Thursday, February 1, 2018

Cats vs. Dogs, ADNs. vs. BSNs, and the Ultimate O.R. Conflict: Burners vs. Knotters

These are certainly disunited times and there are many divisions among  nurses. The  endless ADN vs BSN debate has a life of it's own. Being an old time diploma graduate, I don't have a dog in this fight and will stick to conflicts I have direct experience with. When it comes to controlling bleeding in an operating room there are two very distinct and different types of nurses with profoundly diverging  ideas.  One group, the Burners,  just love to support surgeons using offensive, humming and smoking  electrocautery devices  or "Bovies." The  opposition composed of older, more  wise thoughtful nurses likes to cut ligatures for manual ties. I affectionately refer to them as the Knotters because nothing maintains hemostasis like a tightly secured and knotted ligature.

Opening an abdomen is done in sequence and when you are waiting for someone to fall asleep before you scar them for life, it's prudent to take a thoughtful, careful approach to minimize the inherent barbarism. Compassion is always best delivered person to person rather than nurse to patient so it's a good practice for the scrub nurse  to stop and think if this is how you would like to be treated lying on that cold, skinny table. Can you imagine your naked derriere  plastered against that gooey, mucilaginous, ice cold  Bovie  grounding plate smeared with conductive gel while the surgeon makes like Smokey the Bear and burns every bleeder in sight?  The alternative, silently tying off bleeders with ligatures is more appealing to the senses and exudes a kinder, gentler, more considerate approach.

 The buzzing behemoth  of a  Bovie  unit is the  Burners favorite piece of OR furniture (back in the day we had furniture, not equipment.) Bovies were an electrocautery device that looked like a Maytag and had connections for three electrical cords. One was plugged into the wall socket, the other connected to a large metal grounding plate the size of a cookie sheet which was smeared with conductive gel and unceremoniously scooted under the patient's buttocks right before they  fell asleep. the third cord was connected to the business end of this buzzing monstrosity of a machine and resembled a ball point pen.

Some of the Burners were frustrated artists and made the application of conductive goop to the Bovie grounding plate an exercise in self expression. That big metal plate was their canvass and the goop their medium. I noticed one of these Burners with her bouffant cap on sideways to mimic an artist's beret scribbling away with the goop and mentioned her sketch looked like it was part of a freight train. "Oh no...It's a caboose for the  patient's caboose," she haughtily replied. Never interrupt a burner at work on her art.

I always shuddered when I considered the last conscious thought  a patient had before anesthesia induction  was what it felt like to land their  keister on an ice cold, gooey piece of ice cold  metal. It reminded me of someone sitting in a giant tub of Jello. YUCH!

The Bovie generated a high frequency alternating current that was passed through the patient's body. There was minimal resistance at the grounding plate on the rear end, but lightening in a pen at the business end controlled by the surgeon operating a foot switch. There was big time electrical resistance at the Bovie tip: enough to occlude a vessel in a jiffy.

After the skin incision, venous bleeders begin to appear as little dark blue puffs of blood. The glistening white fat tissue forms a beautiful background for the little  pops of blood as the veins are cut. This part of the surgery always reminded me of those old 12 O'clock High TV shows with Robert Lansing. The puffs of blood resembled the bursts  of the anti-aircraft flack exploding near the vulnerable B-17s. "Hey doc we have a bleeder coming up fast at 12 o'clock," I sometimes felt like hollering out. The Bovie smoke further added to the flack resemblance. Members of the Greatest Generation made us Boomers look like slackers and surgeons from this vintage were very proficient Knotters.

Burners were very fond of simply snatching a bleeder in the jaws of a hemostat and then tapping the ringed handle with the Bovie. A puff of nostril bludgeoning smoke and that was that, no more bleeding.

For the knotters this was a time to pause and hand off meticulously cut strands of ligature. Back in the day I could take an endless spool of 3-0 silk and in the twinkle of an eye cut it into 18 inch lengths all exactly the same. These ligatures were held out like an offering to the surgical gods for the good doctor to  grasp and masterfully tie around a vein that had been lassoed by a hemostat. The scrub nurse then trimmed away the excess suture a millimeter distal to the knot with a straight Mayo scissors and it was time to move on to another bleeder. There was a reassuring rhythm to the process that was like meditation.

Hand tying did take longer than using a Bovie, but I always thought that tying off ligatures was a good way for the surgeon to limber up his fingers  before tackling the more serious stuff inside the abdomen. A time to reflect on the future course of action.

A knotter happily unwinding a tie from a ligature spool.
Ties and non-swaged  sutures were so revered they deserved
a dedicated table with 4 spools on the right and 4 on the left
Now for that burning question: Which of these tribes do I self identify?  I  survived long enough in the OR to beat those nasty Burner impulses into extinction and am an old foolish Knotter.


  1. And the Burners were exactly why I could never have become an OR nurse... one of the few scents I couldn't tolerate!!
    Give me a Code Brown anytime over a Bovie stench...

  2. I'm off topic here OFRN but I was browsing your older posts and came across March 2016 where you have a video of a surgeon dealing with a man with acute injuries to his limbs and you comment that modern doctors are so much more approachable in their manner than many of the old time ones were. I felt this was so true I had to comment...

    I don't know if you had the rule that we here in Australia had, that a surgeon had to be referred to by the title "Mr" not EVER "Dr". If you ever accidentally used the wrong title you were castigated in no uncertain terms by an outraged surgeon who belittled you in front of everyone, staff and public alike... Many of them stayed very aloof. Some of them were terrifying to junior staff.

    The young medical officer in your video reminded me of the American registrars we had here and the young Australian surgeons we have now - so much less hierarchical in their approach and thankfully the awful "Mr" business has long gone...

    Thank you as a while away a period of insomnia by browsing through your posts! Always interesting... I never did more than my six weeks in OR back in my training days so I am in awe of your knowledge!

    Cheers from Sue

  3. Thanks Sue, but at my age I have more foolishness than knowledge!

    We always referred to surgeons as "Dr" here in the US, but I can see why some surgeons might prefer "Mr" as a way to differentiate themselves form internal medicine MDs.

    Surgeons believed they were in a special category and above other physicians because by their way of reasoning, they actually did something. My favorite surgeon, Dr. Slambow could make the convincing argument that hospitals should only treat trauma surgery patients.

    As an oldfoolrn, I've been on the receiving end of several surgeries and surgeons of today are definitely different than the old school docs of yesteryear. Modern surgeons are more patient centered and are very approachable compared to the old ones. Often times, Dr. Slambow refused contact with the patient's family and delegated communication with them to the circulator. I cannot imagine that happening today.

    Thanks for being such a loyal reader.

    1. Reading your blog is a real treat for me as someone who trained in the early 1970's (January 1975 I started training) - I feel positively archaic now! When I tell modern nurses how things were back then they look at me as if I lived in the Dark Ages... so it's quite comforting to read a blog by someone who knew much the same times as I did! Cheers, Sue.

  4. These are some of the Bovies available today

  5. Modern Bovies come in bread box sized little boxes and have all kinds of high tech features and use those tiny little pre gelled grounding pads that can be easily applied and removed. Toward the end of my life in the OR we began using Valleylab electorcautery units. We still called them "Bovies" but something was missing. I think I missed that deep pitched resonant humming as those old washing machine sized Bovies went about their business. I guess it's like comparing a modern Toyota Corolla to a 1950s logging truck.