All Nighters in The O.R. Were Real Stinkers

 

Bovie smoke carried olfactory nightmares into every 
nook and cranny

As lengthy night time trauma surgeries came to a close, nurses were often presented with a cafeteria-like  assortment  of wounds to dress. The deep stab wound on the medial thigh called out for iodoform packing which had a nice, sweet, iodine like scent. After the thigh wound was ram rodded  packed to the hilt with ribbons of iodoform, it was time to dress that monstrous midline abdominal wound. Tincture of benzoin would be applied to secure Montgomery strips in anticipation of frequent dressing changes. Montgomery strips spared the patient the pain of abrupt removal of adhesive tape; just loosen the ties to swap out ABDs.

This juxtapositioning of one scent (iodoform) on top of another (tincture of benzoin) often led to the creation of a completely new and frequently unsavory smell that I thought of as the third effect. Under this principle, when two smells are brought together, their individual effects are irreparably  altered  and potentiated into a novel, foul, lingering witch's brew completely  unlike that of the initial contributors. I think the technical name of this newly created stink fest was compound smells.

 The addition of residual  Bovie  smoke made  the foul smell penetrate every nook and cranny of  just about any object or person in it's path. Just as a syringe and needle transported medication to a site, the Bovie smoke delivered the stink as reliably as a  mailman.

Underlying scrub attire reeked of the compound smell when our impermeable surgical gowns were removed. I always thought of this as the diaper principle, because as long as the gown was intact the smell was relatively contained. Removing the diaper...OOPS...I meant surgical gown was another story as the foul odor homed in on awaiting olfactory senses like a cobra strike.

The best part of a  long night  in the O.R. was the beautiful sunrise over Lake Michigan as this usually signaled an end to the mayhem and the arrival of reinforcements in the form of day shift nurses. Fresh, kindly arriving nurses always stopped to help the  worn out, bone tired trauma victims and I'm referring to personnel-not patients.

One July morning, my friend Janess, bounced into the room as a case came to a conclusion to act as cheerleader and help us off with our gowns. I noticed her eyes and jaw roll as her eyebrows popped toward the top of her head as she assisted. She looked distressed - to say the least.

 The next day I thanked her for the moral support adding, "We must have looked pretty bad, Dr. Salmbow and I felt like we had been beaten to a pulp after that doozy of a case."  I'll never forget her immediate response, "It wasn't how you looked. It was how you both smelled."

Lights Out in The O.R.

 

Late night trauma surgeries were performed in  a parallel universe diametrically opposed to run of the mill, day-to-day, elective surgery. In place of the measured orderliness, gowned and gloved players were often blinkered by an all consuming bone tired, sense of fatigue that descended on the room like a choking mist. The emergent condition of the patient spurred a driving sense of expedience among the weary staff. Fatigue and the hurry-up nature of trauma surgery can have bad consequences no matter how well intentioned the staff, a lesson I was about to learn the hard way.

Delusional thinking, fueled by the infinite wisdom of youth, falsely told me that fatigue was a nonissue.  I sometimes played make believe, telling myself  that fatigue actually made me perform better by focusing on the things that really mattered.  I often felt like the grand wizard from the land of OZ. Hidden behind the curtain of mask and gown, I was just pulling on the strings and manipulating the levers to quickly load needle drivers and collect bloody sponge sticks.

My delusion of being fatigue proof was about to be shattered when the phone in the call room awakened me with an 0200 hour  emergency one early Sunday morning. The trauma gods always got restless on Saturday nights in Chicago. It was a harried nurse from the ER advising me that a hot trauma was being loaded unto the elevator for a nonstop flight to the 7th floor OR. A teen aged stabbing victim with volume depleting abdominal bleeding was our patient and the ER nurses had applied a scultetus abdominal binder in hopes of slowing things down. Not an encouraging prognostic sign.

The Lakeview  neighborhood was home to the Aristoctats, a youth gang that often meted out punishment with the blade of a knife. Firearms were thought to be unmacho and eschewed with youthful vigor. Not a bad concept in my book, as knife  wounds were more amenable to surgical repair. 

Although these kids looked menacing on the street, on the OR table they looked like the vulnerable little children they were. Their vicious behavior was often mixed with the typical adolescent sense of humor and more than one of them smiled as they related, "It's not how deep you stab your knife, it's how you wiggle it around."

I had just finished setting up my back table as the bleeding youngster crashed through the doors accompanied by the usual cast of lifesavers, pushing the gurney like it was a guided missile. Dr. Slambow had gowned and gloved himself while I quickly tossed  together a basic laparotomy setup. I was loaded for bear, complete with a boatload of Satinsky vascular clamps. My heart always did those little flip flops when an attending surgeon volunteered to gown and glove independently without the help of a nurse. Something unsettling was usually close at hand.

Dr. Slambow urgently announced that this was going to be a "Whoop-dee-doo" case. (His unique vernacular for an O.R. free-for-all.)  He  was going to start cutting  immediately without the anesthetist present. The patient was unconscious with a secured airway, but cases like this always hit me with  a feeling of raw, primal panic. Obeisance to sterile technique was tossed to that void behind the vacant ether screen and  questions like, ""What if he wakes up while we're inside his belly?; Can we stop the bleeding in time?;  Do I have all the instruments and supplies?;  What happens if that fenestrated sheet that I hastily tossed over the patient for a crude drape falls off?" I don't think there is anything more pathetic  when a drape falls to the floor exposing an unfortunate  little kid with a big hole chopped down the middle of his puny, little bread basket. Truly the stuff of nightmares, at least for me.

Things went better than expected. After Dr. Slambow carved a midline incision and  sucked out the blood things began to slow down. The inferior vena cave was intact along  with all of the other major vessels. The bleeding was brisk but confined to lots of superficial venous circuits and the spleen. After a quick splenectomy, the bleeding was pretty much under control. Dr. Slambow would clamp off a group of bleeders together and give the command to "meatball it" so the resident would tie the mess off in the shape of a little sphere. After making a few meatballs we were done cooking and the patient was doing well.

The O.R. room for trauma  was one of the oldest on the floor, selected because of its proximity to the elevator and nearby autoclave which although vintage, worked great for flashing a last minute instrument or preparing Thanksgiving dinner. We even nicknamed the old autoclave Mr. Yell N' Cuss because that's what we did when the door was unbolted and we got hit with a burst of steam due to a constipated venting mechanism.

During  the emergency trauma  surgery  I noticed, Clarence, our diligent housekeeper, peering through the porthole-like window in the door. I thought  that he was admiring our lifesaving surgery, but when the case was over, Clarence wheeled his mop bucket in with a perplexed  expression. "You folks 'spear- menting again?" he asked. "What do you mean by that Clarence?" I asked.  "You done that whole operation without the great big overhead lights tuned on!" Oh my gosh, I could not believe what we had done. I ran to the surgeon's locker room and updated Dr. Slambow on our oversight. In a tired voice he wearily explained, "Well the ambient lighting was pretty darn good and we weren't deep within a body cavity. Sometimes things work out in spite of our screw-ups."

Alice Was the Grand Poobah of the Operating Room

God bless dear old Alice until she eats you alive

I've posted many times about my all time favorite OR supervisor, Alice.  During these sometimes discordant  COVID times I miss her strong willed imposition of order and discipline. Alice was like a gas heeding the laws of physics.  She could fill the entire room with her  presence  by virtually wearing authority the way a meticulously attired nurse wore her blindingly white uniform. At the ripe old age of fifty something, command was hers because it was earned by spending decades in the boiling cauldrons of  operating rooms and their combative surgeons. She had dodged more flying instruments and administered more scores of painful knuckle bashings with a sponge stick than I care to remember.

Her repertoire of corrective interventions consisted of humiliation, infliction of pain and  shows of physical strength (Alice had the upper body strength of a linebacker on steroids.) Pain was usually delivered by a snapping blow to the wrist and/or fingers by the business end of a long sponge stick. The length of this instrument could deliver a blow of variable power based on where the fingers grabbed it to form a fulcrum. I usually sustained  the full meal deal for my transgressions with Alice grasping the instrument at the hinge and really winding up. Passing an instrument to a resident before serving an attending or counting sponges too fast or slow were typical transgression. Any break in aseptic technique was also harshly corrected.

While scrubbed on a long, grueling oncology case I began subconsciously doing hamstring stretches at my Mayo stand and lo and behold Alice strolled in. I knew I was in for one of Alice's lectures about how scrub nurses were supposed  to be uncomfortable and any unnecessary movement was a vector for the spread of that dreaded entity known as perineal fallout. Personal comfort and well being of her charges was as much  a priority to Alice as mindfulness was to Moe Howard of The Three Stooges. Luckily, Dr. Slambow saved my hide. As he was meticulously fileting a duct he said, "Alice can't you leave him alone. I can't do this without him." It really paid off making
your services indispensable to surgeons. I always thought of it as the best job security move a scrub nurse could make.

Alice's show of physical strength was also quite impressive. I've seen her single handedly transfer patients of her weight with the ease of an Olympic weigh lifter. She claimed that manually cranked beds were one of the best forms of upper body exercise and who would argue that point with a hulking Alice?

Alice made it a special point to mentor medical students in her own unique fashion. I knew what was coming next when one especially whiney student complained she could not see the operative field. Alice stealthily approached the novice from behind and ram rodded her lunch hook-like hands under the miscreant's arm pits and lifted her a couple of feet off the floor. She always followed maneuvers like this with a suggestion to utilize platforms instead of bitterly complaining.

Old nurses like Alice lived for nursing which was the alpha and omega to their life. Her idea of self care was a quick break for a Coke and a smoke. I never questioned Alice's dedication to her patients because it was her whole life.

A Heminephrectomy and a Stock Tip

I really, really, disliked scrubbing in surgeries that involved partial removal of a kidney. The positioning of the patient  on the OR table involved a number of hacks worthy of a MacGyver  Award.  A side lying position, with a break in the table at the inferior thoracic level was a worthy challenge to maintain with sand bags, chunks of foam egg crate mattress, bean bags sans the beans, rolled up surgical towels, and long lengths of 2 inch adhesive tape which were all  included in the patient  placement armamentarium. Anesthesia was worried about compromised gas exchange with gravity pulling abdominal contents downward on the diaphragm while nurses fretted about a tumble from the table.

Once the procedure was underway the nephrology surgeon began his solemn narrative of all the challenges involved; too much monkeying around near the adrenal glands atop the kidney could blow blood pressures sky high, the renal artery had lots of anatomical variations so it was tough to figure out where it ended and the arcuate artery began, and finally, modifications to the fascia were required to hold what was left of the kidney in place. Old school surgeons just loved to hang the crepe before a difficult procedure because then even a bad result might look OK.

After a lengthy discussion of renal pyramids and poles (I could never make sense out of the difference between the two,)  the surgeon excised the pathologic portion of the kidney that most commonly  harbored a benign tumor or cysts. At least most of the partial nephrectomies offered a cure.

Now the fun part for the hapless scrub nurse begins.  To seal the exposed surface of the incised kidney, miniscule pea sized chunks of fat are sutured in place. This time consuming task requires lots and lots of sutures and by the time about half the job was done my bony fingers were aching from loading endless needle holders.

Fatigue can be the impetus for saying stupid things and my preternatural foolishness didn't help matters as I muttered, "Why don't you just throw a couple of stitches around one big hunk of fat and be done with it."

The surgeon gave me one of those churlish looks and quickly changed the subject to one of his particular areas of expertise, stock marked tips. According to this  financially savvy surgeon,  Abbott labs was a sure fire winner and a must buy stock because the share value had been temporarily  eroded by a contaminated IV fluid SNAFU. As soon as the problem was corrected, the share value would soar. As  he enthusiastically  expounded about this must buy stock, the old Airshields ventilator pumped a potent halogenated anesthetic agent into the deeply obtunded patient.

The case proceeded along uneventfully and I helped gently transfer Mitch, the still anesthetized patient unto the gurney. A nurse was always with a patient like this to maintain an airway on the  open road to the recovery room.  I was carefully making sure his silver metal oral airway (no cheesy plastic throwaways like those in current use)  was in place  as I  guided his mandible forward to keep him breathing.

With unexpected gusto Mitch suddenly aroused, pushing my hand away and yanking out that pesky airway. His first words upon regaining consciousness? "Call my broker. I want in on some of that Abbott Labs stock."

Old School Automobile Lap Belts Engndered Bucket Handles and Fruit Loops

Cars from the 1960s were rolling deathtraps. Two  tone paint jobs, wide whitewall tires, and chrome bumpers looked snazzy, but in a motor vehicle accident (incident or crash in today's lingo) the passengers were propelled into rigid spear like steering columns or protruding cowl like hoods over the speedometer which, to say the least, were evisceration proficient. Any poor soul lucky enough to escape compression injury via steering column impalement or gutting by the speedometer was hurled head first through the windshield and wound up with spidery split open lacerations on their forehead and all too often, hopeless neurotrauma.

Initial efforts to restrain vehicle occupants and  transfer some of the destructive forces to crumpling sheet metal consisted of lap belts.  Curiously, lap belts were always referred to as "safety belts," instead of the current seat belt terminology. These girth gripping girdles prevented some of the unfixable neuro trauma at the expense of the abdominal organs which ,at least, were potentially fixable with timely surgical intervention. Typical abdominal trauma from car wrecks  involved banged up and bleeding hollow viscus organs, blood oozing spleens, and contused and bruised livers. Retro peritoneal renal injuries were less common. Maybe all that fat surrounding the kidneys protected them from some of  the trauma.

Typical stigmata of lap belt trauma consisted of a 2 inch wide ecchymotic banding across the lower breadbasket. This ominous finding almost always meant internal injuries and called for the immediate diagnostic peritoneal lavage. After cannulating the peritoneal cavity about half a liter of normal saline was infused. After  about 10 minutes the saline was allowed to drain back out by gravity. Any blood in the drainage meant a quick trip to the anxiously awaiting personnel in the OR.

Innovative lap belts caused a surge in a new kind of deceleration injury, bowel/mesenteric separations which were a good trade off for the neurotrauma sustained from crashing head first through the windshield. Most abdominal trauma was fixable if caught in time, while neuro trauma usually meant a grim prognosis.

The bowel is fixed at the flexures,the ligament of Treitz, and last but certainly not least, the rectum.  With the colon and small bowel moving forward at 60mph ( or whatever speed) the sudden traumatic stop of an accident pulls like a John Deere tractor on the intestine adjacent to these tack down areas dividng bowel from it's lifeline, the messentery. Without mesenteric connection, the section of isolated  bowel withers up and dies like a man in the desert without water.

Mesentery supplies vascular, nervous, and lymphatic connections to the bowel. It also holds our  intestines up out of our pelvis where there are enough problematic structures without dropping another player into the mix. Mesentery is one of the most underrated abdominal players.

Suspense reigned as the surgeon cautiously entered a traumatized abdomen and when the problem was finally delineated and deemed curable, a feeling of jubilation and relief was experienced by the team. Hearing Dr. Slambow, my general surgeon hero, deliver his diagnosis was always a musical treat. As the Airshields ventilator chugged out bass beats in the background there was proprietorial pride in his harmonius voice as he practically sung out "bucket handle," four notes, key of "C," ascending. The hootenanny proceeded as the intestinal resections marched along with needle drivers clicking away like castanets and heavy instruments adding dissonance clunking away in the lap tray on the back table. The finale was always the best part as we stepped down form the podium with a meticulously patched up patient that was sure to recover.

 How did this injury acquire it's strange moniker? The section of large bowel stripped from mesentery did indeed look like the handle of  a bucket so the name fit. Small bowel separations were more subtle and were named after the little cloth hanging loops on the back of men's shirts of the day. Even though they did not resemble the popular breakfast cereal, everyone knew what an intestinal fruit loop injury looked like.

A bucket handle injury of the transverse colon and 3 fruit loops down below 

where small bowel parted ways with mesentery. That lower separation
is beginning to show the effects of devascularization.

(Photo courtesy Dr. Michael McGonigal)

When the call room phone incessantly rang  at 2AM and the harried voice on the other end intoned "Motor vehicle accident ETA 10 minutes," my feeling was similar to one of those daredevils going over Niagara Falls in a barrel. Lots of mental anguish leading up to the case because the final landing outcome  was unknown. Bucket handles and fruit loops usually led to a successful plunge over the falls.

The Surgical Abdomen

While fresh, young  surgeons pour over detailed cross-sectional CT scans or overpriced, extravagant ultrasounds, old surgeons relied on the wisdom gained from a physical exam and meticulous history taking to delineate abdominal pathology. "Hot Bellys," in the vernacular of the day could be a real hornets nest to deal appropriately with, and the wily veterans had there own brand of diagnostic techniques which were crude, but effective.

Decisive clinical diagnosis was elusive, but a strange hodge-podge of clinical maneuvers (if you could call them that) were enlightening to the battle tested old surgeon. Observations were also key element  of the work up.  A "sweated brow" or "a hypovigilant countenance" suggested a septic process. Jaundice suggested some sort of hepatic dysfunction and a strange blue periumbilicular coloration signaled an internal bleed.

The exam of the acute abdomen consisted of, euphemistically, what would be termed palpitation, percussion, and auscultation, but was really poking, pushing, lifting, listening, and twisting limbs around with gusto, much like a pretzel.

The psoas test was performed by forcefully flexing the thigh while rotating the foot outward. The test was contraindicated with concaminant orthopedic injuries. A positive response elicited a vociferous verbal response from the hapless victim  patient and suggested a lower abdominal process.

A shake test was of great value when the patient had difficulty identifying the area of maximal belly pain. While in a supine position the patient's hips were slightly elevated off the bed while a vigorous to and fro shake was delivered. Dr. Slambo, my favorite general surgeon, had an interesting method of augmenting the shake delivery that only applied to ambulatory patients weighing less than 75 kg.

With the physician and patient standing back to back with arms interlocked together at the elbows a gentle elevation is initiated by the good doctor leaning forward. The optimal height was with the patient's feet about 6 inches off the floor. The abdomen is bowed such that the viscera are near  the surface while a side to side shimmy/shake elucidates the problematic quadrant. The technical name of this procedure (according to Dr. Slambow)  was the elevated, gyrating, gambol gambit and it was far better than one of those new fangled CT scans when it came to elucidating the exact focus of abdominal distress..

Dr. Slambow also knew how to augment just about any type of palpation technique with a miraculous gooey, slippery substance known as ordinary Surgilube. He began with a full tube, superior to the umbilical concavity and began squeezing until there was a generous pool of  goop.  He then began exploring the aching quadrant with his hand gliding across the abdomen like a shoe that stepped on a banana peal. The quantity of Surgilube used during the procedure also provided valuable insights when planning the surgical intervention. More than 1/2 a tube of the gelatinous goo signaled problematic obesity that called  for extra long instruments and a platform for Dr. Slambow to stand on while he looked down into the wound.

Fist percussion commonly known as a blow to the upper bread basket was performed along the anterior thoracic wall by placing one hand on the skin and beating it with a fist. Exquisite pain evidenced by vociferous howls indicated cholecystitis or hepatic issues.

Murphy's inspiratory sign can be demonstrated in acute cholecystitis  by asking the patient to take a deep breath while pressure is judiciously applied below the right rib cage. As the liver descends, the inflamed gall bladder is brought into contact with the abdominal wall causing immediate cessation of the inspiration.

I really liked scrubbing on acute abdomens because the offending problem was identifiable and fixable. There was no better feeling than seeing a seriously ill person stroll out of the hospital with a new appreciation of life. Viewing that so vulnerable  prepped abdomen supine on the table awaiting the surgeon's ministrations always put me in a contemplative mood with the realization that despite all our political and religious differences  we are all just meatsacks enjoying an undeserved period of wellness so no matter what or who, With this thought lurking in the back of my foolish mind, I tried to be nice to everyone and treat patients as though they were my mother, father, or child.

A Vintage Operating Room Table

A classic Amsco O.R. Table. Turn one big wheel for elevation, the other for tilting

the head up or down. Grab the gear shift handles to activate breaks. Shift into first

gear and use the stirrups for gyne and urology procedures.

Old time operating rooms were furnished, not equipped like today's technological marvels. The focal point of just about any OR is the table because that's where the all the action happens. Vintage surgical platforms were crude, but effective pieces of furniture that could function without electricity. No complicated owner's manual  necessary. The adjustment wheels applied torque to gigantic screws that moved the table.

One of the design flaws was locating the position of the exposed screws with their inclined plane below the table.  Accessing the controls of a draped table required a trip down under for the circulating nurse. Circulating nurse was one of those new fangled terms and fools older than me called them "hustle nurses."  I was a frequent volunteer for this duty because I relished the serene environment  under a draped OR table while all that noise and fuss emanated from above.

During my under table sojourns it was all too easy to allow for some foolish daydreaming. Those big shining control wheels looked like they belonged on a yacht and sometimes I  imagined myself at the helm of a pleasure vessel on peaceful  Lake Michigan or driving a race car in the Indy 500.  A break from all the drama above always refreshed.

The exposed screws were also in a vulnerable spot when it came to collecting fluids from above. Blood would clot and dry on the surface of the adjustment screw so that subsequent rotations would produce a colorful rooster tail  of flying red flecks that reminded me of those spinning fireworks shooting sparks. The mini pieces of dried blood flying about would also refract the light from the big overheads creating a miniature light show that was a sight to behold

Surgeons had no direct control of patient positioning and were at the mercy of nursing and anesthesia to adjust the table. Positioning attempts were initiated immediately after the one...two...three... count  transferring the patient from a cart. Kindly surgeons like Dr. Slambow would always help lifting and transferring patients from the cart to table. Non verbal, cold as ice stares awaited less helpful surgeons who soon learned the up side of team work.

There were no specialty OR tables back in the days of one size fits all surgical platforms. Sand bags, rolled towels, airplane belt restraints padded with egg crate, and whatever else we could scrounge together made up our somewhat barbaric positioning armamentarium. (I just love that A...… word because it sounds like I might know what I'm talking about!) When we applied a restraint belt to a conscious patient the party line was always, "Since the table is so very narrow we use this for safety." There was no mention of the fact the belt helped keep them on the table if an abrupt anesthesia emergence occurred giving an alternative meaning to ambulatory surgery.

What Blood Loss??

 What blood loss? That's all irrigation in the suction bottle. At least 2 liters.

A good scrub nurse always agrees with the surgeon even if the patient lost a unit or more  of blood. I felt just like Nancy when concurring with a surgeon understating the blood loss. I always felt there were 3 categories of blood loss estimates: ABL, anesthesia estimated blood loss -  EBL, estimated blood loss by the surgeon  and NBL negotiated blood loss after the surgeon vs. anesthetist argument concluded. Actual blood loss was one of the great mysteries.

I promise this is the last of my political foolishness. Blame it on my brain freeze.

The Smoking Finger

No, I don't have one of those fancy new fangled phones

that take photos, so I put what's left of my index finger in the scanner.

Surgeons and nurses toiling in an operating room become habituated to a very controlled environment where everything from lighting to air quality is subject to rigid regimentation. Unpredictable events throw a monkey wrench in the midst of this enforced order, often times, leading to a cascade of adverse events  which can result in personal  injury to staff.

Voice modulation morphs into a surgeons unduly harsh verbal  admonishment of the offending party. Harried nurses, desperate for a resolution to the problem throw caution to the wind and find themselves in a precarious situation while attempting to solve the problem. Desperation seldom leads to reasoned thinking. The ensuing pandemonium is enough to flummox a pope.

Operating rooms can be dangerous places. Surgeons waiting for someone to fall asleep before cutting them might, at face value, seem unsavory, but the notion of live by the sword; die by the sword holds true in the OR.  Those sharpened chunks of stainless steel do not discriminate when inflicting their trauma and Bovies don't care what  tissue they roast.

 As a circulating nurse I was known for constructing elaborate platforms for height challenged scrub nurses. My colleague, Janess, loved my elevation tactics and was so enamored with one of my creations she failed to notice an unusually low hanging overhead light. As she emergently  ascended my stairway to operating room heaven for an urgent trauma case,  the crown of her head struck the low hanging illuminary with a sickening THUD..CRASH. After finishing the case, a close inspection of her cranial vertex revealed a hematoma the size of the distal end of a Babcock. After a quick neuro check and 15 minutes with an ice pack she was back on duty. I've witnessed several intraoperative injuries to staff and not a single nurse or surgeon broke scrub, no matter the extent of the injury.

Karma can be a cruel mistress and I soon received my payback for contributing to Janess's unfortunate mishap. I was finishing up a case with Dr. Oddo that entailed resecting a menengioma. These tumors are outside the brain and with removal have an excellent prognosis. I was in a great mood thinking about how we were actually being  of some service to the poor soul suffering from this nasty,  neoplastic malady. One thing I've learned over the years is to be wary of those euphoric Kumbaya moments when everything seems to fall in place because a true shitstorm is often in the works.

Dr. Oddo had been using a foot pedal actuated Mallis bipolar cautery during the case. This nifty little device looks like a pair of tweezers with an electric cord attached to a high voltage generator. When Dr. Oddo tramped on his foot pedal electricity flowed between the tips of the tweezer like device cauterizing anything in between. It was a great little gadget for controlling bleeding in small vessels.

Dr. Oddo loved to instruct the anesthetist to lighten the anesthesia near the end of a case. One  of his favorite phrases in the post-op report was, "The patient was able to transfer from the OR table to the awaiting carriage independently." This sometimes made for exciting moments near the end of surgeries when the patient took ambulatory surgery to a new level and decided to bail out before the final skin sutures were in place.

Sure enough, just as Dr. Oddo started closing the skin flap the patient began to emerge from general anesthesia. As he came to, his right leg spasmed into a mighty lateral kicking motion impacting Dr. Oddo's leg poised with his foot just above the Bovie actuating pedal. I was tidying up by clearing off the operative field and was preparing to wipe down the distal, business end of the Bovie forceps. The patients kick to the good doctor's leg turned the Bovie forceps ON and as the juice flowed a sickening burnt flesh/charred rubber glove malodorous scent filled the air.

The Bovie had cooked my right index finger on the distal phalange. As the smoke cleared I requested a new glove and plunged  what was left of  my smoking finger into a fresh sterile barrier. There must be some truth to the notion the body releases pain killers when traumatized because initially I was pain free. Upon finishing the case and pealing off the second glove the extent of the injury became apparent. The end of my finger had extensive "remodeling" with the distal aspect about 1/3 AWOL.

Dr. Oddo helped me remove the melted latex glove from the wound and suggested wrapping the finger with iodoform gauze. Dr. Slambow was consulted and said "welcome to the club" while showing off a massive scar on his right palm. After about 4 weeks, it was time for the unveiling. Dr. Oddo involved himself in a spirited debate with Dr. Slambow questioning whether  the nasty blackish tissue around the wound was eschar or scar tissue.

After the unveiling and the scar/eschar mess was pealed off I had a functional but rather disfigured index finger with a square tip and missing 1/2 the nail. I never missed a day of work and today I regard what's left of the end of that finger as a badge of honor. It's better than thinking of it as a living monument to my foolishness.

Is Surgery A Spectator Sport?

Observers in a sanctioned overhead viewing site 

advancing their surgical acumen. Serendipitous 

snoopers were another story.

Vintage hospitals went to great lengths to provide surgeon and/or nurse wannabes the opportunity to observe surgeries. European hospitals even referred to their operating rooms as "theaters."  I once worked with a charming British surgeon that affectionately  referred to  us "theater nurses." This soft spoken man actually  thanked  us personally after a case was finished even if our performance was not up to snuff.  A different breed of surgeon compared to his American colleagues.

Surgical spectators were all different and the most interesting  involved the serendipitous observer who happened to be in the right wrong place at the time of the surgical experience.  Don't get me started on those whippersnapperrns who freely use that confounded "experience" word to describe a planned operative  anatomical alteration, but I figure if you can't beat 'em, join 'em. Who says you can't teach an old dog new tricks?

The operating rooms where I toiled were on the very top floor of the hospital and offered a beautiful view of Lake Michigan which was 8 blocks due East. Large picture windows offered surgeons and nurses the opportunity to feast their  weary eyeballs on a  tranquil visual treat of sailboats and sparkling blue water far off in the distance. A welcome reprieve from eyeball stinging Bovie smoke and squnting to thread fine needles with 8-0 white silk while a surgeon hollered at you in the background for being too slow for his speedy needle plunges.

Everything was fine and dandy until the esteemed members of the hospital board decided to erect a high rise employee housing palace  next to the hospital. Nurses were agitated because these were luxury apartments and unaffordable for all but the most privleged office sitters. We were stuck in our 3rd floor walk ups where heat was a rarity even on the coldest winter nights.

Various members of Chicago's building trades toiled on the construction crews erecting this palace for the medical center moguls. They were a cast of colorful characters to say the least. Ironworkers in particular were a flamboyant, in your face sort of personality. I think it had something to do with their performing hazardous work at elevations where one false move meant falling many stories to a colorful  death.

As the building began to rise, we eagerly watched the progress while standing at the scrub sink which was probably less than 50 feet away from the ascending steel I-beams. You  could hear the ironworkers incessant babble before you could see them.   We joked with the surgeons that the ironworkers must be afficionados of expensive German automobiles just like them because they bantered constantly about "beamers" while guiding the gigantic steel beams into place.

The merriment came to an abrupt halt when the ironworkers ascended to the level of the operating room windows. This rag tag bunch of haggard workers acted as though they found a visual paradise. They glared and made contorted expressions as they avidly observed the goings on in the operating rooms. If they found the proceedings in one room not to their liking a short stroll along the steel beam provided a different procedure to observe. Legitimate surgical observers were limited to viewing the proceedings in just one room while the ironworkers enjoyed a virtual cafeteria of surgical sightseeing.

Their ringleader with his distinctive orange striped  hardhat led his merry men along a steel beam parallel to the OR windows until they found a procedure to their liking. The cysto room was the least popular after a worker nearly stumbled off a beam while observing a meatotomy. That procedure shivered my timbers too, so I could empathize with their revulsion.

The most popular room for these happenstance journeymen observers was the orthopedic room. A hammer is a hammer whether the one doing the hammering is a surgeon or an ironworker. The orthopedic surgeons were kept busy reducing and stabilizing bones just as the tradesmen were with steel beams. Both used lag screws and plates in their work. A brotherhood of sorts was established.

The surgeons took little notice of these nosey nitwits, but nurses thought the activities bordered on voyeurism and should be halted. Plan "A" was to scare them off. Sponge racks were crude, nasty looking devices ostensibly designed to facilitate counts, but really served to provide the surgeon of a visual reminder of blood loss. These morbid contraptions were wheeled, so positioning loaded sponge racks dripping with blood  in front of the windows worked to frighten off the men of steel. Some nurses took to displaying suction bottles full of blood on the window sills, but gradually the men of steel acclimated to our repulsive displays.

Alice, our beloved supervisor came up with the ultimate solution to the problem. Being an ultimate Killjoy, she used autoclave tape to suspend surgical drapes over the windows. some problems work themselves out with benign neglect. The observation opportunity ended with our move to the new operating rooms in the Stone Pavilion. Windowless operating rooms were very popular in the mid 1970s and put an abrupt halt to all the fun.

Retention Sutrures

Old school surgeons had a tendency to overdo just about everything from meticulously double tying simple bleeders to throwing in heavy duty retention sutures for added insurance against impending complications. A patient with wound dehiscence or more bluntly a burst abdomen was like a graphic, negative advertisement of surgical ineptitude. Something  to be avoided at all cost.  The  illustration above shows a wound that is beginning to "dehis" on the right side, but the retention sutures are averting a catastrophic blow out.

There was little science in deciding when to deploy torturous retention sutures and empirical notions ruled the roost. The end result was almost every obese surgical patient suffered the excruciation of miserable retention sutures which were applied in wide suture bites through skin, abdominal fat pad, and firmly anchored in the muscular abdominal wall. The dimpling of the  delicate skin before it yielded to the vicious thrust of a gigantic cutting needle pulling heavy suture was a chilling sight. A surgeon strafing a delicate abdomen with retention sutures shivered my timbers like nothing else. Orthopedic surgery with all it's bone crunching sawing and drilling was small potatoes compared to the forcible  application of retention sutures.

These gargantuan  sutures were usually left in place for about 2 weeks of abdominal throbbing madness for the hapless patient. Removal  was the most painful part of the surgical experience. ( I just love that new fangled vernacular where just about everything in modern healthcare is an experience or journey.) How about that, I can write like a whippersnapper if I try really hard!

The suture extraction process was very painful as a result of tissue adherence during the healing process. Sutures were practically cemented in place.  The fact that the abdominal wall was richly innervated exacerbated the situation. Considerable traction was necessary to pull the unyielding suture free from it's tenacious cementation in the underlying tissue. The sordid suture removal   affair reminded me of pulling cold taffy accompanied by loud screams and anguished howls. The task was almost always relegated to the least senior resident. Thank heaven, nurses never removed retention sutures.

One aspect of retention sutures always reminded me of an executioner applying a hood to the condemned before the act final was completed. This action was ostensibly done to make it easier on the prisoner, but the only real beneficiary was the executioner who could not see condemned man's suffering. For patient "comfort" the retention sutures were cushioned with short lengths of latex tubing where they contacted the skin. These bolsters or bumpers as they were called were custom made by the scrub nurse trimming a length of tubing as the sutures were placed. Any "comfort" from these little gems existed solely in the mind of the surgeon.  Retention sutures fueled post-op pain like pouring gasoline on a fire whether bolsters were in place or not.

More recent knowledge suggests that alteration  in the integrity of connective tissue is responsible for wound dehiscence and not necessarily obesity. The retention suture for all obese patients was not appropriate. Hopefully laproscopic procedures and improved techniques have made retention sutures extinct.

High Tech Hemorrhoid Surgery Meets Old School Positioning Techiques

The advances in modern surgical technique always amaze me. I recently found myself fascinated by a  newfangled hemorrhoidectomy procedure. The surgeon was working with a high tech laser device and magically zapping the 'rhoids into submission while an assistant struggled to manually pry the buttocks apart with the patient flat on the table. High tech meets low tech in the totally unnecessary and difficult manual retraction for operative site exposure. Leave it to OFRNs like me to offer tips to improve the bottom line.

Old school hemorrhoid surgery was a backward, crude sort of affair. A surgical assistant grabbed the offending hemorrhoid with a Babcock and pulled it skyward. At this point Dr. Salmbow would give the command, "Meatball it!" The stretched pile was quickly tied off with a ligature and cut free with a Metzenbaum scissors. Then it was on to the next 'rhoid. At the conclusion of the case some wise guy was sure to proclaim, "We really Wrecked EM." Nurses were always advised to chuckle at a surgeon's attempts at jocularity.

Proper positioning was key to this procedure and there was none of that  struggling or manual prying of the offending, shielding nature of the site occluding  buttocks. Old school OR nurses were adept at exposing just about any body part with the use of sandbags, rolled washcloths or towels, airplane belts,  and  3 inch J&J adhesive tape. The secret ingredient was tincture of benzoin which was the old time equivalent of modern super glue.

Hemorrhoid surgery began by placing the patient in the jack knife position as shown above. The buttocks were then liberally painted with tincture of benzoin which usually brought out the Picasso in me although  I suspect he never had a palette like this. The benzoin served to affix the adhesive tape aggressively to the skin. Next a 3 inch by 2 foot section of adhesive tape was applied to the buttock and then pulled laterally like a piece of taffy. When the "pull" was sufficient the opposite end was wrapped around the under table rails of the OR table. An additional strip of tape could be applied at a right angle to  this main "spreader" for oversize patients. The end result; a perfectly exposed operative site.

Abrupt removal of tincture of benzoin secured adhesive tape frequently enhanced a patient's emergence from general anesthesia. That stuff was a real challenge to separate from the skin in a civilized manner.

I often thought that the Preparation H folks should advertise by showing snippets of forcible hemorrhoid removal. Hemorrhoid surgeries were enough to convince me of the value of topical treatments.

Ring Stand Challenge Racing

An official makes last minute preparations to the race course.

Old school operating rooms were brimming with an assortment of unsavory, unpleasant and downright dangerous tasks; from unclogging floor drains occluded with who knows what to running test firings on  hissing and sputtering behemoths that passed as autoclaves. Who cleans up the room after a trauma case and who tends to the patient?  We used to draw straws with discarded suture for the equitable assignment of these nasty tasks. For the athletically inclined, the alternative to games of chance like the drawing of straws  was ring stand races with the winner awarded the undesirable  task of their choice.

Ring stands were a piece of operating room furniture designed to hold large basins of solutions used during the case. Before the advent of modern  disposable surgical gloves ring stands were used to rinse talc off reusable gloves. This ubiquitous piece of equipment was a favorite plaything for old school OR nurses. Contests of skill involving the tossing of various objects through the ring stand gradually evolved to attempts involving the passing of  an entire nurse's entire body up from the base of the stand and out of the elevated dastardly top disc that served as the finish line. The contest obviously favored the petite, lithe, thin contestant. Since I met none of these criteria, I was an almost certain loser and frequently found my self with a ring stand stuck on my ample waistline. My buffoonery quickly transitioned to outright embarrassment as the laughing of my colleagues crescendoed .

An official race began with 2 nurses facing the race course ring stand. On the "GO" command the nurses slid down to the floor like a limbo dancer and contorted their way up through the opening in the ring stand. The next stage of the contest was the hard part and involved slithering your body all the way through the ring stand with the victor emerging free of that confining circle. Older nurses always positioned the ring stand parallel to the OR table and leaned against it for assistance. Lithe youngsters could use their upper arm strength to rise above the confining circle. Victory was sweet with the winner having a justified sense of power knowing the choice of unsavory tasks was their choice.

For my next post, I'm thinking about another piece of OR furniture that could be more fun than a barrel of monkeys - the kick bucket.

Caring For Amputated Limbs

The brave new world of modern healthcare culture continues to dumbfound, agitate, and get stuck  in my old foolish, wrinkled up craw. The latest outrage?  I was reading an expert's answer  on Quora that amputated limbs are treated as "medical waste" and are disposed of by encasing them in a red sealed plastic bag marked with a biohazard symbol and sent on their merry  way to a landfill or incineration.

Self respect starts with caring for others in a dignified fashion.

Don't even think about tossing this in the trash!

Since everything in healthcare is governed by money, I suppose this is the cheapest  most cost effective means of limb disposable. Preoccupation with money when it comes to caring for people leads many in the wrong direction. Patients are never clients or accounts and caring for them is not an "industry."  That amputated limb was once a part of someone who is going to have a tough time, to say the least, of dealing with a new body image and learning a new lifestyle. An amputated limb is not an inflamed appendix or a gall bladder full of stones to be tossed in a kick bucket and tossed aside, it was part of someone and their identity. Who knows? Maybe an integral component of the patient's spirit was living in that limb. Treat body parts with the respect they deserve.

Alice, my favorite OR supervisor taught me how to care for an amputated limb many years ago. Alice could be a mean, cantankerous taskmaster, but I agree with her wholeheartedly about showing care and respect for an amputated body part. Despite their harsh appearances, old school nurses had and an innate sensitivity and were determined do-gooders.

When it came time to care for my first amputation patient in the OR, Alice was on hand for direction. "The first order of business is to line up 2 carts just outside the OR. One cart is for patient transport ant the other is used to transfer the amputated leg to the morgue. I don't ever want to see one of my nurses toting a large specimen through the halls like it was a suitcase. You will reap enough negative Karma to burden you forever with that trick." That last line said with Alice's all-knowing conviction made me shiver in my OR shoe coverings as I imagined an amputated limb coming back to haunt me. You better believe I conducted myself with dignity when showing respect to that amputated leg.

I carefully placed the amputated leg smack dab in the middle of the cart and carefully covered it with a white sheet. The trip to pathology was uneventful until I nudged open the door to the morgue and found the pathologist in the midst of an autopsy. He had just plopped a liver on the overhead scale when he noticed me and nonchalantly asked, "what can I do for you?" I stuttered and stammered that I was here with a large surgical specimen. He called  over to  a resident and advised , "Take aerobic and anaerobic cultures and some tissue for microscopy then show the nurse how to put the leg at rest."

One of the hospital  board members was a funeral director and donated a very nice metal casket to the hospital for one specific purpose; the dignified burial of amputated limbs. After the path resident obtained his specimens the amputated leg was wheeled over to the elevated casket in the back corner of the cooler. I gently raised the substantial lid of the coffin and gently nested the  severed limb inside. There were a number of other limbs resting comfortably in the ice cold  casket and when I was finished with the transfer I covered them all back up with a hand knitted shawl lovingly crocheted  by a dedicated member of the Ladies Auxiliary. The limbs were at peace.

The hospital purchased plots at a nearby cemetery where the limbs were carefully buried when the casket was full. I was curious how often burials occurred and was advised it was an annual event complete with a religious official and a few of the path personnel to show their respects.

Years ago I entertained myself with notions of working again as a nurse, but as I thought of the money grubbing corporations running the show my mind did an abrupt 180. My values come from a different place in time and although I failed many, I think my heart was in the right place. I plain just don't believe in nursing the way it's practiced today and the image of treating limbs like trash haunts me.

A Dubious Award for Bovie Smoke Control

There is a cornucopia of awards for modern day nurses. I've previously blogged about this trend which seems to have proliferated to the point of ridiculousness. An organization supposedly representing operating room nurses is now offering an award for an expensive system that attempts to contain the smoke liberated by the cauterization of human tissue. They  have "partnered" with a commercial entity that manufactures these devices. The coveted award is called "Go Clear," and there are gold, silver, and bronze permutations. I can visualize the winners standing on a podium resembling an OR table in their AORN approved bouffant head coverings looking more like chumps than champs.  Any nurse that had the unmitigated gall to seek personal enrichment by huckstering anything by enticing folks with awards would have been shown the door in a vintage hospital.

After a cursory review of the literature, I found there is little in the way of hard science to prove Bovie smoke is harmful and no published randomized trials. Sure it contains some nasty substances and most folks find it unpleasant but old OR nurses would laugh in the face of someone selling an expensive toy to "go clear." If Bovie smoke is one of the worse things you smell as a nurse you must be spending too much time sitting in an office and please, don't get me started on nurse office sitters.

OR nurses were so acclimated to Bovie smoke they could correctly identify the type of tissue being cauterized by the scent of cautery smoke and regarded this ability as a badge of honor. Remember that old TV game show, "Name That Tune"  where contestants said they could identify the song in 3 notes or less?  Vintage scrub nurses played a variation of that game by playing "Name That Tissue Smoke."  Pleura was the easy one for me and I could name that tissue in 1 whiff because of the characteristic sweet/sour smell released by the smoke plume.

There are cost effective ways to mitigate Bovie smoke that do not involve the unsavory element of money changing hands. We were conditioned to believe nurses were meant to be poor and efforts toward personal remuneration were sinful. My what a different world today where patients check in and check out of medical office  visits with all the dignity of a Wal Mart Trip. Nurses have more money today but something has been lost in the process. Proud, caring professionals have been rendered mercenary automatons by corporate healthcare.

One of the most efficient Bovie smoke minimization  strategies has presidential overtones and it's appropriately called  the Clinton strategy; don't inhale. Just wait until that perilous  plume dissipates to resume normal respiratory activity. Works every time and doesn't cost a cent.  If you don't inhale it can't hurt you or cause adverse political consequences. Bill was unto something.

Surgical masks are designed to implement a barrier that prevent endogenous operator  bacteria from reaching the surgical site. Masks function both ways and  are also effective filters to block inhalation of Bovie smoke. As proof  I offer the post operative sniff test which involves reversing the mask and thrusting your proboscis dead center into the mask after a long case. Guess what? It smells just like Bovie smoke that's in the mask and not your lungs.

Oldster nurses were frugal by nature and trained to use existing resources to the maximum. If  you are interested in saving your hospital big  money there is post on my blog that explains how to perform a sterile procedure with finger cots. Gloves are not cheap. There is suction available on surgical cases so if you don't care for Bovie smoke just suction away with what you have. Be prepared to be belittled because tolerance of Bovie smoke was an expected virtue and self serving actions like this were seen as a public declaration of your lack of commitment to patient care. Nurses were expected to put themselves in uncomfortable  and self endangering situations. It was all part of being a nurse. A hospital is not Disneyland!

Axillary Fallout a Pitfall in the Operating room

Axillary fallout abatement in action.

Tucked scrub top and containment 

garment under scrub top.

One of my most popular posts is from a couple of years ago and it was about the perils of perineal fallout and measures used to control such a menace in the OR. So as a sequel, I would like to present an equally dangerous infection generating body part, the armpits of OR personnel full of hair, sweat, and bacteria. They smell funny for a reason and attempts to camouflage the odor with topical deodorant only exacerbate  the situation.

Asepsis is one of the foundations of successful surgery and begins with the aggressive scrubbing of the operative site. This "prep" is usually conducted by the circulating nurse or a resident. The rub-a-dub-dub of scrubing  the patient's skin produces a copious (we always got brownee points for using that "c"  word in our care plans-old habits are tough to break) amount of to and fro arm movement. Some preppers even resembled marathon runners with their violent herkey-jerkey arm movements. This violent arm oscillation from a fixed point creates lots of friction in one of the most bacteria infested parts of the body, the armpit, second only to the aforementioned disease producing perineums.

My favorite OR supervisor, Alice, paid special notice to the arm swinging preppers and developed one of her famous theories. Hard scientific theory can become boring, but applied sciences like nursing is where the fun begins. Alice believed the armpits shed micrococci and who knows what else when the friction of the arm swinging liberated them from their hairy denizens in the armpit. The patient was especially vulnerable during the prepping procedure because the drapes were yet to be applied.

Alice just love finding fault with men especially those of a lower caste. Male  nurses were the perfect fodder for her "interventions." Alice had been verbally abused by an assortment of surgeons over the years and this created a revenge oriented mind set. Someone had the temerity to ask Alice why she singled out men for her perineal and axillary fallout ministrations and she knowingly replied, "because that's where all the hair is. It's the friction from rubbing two hairy skin planes together that unleashes bacteria."

Putting the brakes on axillary fallout begins with tucked in scrub tops and as I mentioned in my last post, Alice was an aggressive scrub top tucker inner. After ramrodding the top into the pants, Alice always administered a rough skyward yank of the pants which often changed the timbre of the victims voice and marked the laundry of those with poor hygiene.

When disposable gowns came on the scene in the early 1970s a large cache of cloth gowns was dedicated to the pre-operative skin prep. The old cloth gown served as a perfect containment vessel for corralling free falling axillary micrococci thus averting one of the pitfalls of skin preps.

Time Out - I Contaminated my Gown

President Trump now seems to be buddies with his old North Korean nemesis and  most likely has surrendered his "dotard" title. So.... I've been thinking about changing my handle from OldfoolRN to OlddotardRN because there  is just so much about modern operating rooms that fall beyond my level of comprehension.

What happened to the sacred tiled temples that were once ORs?  Modern ORs have sacrificed  their penthouse location to practically anywhere in the hospital and worse yet resemble a waiting room at the Greyhound station. Valued work areas have been converted to electronic warehouses with enough computerized  doo dads to land a 747 in a whiteout.

The above illustration is the latest  iteration in a long line of befuddling situations. When I initially laid eyes on this young, scrubbed  whippersnappern I had that weird feeling that totally smacked my gob, (see, I can talk like a youngster if I try real hard.) She just contaminated her right hand by elevating it well out of the accepted zone of sterility. Everyone knows that the sterile part of a gown is restricted to below the armpits and above the waist tie-NO EXCEPTIONS.  If Alice, my favorite OR supervisor were on the scene she would be swinging her sponge stick like a baseball bat at this poor nurse's knuckles. Breaks in sterile technique earned the most severe knuckle bashing and I can almost see  Alice winding up like Mickey Mantle at the plate.

I educated myself about the situation and learned this nurse is calling for a "time out," which probably means she recognized the error in her ways and wants a sleeve and a new glove from the circulator. Asking for a sleeve to cover the contaminated section of a gown was a humbling experience because it required the assistance from a sterile member of the surgical team.  A surgeon helping a scrub nurse provided ample fodder for endless jokes. Dr. Slambow, my general surgeon hero usually made the nurse step away from her Mayo stand and assist with the surgery while he assumed scrub nurse duties to demonstrate the correct way of doing things.

There are a couple of other issues with the way this nurse is conducting her duties, but I think I'll let my esteemed readers point them out.

I'm Going to Give You something to Think About! YEOWW

I stumbled upon this old image and it made my knees feel weak and my knuckles throb. It's a spitting image of my old time OR supervisor, Alice, who could wield a sponge stick with all the force of a burly cop swinging a billy club. This photo shows her assessing the severity of the infraction which will determine the location of the fulcrum to swing her weapon sponge stick from when it impacts the knuckles of her hapless victim. Swinging the sponge stick from the distal tip would inflict the most pain.

It looks like she is about to wail away with the fulcrum in mid position near the instrument's hinge. This was for relatively minor offenses  like passing an instrument to a resident rather than the attending surgeon, even though the resident was in the proper position to deal with the problem. Rules were rules-always provide the attending surgeon first.

The most brutal knuckle cracks were for any offense, real or imagined. that broke aseptic technique. Alice was an equal opportunity knuckle basher and residents were fodder for her cruel ministrations as well as nurses. She caught a young resident with his nostrils protruding over his mask and he received a double punishment, Cracked knuckles and a set of dental rolls plugging his nose. I think there might be an old post about that Aliceism somewhere amidst my foolishness.

Blood Bag Blues

It's been a very long day. The somber cacophony of suctions sucking, Bovies burning, Airshields ventilators chugging , instruments clanging, and surgeons bellowing has decrescendoed to a strange and rare moment of blissful silence. Those weary legs wobble like Jello as they acclimate to an absence of weight bearing stress. The impending fatigue unleashes a contemplative frame of mind so different from the acute attentiveness  required of a scrub nurse busily loading needle holders and delivering the exact required instrument at the exact right time. My mind sometimes fixated on the remaining flotsam and jetsam scattered about the tiled temple as I planned my clean up activities.

Drained of their miraculous magenta contents, empty blood bags are neatly stacked sit on the anesthetist's  gas machine awaiting their round trip journey back to the hospital blood bank. The few remaining droplets of blood form an intricate spider web design visible through the transparent container that always reminded me of stained glass. The drained bags are now a component of the detritus remaining as an artefact of the previous surgical adventure with their own tale to tell.

Artefacts and relics mean different things to different people when their intended function has ended. I thought many times how strange it sounded to keep blood in a  "bank," but then I began to figure it out. Some of my very best insights occur when fatigued and sleep deprived as that caffeinated jolt works it's magic.

Blood bank CEOs and commercial bankers have much in common. Blood banks rely on the innate goodness of volunteer donors  whose reward might be a glass of orange juice and a stale cookie. Bankers of money pay paltry sums of interest to the hapless savers and charge exorbitant fees to credit card users. Blood bank CEOs and bankers reap their massive  salaries and stock options on the backs of little people just trying to do the right thing. In nursing it always felt as if large sums of money flowed  right around me much the same as the  blood in a suction tubing. Nursing and donating blood is a waste of time if you are doing it for the money. It may sound strange, but I always felt a sense of pity for the greed consumed CEOs lounging in their administrative playgrounds. They probably never had the warm feeling that comes upon you when really helping someone at a critical time in their life.

Blood had almost magical qualities when transfusions went well and the source of blood loss could be corrected. Used blood bags always had redundancy in miniscule sticky labels with an identification number. There were always plenty of these little stickers left over even when all the documentation was complete. I tried to keep the good juju times a rolling with these little stickers by sticking them on the back of my name badge or wrapped around the earpiece of my trusty stethoscope. I don't really know if they helped, but when times were tough, I could cheer my spirits with a quick glance at the back of my name badge.

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.