilot was Warrant Officer Matt Thomas of Altoona, Pennsylvania. If the stereotype of airplane pilots was that they were cocky extroverts, the stereotype for chopper pilots was that they were moody introverts. Rodriquez and Thomas certainly fit the bill. While Gremlin and the pilots completed their preflight checklists, Bandaid checked the medical supplies, weapons and other gear in the cabin, and made sure that everything was in its proper place and secured. Then the whole crew retreated to the shady side of the chopper, and sat in the open door to the cabin. A canteen filled with Kool-Aid was passed around. Cigarettes were lit. The tedium of waiting began.

  The radio crackled with a mission from control and the crew jumped to their places and the chopper lifted up, tilted nose down, and took off. Immediately after takeoff, radio contact was established with the ground unit requesting the dustoff. Coordinates for the landing zone or LZ were established. Sonny asked if there would be gunships flying cover. The unit replied that the LZ was secure as they had taken out a sniper. Sonny switched to the command frequency and requested a gunship to cover his mission. He was informed that there would be a thirty minute delay. Switching back to the operational frequency, Sonny explained the delay for a gunship escort. The ground unit commander came back that there were two critically wounded, needing evacuation stat, and repeated that the area was secure. The Huey arrived at the LZ, a large area of tall grasses surrounded with trees. The ground unit tossed a smoke grenade which blossomed purple to mark the site and to show the wind direction and strength. “I see Goofy Grape” Sonny spoke into the radio. “Confirm Goofy Grape” replied the ground unit commander. The Huey nosed up and began the descent to the site, when it took several hits above and behind the crew cabin. Gremlin and Bandaid cowered on the floor and reported the hits to the pilot over the intercom. The whine of the gas turbine engine continued, with crunching and grinding noises coming from above, and the distinctive chop-chop sound of the blades grew quieter. “The transmissions gone” reported the copilot, and the chopper began a rapid descent. Without power to the blades, the Huey still made some lift from the blades in autorotation. This was due to the fact that they still had some thrust and momentum. Essentially, the Huey had become a glider. If they had been in hover when they were hit they would have fallen right out of the sky. Matt banked the Huey towards the source of the smoke grenade figuring he could be sure of freindlies there. The Huey’s glide path carried them past the purple smoke into a running landing, the nose touching first, then the tail slamming into the ground. Fire broke out in the engine above the crew. Bandaid helped Gremlin to his feet, as they had both been flung out of their seats into the rear bulkhead by the force of the landing. Gremlin screamed in pain when Bandaid touched his left shoulder, the arm dangling uselessly. Bandaid slung the strap of the rucksack containing his medical supplies over his shoulder, helped Gremlin out the door, and grabbed one of the M-16s and a bandolier of magazines for the assault rifle. The magnesium-aluminum alloy of the Hueys skin and frame had started to burn with its distinctive white flame. They ran and took cover on a small knoll among the tall grasses. A squad of GIs came running from the nearby tree line, grabbed the four airmen, and raced hell for leather for the trees. The distinctive deep pounding sound and rhythm of a Chinese .50 caliber could be heard among the other small arms fire. “That’s the bastard that got us” said Sonny. The firefight raged around them, and then mortar rounds began to explode on the opposite side of the LZ. The Chinese .50 caliber was silenced. Bandaid diagnosed Gremlin with a dislocated shoulder, reduced it, and immobilized it. Then he busied himself with the wounded. Later that afternoon Hueys with gunship escorts evacuated the four medivac crewmen and additional wounded. The two critical wounded they had been called in for had died, despite Bandaid's best efforts.

  The crackle and hiss of Frank’s radio brought them back to the reality of the passenger platform. Frank listened to the transmission, and then turned to the team. “Sorry to tell you, your lady didn’t make it. She died on the OR table.” Four countenances fell in unison, each internalizing the unwelcome news.

Second Chapter

Molly
In which we visit the tree of knowledge and perhaps taste the fruit
  Molly has been around the OR for a long time. To give you an idea of her tenure, consider suture. Nowadays suture is mostly synthetic, at least a dozen different materials, dissolvable or not, monofilament or braided and comes with a bewildering number and types of needles attached. Some needles are permanently attached and others come loose with a sharp tug, called “control release” by the manufacturer. When Molly started in the OR there were only six types of suture material and all the needles were “free”, meaning that they had to be threaded just like your needles at home. There were two choices of dissolvable suture, cat gut and chromic. Chromic was cat gut treated with chromium salts to make it dissolve more slowly. Cat gut was actually made from collagen and fiber derived from slaughter house cattle. There was also the ubiquitous silk, a braided non dissolvable thread. Lastly, there was Nylon, just like that used for fishing line. Occasionally stainless steel wire was used. Once in a while you encountered a surgeon who used cotton suture, a holdover from the WWII era when supplies of silk were very short. Now there is an enormous variety of types of suture available, each with very specialized properties. Every OR nurse used to carry a needle book in her scrubs pocket, made from a piece of surgical towel, and stocked with about 2 dozen needles of various types and sizes. This needle book would be autoclaved (a high pressure steam cooker) to sterilize it whenever that nurse would scrub in on a case. The nurse would replace her inventory as the needles became dull or bent. Free needles are still used on occasion, but they come sterile packaged. Suture is also characterized by its diameter, starting at #5 (like unto kitchen string) descending to #0. Then it further decreases by the number of zeros, 00,000,etc., actually pronounced two-oh, three-oh and so on all the way down to twelve-oh which is smaller in diameter than a baby’s hair and used under a microscope.

  All this information about suture and more is basic knowledge for the OR nurse or tech. Molly excels at imparting all of this extensive body of knowledge to neophytes in the OR. She has trained, or as the profession refers to the process, precepted almost everyone gathered in The Recovery Room tonight.
  In the late seventies two brothers, Stuart and Hubert Dreyfus, researchers at UC Berkley, under contract from the US Air Force, studied how pilots were trained and how they developed over the course of their careers. They identified five stages in the course of development:

1.       The Novice, characterized by a rigid adherence to taught rules or plans, and an inability to exercise discretionary judgment. Molly would say that “they practice cookbook nursing; they need a recipe because they don’t know how things will turn out”.
2.       The Advanced Beginner. This stage begins limited situational perception, with more flexible application of the rules, but all aspects of the tasks presented are treated equally, with an inability to appropriately prioritize tasks. In Molly speak, “they can adjust the recipe, but still don’t get the whole enchilada”.
3.       Competent. The individual in this stage is able to cope with multiple activities and the accumulation of information, and is beginning to see how their own actions influence larger goals. They make their own rules in reaction to situations that do not fit the taught rules. Molly says “these guys can pick the right recipe for the occasion and change it up if it is not turning out right”.
4.       Proficient. The total pro, this person has a holistic view of situations, is able to correctly prioritize the actions to be taken, especially in those situations that depart from the norm. He or She uses maxims for guidance, with meanings that adapt to the situation at hand. According to Molly “you can throw this type into alligators waist deep, and they can still drain the swamp”.
5.       Expert. This Zen master-like individual transcends reliance on rules and guidelines, has an intuitive grasp of the problems faced, has a clear vision of what is possible, and uses an analytical approach in new situations. Molly is famous even among the surgeons for being able to predict when and what complications are going to happen, and make appropriate preparations. The surgeons all tell the residents to ignore Molly at their own peril. While this ability may seem magical, it is actually a result of recognizing certain signs and patterns and applying them to a vast store of experience. Typical of practitioners at this level, Molly is not able to clearly articulate how she knew, but will say “He looked funny to me” or “I just knew”.

    More importantly, the Brothers Dreyfus recognized that there was a progression in the source of knowledge and skill from stage one to stage five. In the first stage, it all comes externally, from the teacher. By stage five, it all comes from within the individual, with a changing mix of external and internal sources in the mid stages. Experts can’t be taught, but they can be nurtured.

     She often speaks of the nurse she knew with ten years experience: “Unfortunately she had the same experience for ten years”. She also tells the neophytes not to get too worried about not getting it. “One day when you have been here about a year, something will click, and you will just get it”. The level of competence has then been reached. It generally takes three to four years for an individual to develop to the Proficient level, at which time Molly bestows the title of “A Good Nurse (or Tech)”. Molly is one of the very few who have made it to the Expert level, a fact that all at The Recovery Room would agree about.

  And herein lies the tale of Lisa, as told by Molly at The Recovery Room:
“At first we all took a shine to Lisa – she had a sunny, happy personality, and was much attuned to others. She would bring in cookies she baked to the classes. A regular little beam of sunshine. Then I noticed she couldn’t tell her right from her left. I had to write R and L on the toes of her shoes with a marker”. Giggles came from around the table. Carl interjected, “I knew a guy like that in basic training in the army. The Drill Sergeant bent over and picked up a small pebble and put it in the guy’s right hand. Then he bends over and picked up a leaf off the ground, and puts it in the guy’s left hand. Then he marches him all around yelling “Rock, Leaf, Rock, Leaf”, and slowly changed it to “Right, Left, Right, Left”. The giggles grew into guffaws.
  Unruffled, Molly continues “As you can imagine teaching Lisa the art of sterile technique was a real joy. Lisa just could not get the rules of keeping a field sterile. Doing practice set ups she would break every rule in a minute or less, contaminating the whole shebang. I had to start putting a cotton ball on everything she would contaminate. Her set ups would look like there was a snow storm. But, slowly she got it, and kept up that happy, chirpy disposition throughout. It took a lot longer than anyone else I ever taught.”

  “Now in those days we had an OR supervisor who was one of the last of the old breed, probably a lot like your Drill Sergeant Carl. Her name was Miss Perdue, everybody called her “Chicky” but not to her face, that’s for sure. Well, I began to wonder why Chicky hired Lisa, as Chicky certainly did not tolerate fools. I went to her and explained about Lisa and suggested that perhaps the OR was not a good choice of practice for Lisa. Chicky gave me a three count stare and told me that she wanted Lisa to succeed in the OR, and that of course she was fully confident that I could make it happen. I began to wonder what lay behind the hiring of Lisa, and what Chicky was saying between the lines.”

  Lisa began to make some progress, and left the shelter of Molly’s lessons into the real world, assigned to be with some of the more experienced nurses. Each day the nurse assigned to Lisa would come back to Molly and report on Lisa’s lack of progress. Most of them requested to be relieved of the burden of the neophyte after a day or two. One told Molly who Lisa’s father was: A big contributor to the hospital and friend of many of the hospital’s board of directors. That answered the question of Chicky’s hiring decision, or more accurately the lack of one. Another of Lisa’s partners compared her to the main character in the movie Fifty First Dates, where a woman had a brain injury that prevented the transfer of short term memory to long term memory, with the result that every morning she began at the day just prior to her injury, and the memory of all events subsequent to her injury were lost. “It’s like she is starting from zero every day, she remembers nothing from the day before”. Lisa began to be referred to as Fifty First Dates, which rapidly became shortened to First Date. A nick name was born, and spread through the OR at a pace only a delicious rumor can compete with. Lisa was utterly oblivious as to the meaning of her nick name, but took it as a sign of acceptance.

   Molly and her husband Ed were childless. Adopting from another country didn’t sit right with them, as there seemed to be no shortage of children needing homes here in the USA. They had tried fostering twice. The first time was an 11 year old boy with such severe behavioral problems that their efforts were entirely in vain, and they breathed a defeated sigh of relief when the courts removed the boy from their care. The second time was a lovely eight year old girl from a home where both parents were in prison, the mother for drug dealing and the father for murder. Despite such a calamitous environment, the girl was a gem, and Molly and Ed lost their hearts to the little girl. After two years, Molly and Ed began to explore the possibility of adopting the child, but the mother was released from prison, and wanted custody of the child. After that heartbreaking experience, they gave up on fostering.

   Instead, Ed had his woodworking, and Molly had her computers. Presently Ed was making a coffee table from a gorgeous slab of walnut cut straight through the center of a log, with the bark intact on both edges. His design was both rustic and sophisticated at the same time, an effect that took all of his great skill to pull off. Molly was working on a program she had written herself to aid in educating nurses and techs to the intricacies of different surgical specialties. The program presented information, asked some questions about the material presented, and if the questions were answered correctly, a reward display appeared to the user. The reward displays were incremental, and became more complex as the student progressed, involving full multimedia capabilities of the computer. Molly had built the computer she was working on herself from the latest and hottest components that she could find on the internet.

   Molly was also deep in thought about Lisa. There had been many complaints about Lisa in the past week. She could not keep drugs of similar names straight, such as Pitocin/Oxytocin, Epinephrine/Ephedrine, and so on. Lisa had thrown out an important specimen, which fortunately was retrieved from the trash, a very messy and unpleasant task.  Her counts of sponges, instruments and sharps were frequently incorrect, leading to delays in surgical procedures while the counts were reconciled. On two occasions abdominal flat plate X-rays had to be taken to rule out retained objects inside patients. And she still regularly contaminated sterile fields. Many of the staff refused to be assigned with Lisa. Molly was beginning to have that hollow feeling of failure and defeat concerning Lisa. Lisa was impermeable to all of the controversy swirling about her, her sunny and cheerful disposition undimmed.


   On Monday morning, Molly arrived at work with a sense of dread. She felt that she had to tell Chicky that Lisa was a hopeless fit in the OR and must be moved on. Molly’s first stop in the OR suite was to check the assignment board. Lisa was assigned to the preop area, where patients arrived to the OR just prior to their surgery, and a last check was made of all their paper work, vital signs and over all condition assessed, verification of identity and surgical procedure and laterality (if applicable) were checked. Family members were talked to and both patients and family members given chances to express concerns and ask questions. Surgeons and anesthesia providers also talked to the patients and their families. These were all important considerations, and were the hospitals first line of defense against mistaken identity, wrong procedures and wrong side procedures. The nurses in the preop area also served as family liaisons, getting messages from the OR to the families. Molly thought about it, and decided to see how this would go before she talked to Chicky. Lisa’s personable disposition might be a real asset in this role.

   At the end of the week, Chicky had received several letters by way of the hospital administration from patients and family members praising the care and concern they had received. Comparing patient records to the letters demonstrated that Lisa had been the nurse involved. Molly thought “Chicky sure knows how to make lemonade”.


First chapter

THE END OF SHIFT REPORT
The Recovery Room
A prolog in which we meet our dramatis personae
  If you leave University Hospital by the back door, which is down a dark hallway never used by the public, and then cross the alleyway, you reach The Recovery Room. Now, if it had been adjacent to a golf course it would have been called The 19th Hole. If it had been downtown among the financial district, it would have been The Office. Out in the burbs it would be The Alibi. But next to a hospital it could only be The Recovery Room. Inside the hospital, the area next to the OR is no longer called the recovery room, but the PACU, which stands for Post Anesthesia Care Unit. They still call the Operating Rooms the OR.

  The Recovery Room is frequented by many people of many walks of life, and is often patronized by various employees and resident physicians of the hospital, but almost never by the Attending Physicians. The Recovery Room is perhaps not sufficiently upscale enough for the Attendings. In the full light of day it looks pretty shabby, but into the evening when the sun gets lower and the tinted lights come on, it doesn’t look so bad. Some of the Administrative personnel from the hospital come here at times, but only when their numbers are sufficient to give them the security of their herd. In ones and twos they get the nervous feeling of herbivores in the presence of carnivores.

  Tonight there are a group of OR nurses, technicians and nurse anesthetists gathering in The Recovery Room, after they give their end of shift reports to the nurses, techs and anesthetists relieving them. The occasion is a farewell to one of the nurses who is leaving for a job in a sunnier climate. The departing one is Carl, a nurse of unusual background, a figure looked up to by the OR staff and many of the surgeons as well. He is less well liked by the managers and administrators, who, while they might not be happy that Carl is leaving, share a certain sense of relief that he is going.

  Carl is unusual as a nurse for a number of reasons. First of all he is male. Secondly, he is somewhat older than his peers. He is in fact a second career nurse, not that unusual these days, as there are more than a few. What is unusual is in the area of his first career, not that he ever talks about it much and then only with his fellow Vietnam veterans. This perhaps explains his dislike for those who are paid to ride desks, go to meetings, come in late, have long lunches and go home early; administrators if you give them a name. Carl calls them REMFs. The R and E stand for Rear Echelon, the M and F we will leave to your imagination. Karen, another OR nurse and a veteran of Operation Desert Storm, is one of the very few he has swapped war stories with.

  Also there is Tim: OR technician and one of the only other men on the OR staff. Tim, he of the million dollar idea, is also a second careerist, having been a carpenter prior to working in the OR. Anne is the looker, the one who induces sudden attention deficit disorder in men on the street, with the resulting collisions with parking meters and other sidewalk obstructions. There is a spirit like a samurai sword, combining great strength and flexibility with the ability to cut to the core, sheathed in Anne.  Nancy is the young widow, single parent, and the nurse who knows how to count. She is also the leader of the Transplant Team. Carol is a Nurse Anesthetist, former OR and ICU nurse, talented story teller, and the pacemaker of the open-heart team.

  To round out the ensemble, there is Molly, longest surviving nurse in the OR, a teacher or sensei to nearly all who have followed her, and as an exception to people of her age bracket, an expert at the digital world, having bought her first computer in 1979, an apple clone. Lately, she has taken to building her own PCs, being unsatisfied with the offerings of the market place. To be the Yin to Molly’s Yang, there is Caitlyn, our story’s neophyte. Caitlyn, who prefers to be called Cate in reaction to her parent’s trendiness in naming her, says “At least they didn’t name me Brittany, Ashley or Courtney”.
  So, let the first round be served, your humble narrator urges you to sit back, and let the stories begin.