Wednesday, November 23, 2016

The Operative Report

I'm a real sucker for a good read and I'm not talking about the high brow stuff like 19th century British literature; but comic books, Mad magazine, pharmaceutical ad copy, small town newspapers and my all time favorite operative notes which eventually evolved into the operative report.

Today, I suspect these important documents that reveal a blow by blow account of the surgery for the medical record  are done by some type of  electronic computer transcriber that probably deletes the surgeon's editorial or grandiloquent ramblings. Old time operative notes were sometimes handwritten with hand drawn illustrations that rivaled Frank Netter's medical art work. Dr. Slambow always had a red pencil on hand along with blue and black ink pens for his illustrations which proved to me the notion that surgery is  indeed part art and part science.

  Most reports were fairly accurate with technical information such as the type of suture used, sponge counts and anatomical reference.  Some surgeons down played serious problems while others could make a sebaceous cyst excision sound like open heart surgery.

When perusing operative reports that minimized problems, I used to say the surgeon had been struck by hyporeportenosis to amuse my fellow nurses. Once I finished reading a real gem of underreporting that grossly underestimated blood loss and muttered my clever new "hypo" terminology to Nancy, a fellow scrub nurse, and she said, "You better not let Dr. Bruiser hear that." The good doctor appeared on the scene just in time to hear her admonishment to me and about all I could do was act dumb. He began asking about what I didn't want him to hear, so I muttered something about the autoclave cycle taking too long. Whew..another close call. Loose lips really do sink ships or get blabber mouth scrub nurses like me fired.

Blood loss was always a hot button issue for any surgeon and rather than a defined amount  like 100cc, terms like negligible, minimal, or inconsequential were used. Another common explanation for excessive blood loss  was,  "I can't determine the exact blood loss because of all the irrigation we used. That is not blood in those suction containers-it's irrigating fluid, just ask nurse fool."  Anesthesia usually had a pretty good notion of actual blood loss and the surgeons idea of  EBL or estimated blood loss was usually way too low, so the term NBL or negotiated blood loss was the amount recorded in the report after the dust settled from all the anesthetist vs. surgeon arguments. It was about as close to the actual blood loss you could get. Incidentally, a wise scrub nurse always sided with the surgeon in any dispute with those on the other side of the ether screen.

Later in my scrub nurse life, the fun of reading operative reports declined, as dictation became the norm. I really loved those old school operative reports hand written at the scene of the crime in the OR suite immediately following surgery. Some of the old handwritten reports were even "validated" by blood or prep solution splatters because they were always physically present near the actual surgery. Transcribed reports somehow lacked the authenticity or intimacy that those blood spattered reports communicated.

Our surgical  transcriptionists were located in an office just one floor below the OR, and sometimes they would venture up to the OR to clarify a point or try to meet up with the surgeon if they liked the sound of his voice. They would intercept nurses at the double swinging entrance doors to the ORs with their inquiries. Once a harried transcriber approached me with a fist full of reports and asked me if I could help clarify the terminology of the dictator. "You've come to the right place, this OR is a dictatorship and it's loaded with dictators." I replied with a smirk on my face. She did not appreciate my foolish humor, but I used to jokingly ask Dr. Slambow if he was the dictator the transcriptioists were asking about. He tolerated my nonsense well and even grunted a phony laugh because he valued my Mayo stand instrument handling skills.

OR reports always started out boring with pre op and post op diagnosis and a brief patient history. Then they could be very interesting. One surgeon loved the adjective "meticulous." Every time he tied off a bleeder it was "meticulously ligated." When one of his patient's returned to the OR a few hours post op with hemorrhage all the nurses had the same thought. "It looks like one of those meticulously applied ties slipped off or came loose."  As soon as the offending bleeder was located and tied off again, he was back to his old tricks. Sure enough the replaced ligature was meticulously applied just like the original.

Dr. Slambow (uh oh, I almost typed in his real name) liked  to end his operative reports with this statement: "At the conclusion of the case the patient was able to transfer from the table to the gurney under his own power."  I can personally vouch for the veracity of his statement. The process leading up to the patients self-transfer activity necessitated very light anesthesia toward the end of the surgery. This produced some very exciting moments, There are copious (our instructors loved that word) nerve endings  in the skin and the final step of suturing the skin often produced a dangerous situation on that thin OR table. The pain of that suture needle thrusting through highly innervated tissue  induced that flight or fight syndrome and the patient tried to exit stage left, directly into my Mayo stand. Dr. Slambow would say something to the effect. "Fool.. The heck with sterile technique, grab his legs before he kicks someone or flies off the table." All this so the good Dr. could conclude his operative report with his time tested and favorite ending about self transferring.

Surgeons also used operative reports as a mechanism to persuade hospital administrators to purchase the very latest instrument or device they lusted after. There was a left handed surgeon that received reverse ratcheting (left handed) instruments of just about any permutation imaginable. He would describe the odd positons he had to assume with right handed instruments and the next thing we received would be a set of left handed extra long  mixters. Scalpels do not favor handedness and some older nurses used to joke with him about providing him a left handed scalpel. Novices like me knew to avoid joking with these old sourpusses.

These paper reports and their associated carbon paper, staples and occasional validating OR blood or prep stain are gone for good, but they  certainly were good reading back in the day.

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