Wednesday, June 15, 2011

Second Chapter

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”.

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