Sunday, July 31, 2011

Seventh Chapter

Seventh Chapter
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.


Anonymous said...

Great new chapter!

orfyn1.0 said...

Thanks for following my stories. I deeply appreciate the feedback.