Sunday, July 31, 2011

Seventh Chapter


Seventh Chapter
Cate
In which we trace a neophyte’s progress
   For Cate, it all started in Chicky’s office. Cate had wanted to be an OR nurse since she had seen the OR in nursing school. Nursing schools no longer taught OR nursing as they had years ago. Now nursing students just followed a patient through the OR and got a sort of overview. When she graduated a little over two years ago she was disappointed to find that new grads were not hired into the OR. You had to get some experience on a med-surg or surgical floor first. Now an opening came up in the OR, and Cate found herself in Chicky’s office for an interview. Chicky didn’t ask many questions, Molly and Anne had done the preliminary screening, and unknown to Cate, had let it be known to Chicky that Cate was their most likely prospect. Instead of questions, Chicky laid it on the line.

   “In the OR, you rarely get strokes from the patients or their families. Your contact with them is brief, and they are not in a state to be receptive to much of the interaction you have with them. The anesthesia will also distort or eliminate most of the patient’s memory of you. There are no boxes of chocolates and very few thank you cards here. Not like the floors at all. You need to be someone who gets their sense of reward from your work internally, not from others. You need to have a thick skin. Surgeons are very impatient with new nurses, and a couple of them are actually hostile. You have to earn their trust and respect. For the most part the nurses will be supportive, but a couple of them also have little time for newbies. Many of the Technicians can be difficult. You come in not knowing much about the OR and the surgeons, but you are their immediate supervisor. Can you see how resentment can grow from that situation? And the pace of the work is very uneven. Turning a room over and getting the next case started is like being in a NASCAR pit crew, more tasks than there is time. Then there is a period of little activity, but you have to remain hyper vigilant, because things can change very fast. You cannot be caught asleep at the switch. And starting out, everybody is going to be impatiently waiting on you to catch up all the time. For six months you are going to be very frustrated, and you will frequently wonder why you thought that you wanted to work in the OR. It will be a great temptation to quit and go back to working on the floor where things are familiar and comfortable.  If you survive that, things will get better, and somewhere about a year into this something will click, and things will fall into place, and suddenly you will be a competent OR Nurse.” And then Chicky asked her only question: “Do you think you are up to that?” “Don’t answer now, I want you to go home and think about it tonight, and get back to me tomorrow.” Cate did think it over, and decided that she still wanted to do it. And she came to understand that Chicky had been exactly on target in her description of how it was going to be.

   Cate had already made it into the compiled legends of the hospital during her first year on the floor, because of a Clinitron bed. A Clinitron bed is a specialized, very heavy and very expensive piece of equipment. Since it is not an item in frequent use, hospitals rent them as needed instead of tying up precious capital. Basically, the bed is sort of like a hover craft turned upside down. Air is blown upwards through a one and a half foot layer of very fine glass beads, like perfectly round grains of sand. A special sheet goes over this, and patients with severe burns or severe pressure sores (decubitus ulcers) are gently supported with the least possible pressure per square centimeter of their damaged skin as mankind has been able to devise short of sending them into weightless outer space.


Cate had a patient in a Clinitron bed, the archetypical “little old lady”. She was five feet nothing, seventy pounds, completely senile, and had fresh skin grafts on the decubiti that covered a large percentage of her buttocks and back. Keeping her on her front side was not an option because of the contractures of her arms and legs, hence the need for the Clinitron bed. It came to happen that the little old lady coded and died. Someone unplugged the bed while everyone else, especially Cate, was busy with all the necessary paper work and phone calls. Sometime later, the morgue attendant came to collect the body, and along with Cate, found the Clinitron bed empty. A frantic search that grew to include the whole of the hospital ensued, with poor Cate at the center. While the search for the body was going on, the rental company came and removed the Clinitron bed. An hour later, the search was still ongoing at ultimate panic level as family members of the little old lady were due to arrive. The phone rang. It was the rental company. Were they missing something? They had found the body submerged in the glass beads of the Clinitron bed. Apparently, when the power was cut, the air stopped blowing and the body subsided, the little old lady being of such dimensions that she was entirely covered. A legend was born.
   Cates first two weeks in the OR was spent with Molly. She learned surgical instruments with the aid of flash cards. She learned sterile technique: only sterile things could touch sterile things, how unsterile things could become sterile and vice versa, by using autoclaves (Hot sterilization) ans Steris machines (cold setrilization) for heat sensitive items. How to do a surgical scrub, gown and glove oneself, how to gown and glove someone else. How to set up an OR, and how to use Bovies, SCDs, lasers, microscopes, harmonic scalpels, Electronic ligating machines (Ligasure), video equipment and surgical cameras, how to work several types of specialty operating tables and how to utilize computers for getting lab and imaging (x-rays and scans) reports, blood bank availability and how to do all the different types of documentation. How to prepare various types of specimens for different labs. At the end of the week she served as first a scrub nurse, and then as a circulator for a mock surgery. Molly had a manikin outfitted with different layers of foam to duplicate the abdominal wall, and inside a bowl of red dyed water with a glove filled with more red water. Molly played surgeon with other nurses as stand-ins for anesthesia, circulators, etc. They simulated an appendectomy, complete with removing a finger from the glove, a stand-in for the appendix. Next, they did it all again, now with Cate acting as circulator. She had to set up the OR, check her patient in, open up all the sterile packages, count everything with her scrub nurse, keep all the records, and rectify all the counts at the end of the procedure. She prepared and documented the ersatz appendix for pathology. Then she learned how to report off to PACU (post anesthesia recovery) in person, or how to phone a report to the ICU and prepare monitors, oxygen, ambu-bag (a rubber balloon squeezed to manually ventilate a patient), and call and hold an elevator to transport a patient to the ICU. It was a lot to learn in two weeks. Then Cate was paired with a preceptor, first to learn to scrub, and then with another preceptor to learn to circulate.

   Many hospitals no longer trained RNs to scrub, that role was filled entirely by OR technicians. But Chicky felt that to be really effective as a circulator, a nurse had to know how to scrub. It was also very handy in crunch situations to be able to juggle assignments, with RNs able to scrub. Molly completely agreed. It also helped the frictions that could occur between Technicians and RNs.

   First, Cate was paired with Julie, an OR Technician. Julie was one of the longest serving techs on the staff, and had the trust and especially the respect of all the surgeons. Molly also made their first assignment with Dr. Johnson, who was as good natured and pleasant as could be to new people in the OR. It was just in his nature to be that way. On this day he didn’t have any really demanding cases either, a couple of hernia repairs, a large sebaceous cyst to be excised, and a breast biopsy. An ideal set up for someone’s first day at scrubbing. Things went smoothly, with Julie standing back and just giving Cate some non-verbal cues as to what instruments would be coming up next. Dr. Johnson started in with one of his stories….

   Doc Johnson as he was known to his friends and neighbors was a gentleman farmer. That is to say, he owned a farm, but did little actual farming himself, as being a surgeon, he really only had time on weekends and the like. However, having grown up on the family farm, he did know farming. His wife kept two horses, which were the passion of her life, and they kept a cow for the milk, and some chickens for the eggs. Doc Johnson milked the cow twice a day himself, and he claimed that milking was the best stress relief that anyone could ask for. Sitting on the milking stool, his head pressed against the cow’s flank, the sounds of the cow’s internal processes in his ear, the feel of the teats in his hands, the ringing of the squirts of milk in the stainless steel bucket, Doc Johnson was in a state of grace akin to a Zen Buddhist Monk in meditation. One of the tasks that he could not justify spending his time on was cutting the grass on the nearly two acres of lawn in front of the house and around the barn and sheds. This he paid his neighbor Dewey to do. Now it came to pass that the Cub Cadet lawn tractor he owned reached the end of its lifespan, and had to be replaced. The salesman at the dealership where Doc Johnson bought his equipment talked Doc into buying a Grasshopper zero-turn machine, which cut a wider swath, and was highly maneuverable as the steering was by a system of two levers, right and left, which advanced, put in neutral or reversed the drive wheels on each side of the machine, just like a vehicle with caterpillar treads. The machine could make a zero radius turn by this means, hence its designation. It could even spin in place. You may have seen one of these in use by professional landscapers. Doc was delighted with the new machine, and when Dewey came over to mow, Doc, in full bloom of enthusiasm demonstrated the capabilities of his new acquisition. As he was zooming around the barnyard, weaving in and out and around the many objects there, he looked over and saw his wife standing next to Dewey, who was speaking to her. Parking the machine, he let Dewey take over and Doc went over to his wife. “I bet Dewey was telling you what a fine piece of equipment the Grasshopper is, and how he couldn’t wait to get on it” he said to his wife. “No, “she replied, “he was telling me that I should never let you buy a chainsaw.”

   The day progressed, and Cate did as well, needing less and less cues from Julie as the day went on. There was only one glitch, a needle missing at the end of one of the hernia cases. A quick examination of the floor turned up the missing needle, and the counts were then correct. She began to feel really good, and at the end Dr. Johnson told her she was doing very well for her first time scrubbing, and that she could scrub for him anytime.


Saturday, July 23, 2011

Sixth Chapter


Sixth Chapter
David
In which we are taken on a spectral tour of the OR suite

   David came to awareness in a swirling grey/white fog. Slowly, pixels of color started to appear, filling in a picture. It took awhile for the picture to resolve into something that David could recognize. He noticed that it was an OR and that Dr. Macintyre, his surgeon was in the scene. Although he could not recall their names, he also recognized Kerry, the nurse, and Carol the anesthetist. There was the long rectangular stainless steel box of the heart lung machine with its whirling roller pumps, rack of tubings and bags of fluid, and the two large diameter plastic tubes leading from the machine to the draped shape on the OR table. One tube was bright red, the other a dark red. David moved closer to the head of the table, and was quite surprised to see himself, face distorted by the breathing tube sticking out of his mouth and taped securely to his face. He reached out to touch the face on the table, but he felt nothing. The next thing that he noticed was the lack of other senses. The pain in his bones and joints was gone; he felt no laboring shortness of breath. These things had been his chief sensations for many years, and now they were gone.  He turned away from the OR table and passed right through the heart-lung machine without feeling it.

Looking around he expected to see everybody looking at him, but nobody noticed. He spoke out, but nobody heard him. David stopped in place and reassessed what he was seeing around him. The scrub nurse was passing sutures to Dr. MacIntyre; the other nurse was working on a computer next to a white board with tallies of several types of objects recorded. A man of his own age was tending the heart-lung machine and the anesthetist was concentrating on the wiggling lines on a monitor. And his body was on the table under the drapes and he was free of the effects of his Marfan’s Syndrome. While he was conducting this survey, he had drifted and he found himself passing through the door of the OR into the Hallway. Through the door, without opening it! David drifted as much as he directed his progress. He drifted through the wall into another OR, and as he assimilated what he was now seeing, he forgot all about what he had left behind in the open heart OR.


   In this OR, Dr. Gerald was resecting a colon. Dr. Gerald was the new junior partner of a general surgeon of long standing in the hospital who was planning to retire in a few years. Dr. Gerald was also just a year out of a colorectal fellowship, so he was in his first year of private practice and like many of his peers, was deeply in debt from his medical education. It was not uncommon for a young physician in Dr. Gerald’s position to be two to three hundred thousand dollars in debt. To compound his financial challenges he was also beginning a family and had just purchased his first home. He was taking on finishing off the basement himself, to make a family room, a spare bedroom and a bath. And that brings us to Tim, an OR Tech who used to work in home building as a framing and finish carpenter. Tim was filling the role of scrub nurse for Dr. Gerald. Dr. Gerald was quizzing Tim on the proper ways to put in framing and insulation against the cinder block walls of the basement. Tim did a lot of work on the side for many of the OR staff and doctors, everything from custom built cabinets to decks. The surgical procedure progressed, as both Tim and Dr. Gerald were in a groove, Tim being two steps ahead of Dr. Gerald in his mind as a really good scrub nurse should be. Dr. Gerald rarely had to ask for an instrument, as Tim already had it in his hand ready to pass it to Dr. Gerald. As their talk turned to two-by-fours, fiberglass batting, foam board and vapor barriers, Janet the circulating nurse gave Dr. Levin the anesthesiologist a look and rolled her eyes. “I feel like I’m trapped in an episode of Home Improvement or This Old House.” She opined.

   David felt compelled to explore, there was a feeling that he should be looking for something. He drifted over to the wall, and since it worked well on doors, he glided right through the wall. In the next room was Dr. Johnson, the senior surgeon at the hospital. It was said of Dr. Johnson “He’s an old dog who knows all the tricks, but more importantly, he knows which tricks actually work”. He was now repairing a routine Inguinal Hernia, or to be more exact, he was watching a senior resident do the actual repair. He was quite satisfied with his resident’s work having nurtured him through all the stages of a hernia repair previously.

   Dr. Johnson was heir to, and lived on his family’s farm, and though he didn’t farm it himself anymore, he still had plenty of stories to tell. One of his favorite subjects was his neighbor, Dewey, who was a deputy to the county sheriff. There had been many complaints about drunken drivers coming from a certain road house late at night, so Dewey had staked it out. He had his cruiser parked out of sight but where he had a good view of the parking lot. After a bit, a fellow came staggering out of the bar, and lurched over to an older Ford sedan. Leaning against the car, he began searching his pockets for his keys. Handkerchief, coins, pocket knife and comb clattered to the gravel. Finally, the keys materialized, only to be fumbled and join the rest of the contents of his pockets on the ground. Bending over to retrieve the keys, the man lost his balance, falling into the car, sliding down the fender, and joined his belongings scattered on the ground. He rolled over and got up on all fours and began to search for his keys. Finding them, he pulled himself up by the door handle of the car, which of course opened, causing him to fall to the ground again. Dewey watched amazed that this guy could even find his car let alone his keys. On all fours the man crawled into the car and began the process of getting up from the floor into the driver’s seat. Dewey winced as the struggle to get the key into the ignition commenced, involving two trips to the floor of the car to regain possession of fumbled keys. Dewey was paralyzed watching the spectacle. Finally, the key turned, the car started, lurched into gear, and wavered onto the road, tracing a weaving path. Dewey fired up the cruiser, lit the lights and followed on a slow speed chase. The man seemed to take no notice of cruiser, lights or siren for almost a mile, and then pulled over to the side uncertainly. Dewey got out and went over to the car, knocking on the window and motioning for the man to crank the window down, which the man did with surprising ability. Dewey expected to be knocked over by a powerful draft of fumes, but was surprised by the complete lack thereof. Still, he had the man get out of the car, which the man did with agility. Temporarily forgetting about asking for the man’s driver’s license, he had the man do a breathalyzer. The indicator on the breathalyzer showed nothing. “All right now” said Dewey, “what the blazes is going on here?” The man replied, “I’m the designated decoy”. Hearty laughter filled the OR.

   David looked around. Somehow he knew that whatever he was supposed to be looking for was not here, so he passed through a wall again. He was getting used to this new mode of getting around, and contravening the laws of physics was beginning to feel almost natural. He also became aware that his sensorium was limited to just sight and sound. No touch, no hot and cold, and most blessedly of all, no pain.

   In the next OR, two gowned, masked forms sat on stools looking into the eyepieces of a double headed microscope. David could make out that the microscope was perched over the head of a draped figure. The two figures were Carl, acting as scrub nurse and assistant, and Dr. Zietsev, an Otoneurologist. An Otoneurologist is an Ear Nose and Throat surgeon (aka Otolaryngologist) further specialized in disorders affecting nerve conduction in hearing loss. Rounding out the team in the OR was Karen, circulating nurse, and Dr. Prakash, anesthesiologist. They were in the middle of resecting an acoustic neuroma, a benign tumor of the acoustic nerve. While not malignant (cancerous), an acoustic neuroma has some very debilitating symptoms and effects: Loss of hearing on the affected side, disturbed balance and gait, vertigo causing nausea and vomiting, loss of sensation in and around the mouth on the affected side, and sometimes a loss of swallowing reflexes causing gagging. Intracranial pressure may be increased, causing headache and altered level of consciousness. Increased Intracranial pressure can be lethal. Surgery for the condition involved drilling out the mastoid bone ( the bump behind the ear ) to expose a space called the vestibule. This leaves a paper thin layer of bone over the brain, and comes very close to the innermost structures of the ear. The facial nerve shares the vestibule with the acoustic nerve and damaging it can lead to paralysis of that side of the face. Needless, to say this is a very delicate and highly demanding procedure. There are only a handful of surgeons in the USA who do the procedure, which can take eight or more hours in the OR. 

  Given the difficulty of the procedure, Dr. Zietsev was very particular about the personnel on his team. He long ago settled on Carl as his scrub, even taking Carl to his lab to teach him to drill out a mastoid, using actual mastoid bones from cadavers. This enabled Carl to anticipate his every move, and have the appropriate instrument into his hand without discussion, and to also aid whenever an extra hand was needed again without the necessity of direction from Dr. Zietsev. Karen came along with Carl, the two being a team unto themselves.

   Zietsev was just as talented musically as he was surgically. His passion was for choral works, and he was director of the University Choir. He made every new face entering his OR sing, as he was always looking for new talent. Carl failed to impress, but Karen had a great contralto and soon was part of the choir. Zietsev had even been a guest conductor with the City Symphony last summer. He played classical music in the OR, and had even gotten Carl interested in Mozart and Bach, despite Carl’s taste for Steely Dan, Supertramp and the Doobie Brothers.

   David felt the need to push on, to find that something that seemed to be his purpose. Drifting through the door, he crossed the hallway and entered the OR opposite.

   Music blared at a high volume; Bruce Springsteen’s Born To Run. This was the room of Dr. Gatling, Orthopedic surgeon specializing in total joint replacements. Born to Run was his closing music. During his surgeries, his taste was quieter, and more eclectic. You might hear Astrid Gilberto doing The Girl from Ipanema followed by Count Basie followed by Stevie Nicks. Gatling was a very talented instrumentalist, specializing in guitar (acoustic steel and gut string, electric and slide) and reeds (baritone, tenor, alto sax, clarinet and flute). Gatling had gone to college, med school and residency in Philadelphia and had worked on the side as a studio musician at Spectrum Sound on Broad Street. He played on many of the Gamble and Huff productions of Harold Melvin and the Blue Notes, the O’Jays, Lou Rawls, and a Philadelphia favorite, Patti LaBelle. He fronted a band of hospital personnel that called themselves “Malpractice”.

   Gatling was telling a story on George, his OR tech. Back in the old days when Gatling was a brand new orthopedic surgeon and had to cover call at all hours, he was called in late, late one night for a fractured hip. George was on call that night along with Meg. In those days women still wore scrub dresses in the OR. When Gatling and George arrived, the OR was out of scrubs for men, so with red faces they donned scrub dresses. With Meg and the anesthesiologist barley muffling  laughter, and  manly legs on display, things moved on. It turned out that the patient was an older gentleman who had an above the knee amputation on the side where his hip was broken. He had been able to walk on a prosthetic leg quite well, and felt that he would be able to do so again when his hip was fixed. The best way to fix the hip at that time was an Austin-Moore.

   Now a broken hip is actually a fracture of the femur (thigh bone) at the narrow neck where the ball of the hip joint attaches to the shaft of the femur. The ball on the end of the femur then fits into a socket of the pelvis to make the complete joint. To do an Austin-Moore, the whole end of the femur is trimmed off and the prosthesis, which is a ball on the end of a spike shaped to fit the shaft of the femur, is pushed down the hollow shaft along with some cement. The cement is basically a putty of methacrylate which is the same thing that super glue is made of. The ball is sized to fit the socket, and all is put back together. Now when the procedure got to the point where they were measuring for the prosthesis, Gatling and George discovered that the spike of the prosthesis was longer than the gentleman’s femur which had been shortened by his amputation. What to do, what to do? Gatling took the prosthesis, broke scrub, leaving George to watch over the open incision  keeping everything sterile. Gatling went down to the maintenance department of the hospital. Of course, maintenance was locked up, and security had to be summoned to open it for Gatling. Imagine the security guard answering a call and finding a burly man dressed in a scrub dress holding a silvery object that looks something like an Indian war club. Using the tools in the maintenance workshop, Gatling cut the spike off to size, filed it smooth, went over it with emery cloth to put a polish on it, and returned to the OR. Meg washed the Austin-Moore several times with iodine impregnated scrub brushes, the same ones used to scrub the hands and arms of the surgical team. She put the custom tailored prosthesis in the autoclave, and ran a double length cycle where pressurized steam at 273 degrees farenheit made sure it was sterile. Gatling rescrubbed, George gowned and gloved him and the procedure was completed in more or less the normal manner. The story got grins from all the team and George and Gatling did a knuckle bump.


   Growing frustrated at not finding the thing he was looking for, David drifted through the wall and found himself just outside the fourth floor, suspended in the air. Looking around, he felt that he was getting closer. He began to move upwards, gaining speed, and his vision narrowed. It began to be pixilated again, a darkness forming in the bright blue sky, and David passed into the realm that no one has ever returned from.

Saturday, July 16, 2011

Fifth Chapter

Fifth Chapter
Carol
In which we have a look behind the curtain where broken hearts are mended
   Carol is a CRNA, a Certified Registered Nurse Anesthetist, an advanced practice RN who has a Masters degree and certification in anesthesia. She worked as an OR nurse for two years out of nursing school, then for five years in a Surgical Intensive Care Unit before entering her two years of schooling for anesthesia. Carol describes the delivery of anesthesia as “Controlled Poisoning”. She is not far from the truth in this assessment, as all the drugs used in anesthesia could have been used by the Borgias for their deadly purposes. The original anesthetic was Ether, first used by Dr. Crawford Long in the eighteen forties. A persistent legend has it that the discovery was the result of an ether party, a popular pastime of medical students of the day. Currently, anesthesia is induced with an IV injection, maintained by an inhalant, and supplemented with paralysis as needed. The injection compounds are all descended from the barbiturate family and have included sodium pentothal, beloved of thriller stories as “truth serum”. As anyone who has actually seen it used in the OR will tell you,  it’s use as a truth drug belongs to the same mythology as the karate chop to the back of the neck producing unconsciousness. Propofol, of Michael Jackson fame, is now the IV agent of choice. As mentioned previously, ether was the original inhaled agent, now supplanted by Sevoflurane and Desflurane. Nitrous Oxide, popularly known as laughing gas, is still in use. Curare, the Amazonian arrow poison, was the original paralytic agent, and is now supplanted by Vancuronium and Pancuronium.

   At the moment, she is studying for her yearly recertification in ACLS (advanced cardiac life support). All the OR surgeons, anesthesia personnel and nurses must recertify every year. There are changes in ACLS almost every year as new drugs come out or as research refines the process. Algorithms are used extensively in ACLS to define the steps to be taken for all sorts of events and contingencies that can occur in the course of treating cardiac arrest. Below is a tounge-in-cheek algorithm Molly wrote once after the ordeal of renewing her ACLS:


   Carol worked with the Open Heart team, and was proud of the fact that she was the only nurse anesthetist on the team. There were two Anesthesiologists on the team, as well as three surgeons, one fellow, one resident, two perfusionists (who operated the heart lung machines), and six RNs. The King of Hearts was Dr. Hector Charles MacIntyre, a dour Scottish-American of exacting standards, volcanic temper, and magical hands. Standing a Napoleonic five feet three inches, he was an alpha male to the core. He was addressed as “Sir” by all the members of the team, including his two junior partners, Drs. Haley and Thompson. Behind his back, everyone called him Hector. He was renowned for tearing up residents and fellows, reducing RNs to tears, and favoring everyone else with his biting sarcasm. Hector did not suffer fools. He commanded enormous respect due to his consummate skill as a cardiac surgeon. Carol had once watched awestricken as he sutured up a small tear in an artery on the back side of the heart. His only view of the tear was in a dental mirror about an inch and a half in diameter, so he had to do each stitch backwards and backhanded from what he was seeing in the tiny mirror. He was using a 7/0 prolene suture which is about as thick in diameter as an eyelash, on a curved needle about the size of this capital letter “C”.  

   His temper was legendary. There were few restraints on the behavior of surgeons; without them there would be no patients, and without patients there would be no income, and without income there would be no mahogany in mahogany row. Once when Dr. Alberts, an anesthesiologist, cancelled one of Hector’s cases because he felt that the patient was an unacceptable risk for anesthesia, Hector kicked a trash can standing next to the scrub sink into many pieces. His rage and cursing could be heard throughout the OR suite, most people just giving each other a knowing look and getting on with their work. Jim, one of the perfusionists, went online and printed out a clipart of a trash can which he taped up in the substerile room between the two heart ORs. It was alongside of a caricature of a Bovie machine that Hector had demolished on another occasion, and several cut outs of cartoon figures of a persons in surgical attire, which represented residents Hector had kicked out of his ORs.

   There has been research into the influence of music in the OR. Basically, the findings are that music chosen by the surgeon is beneficial to his performance. Music not chosen by the surgeon degrades his performance. The type of music does not seem to be relevant, be it heavy metal rock or Mozart, what matters is the surgeon’s partiality. Hector did not allow any music at all. The conduct of every member of the team was rigidly defined, and each could have had algorithms defining their practice. The only member of the team with flexibility was of course, Hector. Conversation was limited to only what was necessary for the procedure.

   The usual day began in the first of the two heart Ors. Dr. Haley or Dr. Thompson would begin the procedure, the fellow or resident would assist the junior partner, or harvest vein graft from the patient’s leg as needed, and things would be much looser in terms of conversation, etc. When the critical point of the procedure, such as going on bypass, was reached, Hector would be summoned. Things became tighter. Hector mostly placed the grafts or valves himself, or directed the junior partner as they performed the critical part. When the critical point was passed, he would move onto the second room where the other junior partner would have things ready for Hector on the second patient. In this manner four to six surgeries made up the normal working day. Throw in the not normal days and the team members usually put in sixty to eighty hours per week. In the substerile room, there was a poster that showed a bedraggled nurse sitting on the side of a bed with the caption “When you are sitting on the side of the bed with one shoe on and one shoe off, and you can’t remember if you are getting up or going to bed, you do know that you are a member of this team”. The team was subject to recall at all hours of the day or night as needed.

   Having recently read Joseph Wambaugh’s The Choirboys, Carol was inspired to announce “Choir Practice” on select Fridays, whereupon the team minus the King would rendezvous at McSorleys Pub, just near enough and just far enough away, and definitely not a watering hole habituated by hospital personnel. After a drink or two, Carol had a way of retelling the day’s events that put the “choir” into convulsions of laughter. This past Christmas Carol was surprised to receive an envelope from Hector that had “A donation for the Choir” inscribed on the front. Inside were two crisp one hundred dollar bills. Carol would tell of other unexpected acts of generosity by Hector:

   There was Bobby. Bobby was the bottom rung and lowest paid person in the OR. Ever cheerful, he was the one who mopped the floors, dug the bits of suture out of the wheels of all the OR furniture, emptied the suction canisters of their unsavory contents, washed and made up the stretchers, ran the errands, lifted all the heavy objects and patients for the nurses, took out the trash, restocked the linens and solutions. In short, he made the OR the clean and efficient place it needed to be. Perhaps because of his lowly status, he was able to approach Hector with a familiarity that was not dared by others and was certainly not tolerated in anyone else by Hector. Bobby’s passion was the city’s NBA franchise. He would greet Hector with a big smile and share the team’s latest triumph, defeat, escapade, rumor or bit of intelligence concerning trades or draft picks. Hector would respond on the level with Bobby as if there was no difference in their status. He seemed to enjoy the exchange of basketball trivia with Bobby. No one else, not even the junior partners, got that kind of attention from Hector. One day, there was a big change in Bobby. Gone were the smiles and cheerful demeanor. People wondered if Bobby had a death in the family. He wouldn’t talk to people. Reading the sports’ section of the paper, it fell into place. It was announced that there would be an unprecedented hike in the price of tickets for the team’s games. A little calculation revealed that even Bobby’s usual nosebleed section season tickets were now out of his reach. The next day Bobby found a blank envelope taped to is locker door with two courtside season tickets inside.

   Then there was Rhonda, a single Mother, nurse, and not even a member of the heart team. Her son developed a rare metabolic disorder. It turned out that the only physician treating the disorder was in California, three thousand miles away. Hector chartered a plane, and paid for a hotel for Rhonda and her son to make the trip out to California.

   As much as it bothered her, Carol found that patients tended to blend into one another, and unless there was something special or remarkable about one, they were soon forgotten. A name might come up in conversation that would be familiar; but it would require more than just a name or face to retrieve a memory. Given the volume of patients through the heart ORs this was perfectly understandable. There were however two patients that Carol would never forget.

   Frank was one of them. Carol first saw Frank in the ICU. She had gone up with Dr. Miles, an Oral Surgeon, to sedate an upcoming heart patient so that two bad teeth could be removed. This was a not unusual situation. Bad teeth acted as an antibiotic resistant reservoir of bacteria that might cause endocarditis (an infection of the lining of the heart cavity) in an otherwise healthy person, but it was a certain outcome in patients undergoing heart procedures. Reviewing Franks chart, the history and the numbers painted a picture of someone barely hanging onto life. Frank was only forty-four years old. Entering Frank’s room, the first things to strike Carol’s eyes were a number of papers on the walls. They were crayon drawings with legends such as “We Love you Daddy” and “Please get well Daddy”, obviously the work of at least three small children. Carols felt a tight squeeze in her own heart. Frank was already barely conscious, it didn’t take much to sedate him, and the two teeth were quickly removed. Afterward Carol reflected that there must be a great strength inside of Frank to keep him alive at all. The next day Frank arrived in the Heart OR. During the procedure it became apparent that there was extensive damage to his heart, and blockage of the coronary arteries that the stents placed by the cardiologists did little to relieve. Never the less, he made it out of the OR to the ICU. Over the course of the next couple of days, Carol quizzed the junior partners on Frank’s progress. They reported astonishment at the speed and strength of his recovery, and he was discharged to cardiac rehab in near record time. At the last report, he was home and back to work.

   The second was David. At twenty-nine, he was the youngest patient Carol ever had in the Heart OR. David had Marfan’s Syndrome, a genetic disorder of the connective tissue, which forms the structure  and support of tendons, ligaments, blood vessel walls, cartilage, and many other structures. People with Marfan’s Syndrome are often tall and thin, particularly long in arms, legs, fingers and toes. Eye problems are common. Often it is said that Marfan’s Syndrome victims look like Abraham Lincoln, and there has been much speculation as to whether Lincoln had Marfan’s. In the most severe cases, the heart valves are affected. The aortic valve does not fully seal, blood back flows into the heart, causing it to enlarge, and increases the hearts workload. The Mitral valve prolapses, a less significant problem, but contributing to poor oxygenation of the blood and poor circulation.

   David had already had repairs to both of his aortic and mitral valves, and when the repairs broke down, replacements of both valves with artificial ones. Now the artificial valves were dehiscing (separating) from the heart. Because of the difficulty of the situation, a minimally invasive procedure would not be possible as was done previously. This would be old school, involving splitting the sternum and opening the chest wide.


   David went under anesthesia and onto bypass with the heart-lung machine without incident. The valves were exposed and removed. Hector measured carefully for the size of the new prosthetic valves, and special horseshoe shaped reinforcements so that the heart would not dehisce from the valves so readily. Hector placed each suture with great care, placing a clamp on the ends, and then clamped to the drapes so that they were arrayed like the rays of the sun instead of tying them down immediately. When all thirty eight sutures for the aortic valve and twenty nine for the mitral valve were in place, they would then be knotted and the ends cult off. This was to ensure that the tension of the sutures would be even. Denise, the scrub nurse, gave alternating green and white sutures to Hector so that each would be tied without mix up with its closely neighboring sutures. Everyone collectively held their breath as Hector knotted the sutures down, praying that the delicate tissues would not tear. At last the valves were in place, and the heart walls closed. Hector called for the internal paddles, placed them on either side of the heart, called out “Hit It!. Kerry, the circulating nurse pushed the discharge button on the defibrillator, and the electric shock was delivered directly to the heart. It didn’t start beating. Hector ordered the voltage increased. “Hit It!”. The heart didn’t beat. “Restart bypass” Hector directed. The roller pumps began spinning again, squeezing blood through the clear plastic tubes. Carol ran down the status of the electrolytes and the levels of oxygen, carbon dioxide, bicarbonate and pH of the blood. She had been sending off tubes of blood for these tests, called “blood gasses” at regular intervals. The numbers were all good. Hector said, “Give it ten minutes on bypass to rest the heart, and then we’ll try it again”. In ten minutes, the process was repeated. No beats. Epinephrine was given directly to the heart. No beats. It was all repeated again and again. After an two hours of every technique and trick he knew, Hector faced the inevitable. David’s heart would not beat on its own. For the first time ever, Carol detected defeat in Hector’s voice. “Turn it off. Time of death..” He looked up at the clock, “Thirteen twenty-six.” Kerry choked back a sob, Denise was frozen into immobility and looked lost. Hector slowly, silently stepped away from the table and stripped off his gown and gloves, pushed through the door, and trudged off to talk to David’s family.

Saturday, July 2, 2011

Fourth Chapter

Nancy
In which we learn the circumstances of a most unusual bequest
  All patients coming to the OR are given a score on the ASA Physical Status Scale. The score from this scale correlates very closely with the probability of complications for an individual. The higher the score, the more likely complications will occur, and the more likely the complications will be serious. The Scale goes like this:
ASA 1 – A normal healthy patient with no co-morbidities
ASA 2 – A patient with mild systemic disease, such as diabetes controlled with diet or oral drugs, or an obese patient, or an otherwise healthy patient who smokes, or a patient with well controlled hypertension.
ASA 3 – A patient with severe systemic disease and or co-morbidities, such as poorly controlled diabetes or diabetes with renal impairment, or morbid obesity, or heart disease or angina.
ASA 4 – A patient with severe systemic disease that is a constant threat to life, or combinations of severe systemic diseases such that there is an imminent threat to life.
ASA 5 – A moribund patient who is not expected to survive without the operation.
  ASA 6 - A patient declared brain dead whose organs and or tissues are being removed for donor purposes.

  It began with a call from the warden at the State Penitentiary. A death row prisoner, scheduled for execution in a month, wished to donate a kidney to his mother who had end stage renal failure. The Governor had approved the prisoner’s request. The Chief of Security from the Penitentiary came to look over the Hospital and OR, and to plan the donation with the Hospital staff. They met in Chicky’s office. Included in the meeting were Nancy, the head nurse of the transplant team, and Dr. Mike Moatz, the transplant surgeon. Chicky’s office was in a former supply storage area, just large enough for her desk, four tall filing cabinets and a small table with four chairs. No windows. Each of the filing cabinets was of a different color, the chairs were mismatched, and the desk looked like a survivor of the sixties. The chair behind the desk was new looking and of the quality the office supply catalogs called “Executive”. Four Diplomas hung on the wall, one from a hospital school of nursing, a BS in Nursing from a state university, A Masters in Nursing from a small Catholic University, and an MBA from another state university. On the desk was a new top-of the-line Intel Quad-Core laptop purchased by Chicky personally, with Molly’s advice, to replace a generic and antiquated Pentium III PC provided by the hospital. Chicky had always been amused to note that the computers in the executive suite were always the newest and fastest models while those used by the actual workers throughout the hospital were always a generation or more behind.  Chicky’s Spartan quarters were on a par with other nurse directors/managers and did not compare with other non-nursing department heads well. Those Physicians among the hospitals officers had the most palatial offices of all. It was no coincidence that the staff referred to the area of the executive offices as “Mahogany Row”. Office d├ęcor in the hospital was a matter of stroking egos.

  It took little time for the Chief of Security to outline the requirements for the situation. The prisoner had a violent history, and had been involved in several altercations with the guards. A condemned man, he had little or no incentive to be cooperative. He literally had nothing to lose. Solitary confinement, being fed on “The Loaf”, had no observable impact on his demeanor. “The Loaf” was the modern equivalent of bread and water, being a bread-like mass concocted of various food items making up a complete nutritional diet in a monotonous and unappealing cube.

   After much discussion, a plan was formulated that accommodated the sterility and operational needs of the surgical procedure and the restrictions necessary for tight security. Everybody’s thoughts were of a hostage situation or worse. It was obvious that the Chief of Security thought the whole matter a bad exercise of judgment, but you don’t argue with the Governor. The OR staff was focused on the need for the kidney in the knowledge of the scarcity of organs. The average time on the waiting list for a kidney was seven years. Ten years was about as long as a person could go on dialysis, so most transplants were the best match available, often quite short of a perfect match. This meant that the recipient had to be put on large doses of immune-suppressants and steroids to avoid organ rejection. This in turn made them very susceptible to infection and other disease processes, yielding a shorter life span than a really good match.
  Nancy changed out of scrubs in the locker room, and walked to the parking garage. She got on the lift which rose past the levels reserved for physicians, the levels for administrators and arrived at the open season levels next to the roof. She located her well used minivan which bore all the signs of children: toys, food stains, a child seat and cartoon stickers on many of the interior surfaces. On the drive to one of the suburbs of tract homes she had the radio tuned to NPR, but wasn’t hearing it, being lost in thought about the upcoming “harvest”, as an organ donation was known to the surgical community. Nancy had flown to remote hospitals, and been in most of the hospitals in the metropolitan area for organ harvests and had even been to the Medical Examiner’s office down town to recover cadaver skin, bone and corneas. But this harvest was hands down the weirdest of all.

  That night, after the children were bedded down, and before Nancy’s husband Steve headed out for his night shift with the police department, Nancy asked if he knew anything about the unusual organ donor. “He’s a real bad one” Steve answered, “He shot and killed two men in a drug deal that went bad, went home and to top it off, beat his girlfriend to death with a chair. In my view, death by lethal injection is too good for him. You guys should take his kidney and then not bother to wake him up.” He hugged and kissed her, went out to his police cruiser and headed off to the station. In the days leading up to the harvest there was much discussion among the OR staff, and Steve’s opinion seemed to be shared by many. Most organ donations were from cadavers, brain dead from one cause or another. A nearby state did not have a helmet law for motor cycles, providing a steady stream of donors such that Nancy’s team mates began to refer to the machines as “donorcycles”. The first time Nancy had seen the respirator and monitors turned off with the brain dead donor still on the OR table, all the monitor tracings going flat, it creeped her out. Nancy had participated in live donations before, with the donor a close relative of the recipient, and the two surgical procedures being carried out simultaneously in adjacent ORs. This time, the recipient would be in another hospital about an hour’s journey away from the donor.

   The night before the harvest, Nancy tossed and turned. There were so many implications of the harvest that were troubling, not the least of which was a report in the news of organs from executed prisoners being marketed in China. News of the harvest had also leaked to the media the day before. The botoxed anchor of the local TV news and his generic surgically enhanced blonde sidekick, half his age, reported with earnest, serious expressions that the prisoner had refused all appeals, and wished to die rather than spend life behind bars. The leak also created a fear of a media circus descending on the hospital. Nancy had a mental image of a large crowd with signs and banners on the front lawn being led in protest songs by a banjo playing Pete Seeger. Opposite was Rush Limbaugh leading a crowd with “Roast in hell” and “Bring back public hangings” signs. Due to security concerns, changes had been made in the plans for transport of the prisoner, security around the hospital increased and a public relations campaign planned.

   On the morning of the harvest, Nancy arrived at work as usual. There were no TV vans with satellite dishes, and no Pete Seeger, which calmed one of the anxieties fluttering in Nancy’s stomach. She changed into scrubs, checked the schedule board, noted that the harvest was on first as she had expected.
Donning her surgical mask, Nancy went to the OR and began arranging the equipment, checking that all was in proper working order. Then she went through the small substerile room that was shared by the two adjacent ORs. The substerile room was an area containing a sink, an autoclave for sterilizing items, and a warming cabinet for keeping blankets and fluids slightly above body temperature. Some linen and other supplies were stored there as well. Nancy made sure that the area was clear to allow free passage through the substerile room. Security dictated that no instruments or any objects that could be used as weapons could be in the OR with the prisoner until he was under anesthesia and unconscious. So Nancy and her scrub tech Tim would have to open up their sets and supplies to set up their sterile table in the adjacent OR and then move it through the substerile room when they got the signal. Tim was already in the next OR, and had gathered all the needed sterile sets and packs. He left the OR to scrub up, and Nancy opened all the sterile items. When Tim returned with his hands raised in front of him in the manner familiar to all who have seen Medical shows on TV. Unlike The TV shows, masks are always worn while scrubbing, and by anyone around someone scrubbing, and always in the OR. It was a favorite pastime of the nurses and techs to spot all the breaks in sterile technique by the actors posing as surgeons and nurses, and there were always plenty of them. The intimate conversations of the TV nurses and surgeons complete with voiceovers while in the OR were also a source of mocking amusement. Nancy tied up Tim’s gown after he had donned the gown and gloves. She left Tim to do the sterile set up, and went to the pre-op area to see the patient.

 The prisoner was in the isolation room, separate from the common area of pre-op, usually reserved for those patients coming to the OR with an infection or contagious condition. Upon entering the isolation room Nancy immediately saw the heavy shackles on the patients’ hands and feet, firmly binding him to the gurney. She advanced to the gurney, pulling up a chair so that she would be at eye level with the prisoner/patient. Nancy had given much thought as to how she would approach this patient interview. First of all, she had decided that she must think of him as Mike ______, not as the prisoner, or as the patient. Before she could initiate a greeting, Mike spoke up “Sorry about all the chains, I can see they spook you. The hell of it is, I would do things in other situations, but not now – I don’t want to f***k things up for my Ma. Life has been a real s**tstorm for her, being sick and all, so this is the thing I can do for her.” Nancy replied “Thank you for that Mike, my name is Nancy. I’ll be your nurse in the OR. Right now I need to confirm some of the information I got from your chart, and then ask you some questions.”

  Nancy started down her check list of innocuous seeming questions, almost all of which the patient would have been asked before. The repetition of the questions while annoying to the patient, was intentional. Nancy could not count the times that patients suddenly remembered something important when asked the same question for the fourth time. And as routine as the questions sounded, they all reflected matters that were matters of safety and even life or death. For example; “When was the last time you had something to eat or drink?” With the induction of anesthesia there was a very real risk of patients suddenly vomiting, which if any of the vomitus was aspirated, posed a very possibly lethal situation. Jimi Hendrix died from aspiration when he overdosed, a situation very much like the induction of anesthesia. Another routine question was “are you wearing contact lenses?” Anesthesia knocked out normal protective reflexes, so contact lenses left in the eyes during surgery could result in damage to the cornea, as there would be no eye blinks, or movement of the eyeball as in normal sleep or in an conscious state. Another question always asked was “Have you ever had anesthesia or any problems with anesthesia, or has anyone in your family ever had a problem with anesthesia?” This is because of Malignant Hyperthermia, an inherited defect of calcium metabolism which can be triggered by exposure to many of the most common anesthetic agents. There is no straightforward test or practical screening procedure for the condition. It occurs once in every fifty thousand to one hundred thousand cases. It is associated with a five to ten percent mortality rate. Nancy had seen it once in her career and never wanted to see it again.

   When she reached the end of her checklist she asked Mike if he had any questions as she always did. Mike’s question took her by surprise. Mike asked “What’s it like, going to sleep like that? I figure this is sort of a dress rehearsal for me.” Nancy paused for a moment, then looked him straight in the eye and said “I had anesthesia once. The anesthesiologist told me to pick out a good dream, I felt some cold moving up my arm from the IV and it was as if a switch was turned off. I woke up when it was over and there was just nothing in-between. The time I was out just didn’t exist for me. You are probably right about it being a dress rehearsal. I expect it will be almost exactly the same except that there will be no waking up.” Mike said matter-of-factly, “That’s about what I expected. Just nothing.” He seemed to appreciate the directness of Nancy’s answer to his question. Still looking him directly in the eye, Nancy said “I will be standing next to you during the induction of anesthesia. We will take good care of you while you are here.” Mike nodded. Nancy got up and left to return to the OR.

   Tim had completed setting up the sterile table. Nancy got the count sheets and the pair began counting the table. Sharps, such as blades, hypodermic needles and suture needles were counted in one category. Sponges and towels were counted in a second category. Then all the instruments were counted by type and name. Lastly all the small accessory items were counted. All would be counted again as the abdomen was closed, and a third time as the skin was stitched or as more commonly now, stapled. The point was to make sure that none of these items remained inside of the patient. A retained object was one of those things that was indefensible, an instant judgment against the surgeon and OR nurses. The legal term is “Ipso Facto”, meaning “by the fact itself” negligence has occurred. In cases of extreme urgency, when there is no time to count, X-rays are taken before leaving the OR. All the objects used in surgery are radiopaque, which means they show up on an x-ray. So even in those situations there is no defense. The counting complete, Nancy walked through the substerile room to the other OR, leaving Tim to mind the sterile table. Sterile tables are never left unattended, lest they be unknowingly contaminated.

   Nancy arrived just as Mike was brought in to the OR, still manacled to the gurney. Two prison guards accompanied him, and would be in the OR until he was unconscious, then they would remain just outside the doors until it was time to wake Mike up. The gurney was pulled up even with the OR table, the guards unlocked the shackles, Mile slid across to the OR table, and was once again shackled, this time to the table. The guards moved back, and Nancy took her place to the right of Mike’s head. Dr. Nelson, the anesthesiologist talked Mike through the steps in preparation for induction. Nancy helped to place the monitoring leads, and when all was complete, held the oxygen mask to Mike’s face to pre-oxygenate his blood, the last step before injection of Propofol, the induction agent. Nancy said to Mike “ Would you like me to hold your hand as you go off to sleep?” Mike swallowed hard and nodded to Nancy. She took his hand. Dr. Nelson said “OK, I’m injecting now, you may feel the drug gong up you arm. Some say its cold, some say it burns, but it will only last a couple of seconds.” Mike nodded again and Dr. Nelson injected the milky drug. In seconds Mike’s body visibly relaxed, and his eyes lost focus. Dr. Nelson squeezed the rubber bag a couple of times in quick succession, and removed the mask, tilted the head back, unfolded his laryngoscope and with a deft motion, placed in Mike’s mouth and down his throat. While he was doing this, Nancy drew the clear plastic endotracheal (ET) tube from its wrapper, attached a 10cc syringe filled with air to the small inflation line on the side of the ET tube, and held it in readiness. She felt just below Mike’s adamsapple for the cricoid cartilage, applying a gentile pressure. This caused the rigid cartilage to compress the esophagus, keeping the trachea open and the esophagus closed a precaution against aspiration and lessening the chance of a misplacement of the ET tube. When Dr. Nelson got a good view of the vocal cords, he held up his hand and Nancy placed the ET tube in his hand, properly oriented for insertion. With a skilled and practiced motion, Dr. Nelson pushed the ET tube through the vocal chords and into the trachea. Nancy gently but firmly pushed the plunger of the air filled syringe, inflating the balloon-like cuff at the end of the ET tube. The trachea was now sealed off from the esophagus, preventing any chance of aspiration. Dr. Nelson gave a squeeze again on the rubber bag, observed the rise of the chest, and as pressure was released, the condensation that appeared in the transparent ET tube. These confirmed to Dr. Nelson and Nancy that the tube was correctly placed in the trachea and not in the esophagus.

   Nancy held the doors so that Tim could bring the sterile table through the substerile room into the OR. The guard removed the shackles from Mike. Nancy placed a foley catheter into Mikes bladder, so that the urine output could be monitored. This was important because the first observable sign of hemodynamic instability (the interaction of blood volume and pressure) would be a decrease in urinary output. It would also be a direct indication of Mike’s kidney function. Nancy also placed SCD (sequential compression device) sleeves on Mike’s legs to prevent the formation of clots. If Mike formed clots in his legs, the least serious complication would be a DVT (deep vein thrombosis) which would require him to be on anticoagulants until the clots cleared, which could cause post-operative bleeding. More seriously, if clots formed and broke loose, Mike could suffer a PE (pulmonary embolism) a potentially fatal complication. Then she placed a grounding pad for the elctrocautery, more commonly called a Bovie, which would protect Mike from electrical burns from the electrocautery. Lastly she painted Mike’s abdomen with gluteraldehyde solution to disinfect the skin. While Nancy was occupied, Tim gowned and gloved Dr. Moatz, and his transplant fellow, Dr. Ted Farrand. The trio of sterilely gowned and gloved team members then draped Mike. Tables were moved into position, Tim Passed the scalpel to Dr. Moatz, and the incision was made.


   About an hour and a half later, Dr. Moatz took the kidney to the sterile table, flushed it with Wisconsin University Solution, a mix of nutrients and electrolytes, placed it into a sterile plastic bag, and then into a sterile plastic jar. He handed it off to Nancy, who placed it into a Styrofoam container full of ice, which in turn went into a foil lined corrugated box. She attached all the relevant records and certifications that she had completed in a pocket on the side of the corrugated box, and a duplicate set inside. Until recently swing top Playmate coolers had been the transport container of choice. Thus packaged, there was about an eight hour window for transplant of the kidney, but the sooner the transplant, the better. Dr. Moatz checked to see that all was well with the closure which he left to Dr. Farrand, stepped back from the sterile field, and pulled off his gown and gloves. He took the precious package and left the OR, already on his cell phone to alert the waiting team with Mike’s mother that he was en route with the kidney.

   The closure of the wound was uneventful, Nancy and Tim completed their counts which were correct, and mike was moved from the OR table to the gurney while still asleep and entubated, a departure from the normal procedure which was to wake a patient up and extubate (remove the ET tube) while still on the OR table. In this case, the move was made first to enable the guard to shackle Mike before he awoke. As Mike began to stir, the extubation was smoothly accomplished. Shortly mike became conscious, looked about and grunted “S***t, I’m still here”. In his groggy half alert state he was taken to the PACU, and Nancy and Tim paged for housekeeping and began the process of turning the room over for their next case, a routine Inguinal Hernia Repair. The excitement was over, and they were instantly plunged back into the routine of a busy day.

   About two in the afternoon, another nurse came into the OR and relived Nancy, with instructions for Nancy to go to Chicky’s office. Nancy gave her report and went to the office expecting that it had something to do with the harvest. Entering the office, she saw a uniformed officer and then the pale look on Chicky’s face. Her knees felt suddenly weak. The officer grabbed her and eased her into a chair. “I am very sorry to tell you this” he said, “but your husband was struck by a car while he was making a traffic stop. He was killed instantly.” The officer and Chicky allowed Nancy a moment for the news to sink in. Chicky asked if there was anyone she could call for Nancy. She shook her head side to side. The officer said “We are here to take you home, another officer will take care of your car. The chaplain will be at your home by the time we get there.” He helped Nancy to stand a tenderly took her arm and led her from the office.