Not on My Mayo Stand!

 One of my most popular posts from the  past was about items I never, ever want to see on my OR back table. https://oldfoolrn.blogspot.com/2017/01/not-on-my-back-table.html. Scrub nurses work  at ( or least  they did 50 years ago) from two horizontal surfaces. A large  back table at the foot of the patient which is loaded with just about anything and everything  needed for the surgery and the Mayo stand placed over the patient just below site of the surgery. This stand  is solely for the instruments in immediate use. I've seen some illustrations of Mayo stands that really flustercate my fragile foolish faculties, so here are some thoughts about the care and feeding of Mayo stands from a perspective of many moons ago. (I had to put that disclaimer in because some folks compare my ramblings to contemporary standards and I get harshly critical emails.)

Side hanging  instruments as shown in this illustration desecrate one of the most basic of  OR commandments - Thou shall not let any instrument dangle over the edges of your Mayo stand. The outer ridge of the stand acts like a fulcrum sending your instrument flying if you inadvertently drop an elbow during a critical moment. Flying instruments, depending on where they land, are never a good thing in an OR. A nasty surgeon once lobbed  a Haney clamp at me and then in a Karma driven moment, dropped a weighted speculum on his foot. Yes...there is a flying instrument god in every OR.

I started this post out thinking that maybe I should do the ten commandments of Mayo stands, but that sounds cliched and besides, what happens if I can't think of ten? Maybe it's better if I just ramble  on in in my typical foolish manner.

When in use, Mayo stands should always be at the scrub nurse's waist. A uniform height helps establish muscle memory so that when you go to grab something, your hand goes to the intended spot without thinking. Many nurses need some altitude enhancement to reach the correct height and I went out of my way to construct elaborate altitude enhancing arrangements.  oldfoolrn: Scrub Nurses Flying High

Yikes! When it comes to just about any sort of tubing or cable, be it suction line or Bovie, it's much neater to keep them on the back table until needed. Think of your Mayo stand as fly-over country and pass the long  tubing or wiring directly from the back table to the surgeon. This Mayo also has a towel clip and a Metz scissors hanging over the edge of the Mayo waiting to be dropped or take flight. I do like the way the scrub nurse lined the top of the Mayo stand with a couple of honest to goodness cloth towels. Disposable paper Mayo stand covers and towels generate that raucous rustling noise that really grated on my nerves. It reminded me of opening presents on Christmas morning when I was often stuck in the OR.

Old scrub nurses were real sticklers when it came to keeping all your instruments on one level while they were reposing on your Mayo stand. The only high-rise object tolerated was a stack of 4X4 sponges because when it comes to anything bleeding you can't be too careful. I vividly recall the dressing down a new resident received from Dr. Slambow when he took a loaded sponge stick and  swiped instead of a dabbed at a small bleeder. "You meathead!@#&, you are wiping the clots away." The good surgeon did not tolerate fools well, except for me. 

 

This Mayo stand illustration should be captioned double trouble. A scrub nurse is like a mama bear protecting her cubs when it comes to guarding and maintaining the sanctity of her Mayo stand. Here we see more than one set of lunch  hooks...oops I mean mitts on a Mayo stand. Fifty years ago a stunt like that would merit a knuckle smack with the business end of a scrub stick, especially if my nemesis, Alice, was standing behind that Mayo stand. Alice was an equal opportunity knuckle buster, surgeon or nurse, it didn't much matter. The other faux pas  here involved a specimen jar filled with a likely toxic solution like formalin. Mayo stands are restricted from any liquid that could be toxic. Methylene blue and lidocaine are just fine, but biopsy fixatives are a big no...no. 

Noah was right, everything is better in pairs. When bringing up ratcheted instruments from the back table always grab two at a time. There should be an even number of hemostats, needle drivers, kochers, mixters and babcocks. I never did like the way grabbing a babcock. registered in my ear  when spoken.  Picking up a pair of babcocks always sounded more civil, so don't grab a babcock, pick up a pair. Avoiding odd numbers of instruments on your Mayo stand  helps avert that dreaded foreign body mishap. Thank heaven  this never happened to me (I pray.) .Avoiding some mishaps is  a matter of luck as much as skill. Surgery is a high wire act with lots of distractions and bad things do happen. It was well known that any nurse involved in a foreign body incident would be fired on the spot. We were scared straight.

Some nurses delighted in adding artsy fartsy touches to their Mayo stands and I'm not sure if this is a good thing or not. I'm not very artistic so maybe I have a dog in the manger attitude when it comes to fanciful touches to Mayo stands, especially when the artist is a much more accomplished scrub nurse than me. My friend, Janess, liked to craft lovely designs in her  wax paper sharps bag by cutting designs along the top border of the container. She was an artist with a straight Mayo scissors and I think her flower designs were the very best.

Elite scrub nurses were a very special breed that certainly excluded me with my size 9, hubcap sized hands. Fleet of foot with nimble fingers and a fast firing central nervous system, always totally relaxed, but ready to strike at a moments notice. Probably the ultimate paradox was their narcissism coupled with unyielding selflessness. You have to love yourself if you are going to  do just about anything for another with such blatant disregard of your own needs. 

I'll always remember my favorite scrub nurse mentor, Alice, harping about some Mayo stand minutiae and when it came time for self-evaluation her only fault was having to deal with low motivated sloppy dolts like me. Old OR nurses like Alice were different from the rest of us.

The Grooved Director Surgical Instrument Mystery Explained

The function of a surgical instrument is usually obvious; retractors retract, clamps clamp, cutting instruments cut and forceps hold things. I made a comment about a lovely grooved director instrument on Instagram and was asked, "What is that thing used for?"  When I was a novice scrub nurse grooved directors were widely called for and  used for a hodge-podge of probing, directing of suture and guides for  cutting tasks. As I approached retirement they  remained in the instrument tray on the back table and finally disappeared forever.

Grooved directors always reminded me of Mickey Mouse. The end of the instrument with the ears was called the spoon or saddle. Dr. Slambow, my favorite general surgeon liked to sing Home on the Range while working so I took a  liking to the "saddle" reference. The curved shaft extending from the saddle was called the shank.

 Surgeons are big fans of devices that restrict their view to the work at hand and use drapes and devices like grooved directors to frame their field just like a movie director with  a view finder.  The tiny, circular opening in the saddle was often centered over the opening of a duct or anything else that might require exploring with a probe. The grooved director was positioned at a right angle to the wound or duct and served as a fulcrum for manipulating the probing. Imaging techniques were few and far between in days past. Probes  were a crude but effective tool for exploring. When ducts and wound tracts could be evaluated without probes grooved directors fell out of use as guides for probes.

Grooved directors could also be used as protective shielding tools. The shaft had a horseshoe or curved profile and could be placed over nerves, arteries or anything else that should not be cut. The rare illustration of a grooved director in action shows it placed over a tendon while cutting from above. The surgeon must be an early specialist as general surgeons almost never hold a scalpel like a pencil. He must really be an old-timer. Is he actually performing surgery bare handed? That lovely scalpel is way before my time. BD disposable scalpel blades have been in use since the 1950s.

Surgical residents are very familiar with 3 rules of survival:  eat when you can, sleep when you can, and don't monkey with the pancreas. Grooved directors were frequently used to guide suture away from the pancreas when working on the duodenum. They functioned much like a clothes line prop with the suture strand guided by the groove in the spoon away from the friable pancreas. If left alone, suture assumes a caternary  curve and the grooved director straightened things out.

I managed to put my blowhard nature on the back burner and seek outside input for grooved director information. When I Googled the instrument  I discovered uses like a pediatric tongue depressor or elevator during surgery on the frenulum. That's a new one on me.

I emailed Dr. Sid Schwab from Surgeonsblog fame and he exclaimed, "That's a trip down memory lane!" He used the instrument once or twice on pancreatic duct procedures. Dr. Skeptical Scalpel (on my blog roll) almost never used a grooved director.

Grooved directors fell from disuse like open drop ether anesthesia and Operay lighting systems. Almost everything has a shelf life and I often what modern devices will be extinct in 30 years. Maybe the grossly overpriced, unproven surgical robots?

Curved Surgical Instruments - What's the Deal?

One of the liberties of being "just a  scrub nurse" was the privilege of asking dumb, foolish questions. When there was a lull in surgical action such as waiting for a phone call from pathology or passing  time until an esoteric instrument was flashed,  the time was ripe to pose philosophical queries to the attending surgeon. Surgeons could come up with some convoluted answers to foolish  questions when they were caught off guard. Timing and delivery of the question was the key to obtaining an offbeat answer.

Here is a sampling of some questions I asked in a foolish attempt to resolve the greatest mysteries of the operating room; "Why do cloth shoe covers track blood on the floor a greater distance than new-fangled plastic disposable covers?...  How normal is 0.9 saline?... Can you sleep on a mattress suture?... and perhaps the ultimate question... "Why is the working end of many surgical instruments curved?"

Four lovely curved clamps in the foreground with the tips arching forward. A pair of straight Allis forceps, straight  hemostats, and a lone, proud Babcock sitting in the background. An obscure visual treasure of glimmering stainless steel enhanced with graceful arching curves, glowing in the brilliant overhead light of the tiled temple. The astounding beauty of those gracefully curved clamps surrounded by the deep sky blue surgical  towel is so easy to overlook while we live out our remaining days craving the cheap balm of a glowing screen. Hmm.. Maybe I could scrub for just one more case.😃

Here are some candid responses straight from the surgeon's masked mouth: "Instruments are curved to match the curve of the human hand....Because that is the way it's done Fool, now hand me a sponge stick and get back to work...There are no straight lines to be found in nature; that's why instruments are curved... Curved instruments have greater utility and are more useful."  That last answer probably made the most sense, but it's still not an elaborate rationale for instrument curves.

With the luxury of time to think about it and lots of experience watching curved instruments in action here is  my foolish explanation. When cutting with a straight bladed scissors the operators hand is directly in-line with the direction of the cut. This can obscure the view of the cutting activity. Curved scissors place the operating hand at a 30-45 degree angle (depending on the acuteness of the curve) to the area being cut, providing an unobscured view. Curved needle holders drivers as you whippersnapperrns call them, follow the same principle.

When using just about any hinged surgical instrument the opposable thumb is moved away from the index finger when spreading the jaws or blades, in the case of scissors.  It takes physical space to accommodate this thumb/index finger span. Curved instruments create an angle to move the hand above the area of work providing room for the necessary finger span. A long handled, curved instrument allows the surgeon to work in some very deep wounds such as encountered with obese patients.

Retractors have gracefully curved blades to distribute pressure over a wide area to minimize trauma. Wrapping those blades with saline soaked lap sponges helps too.  I believed that aggressive retraction caused as much trauma as any blade. Whenever a resident was pulling back so hard on a retractor that he assumed the position of a water skier, tissues were being stretched to the limit. Aggressive retraction always bugged me. Surgery should not resemble a taffy pull.

Old school nurses had the responsibility to ensure surgical instruments were in proper working order. If a surgeon encountered a  hemostat or needle driver with misaligned jaws, it was his prerogative to "fix" the offending instrument by opening it up and bending one arm up and the other down. Instruments that had been curved via this "repair" were rendered useless and thrown into the trash where they belonged. Curves, in this case, served to identify a non-functioning piece of equipment.

Surgical Instrument Identification Marking

"Fetch me one of those thingamajigs

with the red and black marking tape"

Carbon based lifeforms have had a fascination with placing marks on things that has evolved over countless millenia. Dogs and cats spray urine and bears strip bark and arrange tree leaves in unique patterns as a marking technique. Homo sapiens of the office sitting operating room  administrative ilk are fond of putting their mark on surgical instruments. See that elegant arrangement of  Germany's finest  set of  VMueller surgical instruments (above)  all decked out with tacky  little identifying bands. I think the green/yellow, red/black tape markings look  worse than a dog spraying a fire hydrant with urine. Marking surgical instruments is a crude way for administrative busy bodies  to seek control over a situation that they have no business fooling around with.


It's not too hard to figure out the marking behavior of dogs, cats and bears, but to find the motivation for  defacing marking surgical instruments we have to delve into the mindset of misguided individuals who likely have rarely set foot in an operating room. How about this gem from an instrument defacing  marking advocate?  "Marking surgical instruments corrects the lack of process visibility and identification for all perioperative stake-holders."

I guess this is a convoluted way of saying you cannot tell what something is just by looking at it or using it. It's not all that difficult to learn the nomenclature of surgical instruments and have a general idea of how the instrument is used. A Penfield is a Penfield because that's what it is. The black and red tape is not what gives an instrument it's identity. So the instrument is the instrument, ineffable, a well defined entity completely independent of the strips of colored tape applied on the whim of an administrative wisenheimer.   If you are working in the perioperative arena and don't know the identity of your instruments, the only steak you should be holding is a T-bone.

"We mark our instruments so as to organize them into sets for a specific case. Green/black markings mean the instrument is part of the fem-pop bypass tray," said nursing supervisor, Mary Marks-a-Lot
This is wrong headed thinking of the highest order. The surgery determines the type of instrument used not the instrument determining  the surgery. The tail is wagging the dog with case specific instrument trays and the circulating nurse  will be running like a whippet to the nearest autoclave to flash sterilize the instruments you really need for unexpected circumstances. I often fantasized about instrument marking misfits standing directly in front of the autoclave when I suddenly cracked the door after a flash sterilization cycle. Maybe a blast of scalding steam to their sensory regions would bring them to their senses.

Instruments used in case specific trays are also more subject to wear and tear because they are used in the same manner time after time. For maximum instrument life it's best to use them on a rotating basis with different cases through varying services. Auto mechanics don't have a breaker bar just for working on struts - they use it wherever it's needed. Surgical instruments should be used as needed and not assigned to a case specific use.

Scrub nurses have enough to keep track of; sponges, needles, and instruments. an additional duty of inspecting each instrument for loose or missing tape is stretching the limit. ID tape is just one more unnecessary worry for a harried nurse.

Microorganisms are crafty little devils and I suspect they could use the ID markings as a sort of shield to escape the unpleasant effects of gas or heat sterilization. I always suspected that tape margin where it interfaces with the instrument surface as an area for assorted biomass crud build-up. Instruments just look cleaner without identification tape.

I usually tried to avoid pharmaceutical reps and medical equipment sales people like the plague. The very reserved German fellow that represented VMueller instruments was a source of information and a true expert on the care and feeding of surgical instruments. He summed up my feelings perfectly when he surveyed an instrument tray with ID tapes plastered on his beautiful product, "Dumkopfs!" he hollered followed by some German cuss words He did not have to explain who or what he was referring to while I nodded my head in somber agreement.

The Souttar Craniotome

Every surgical specialty has a memorable instrument from the past that inspires trepidation in modern folks; urology had the Kollman dilator, OB had the cephalotribe,  and neurosurgery had a host of ghastly  tools to fashion approaches to the brain.

The dicey part about accessing the brain is that it's covered in a very durable, hard, boney box-like structure, the skull. The dura which covers the brain lies directly beneath the skull. The trick is to get through the bone without harming the underlying dura. Just like fashioning a small round opening in a boiled egg without touching the white.

Modern pneumatic craniotomes  in use since the mid 1960's do a great job of this. There is a blunt foot on the end of that whirling dervish of a  cutiing blade that leaves the dura unscathed. It was invented  by John Nash who ironically became one of the first customers to utilize his invention. He required a craniotomy for a brain abscess shortly after marketing his device.

My favorite neurosurgeon, Dr. Oddo, just loved antique neurosurgical  instruments and had them proudly displayed in his office. I was fascinated by an unusual device for cutting thorough that bony barrier, the skull. The Souttar crainitome  consisted of   a solid 6X1 inch stainless steel post with an adjustable expanding  base, a pivoting arm that moved around the post, and a cutting wheel that resembled a plumbers pipe cutter.

Dr. Oddo was more than delighted to explain the operation of the Souttar craniotome which was invented in the early 1930's. It was designed to cut a perfect circle in the skull in whatever diameter the surgeon desired. Asking dumb questions was one of my signature moves so I asked Dr. Oddo what's wrong with a square or rectangular opening into the skull. "Intersecting lines never work in neuro surgery. If there is pressure building up under a square opening there will be greater pressure in the corners. An oval or round opening heals best and permits pressure equilibrium beneath the bone flap."  Thanks for the enlightenment Dr. Oddo, but can bone wax be used to polish a surgical instrument? Can ambulatory patients receive care at Chicago's Lying In Hospital? How normal is normal saline? Do blood gases smell funny?  Oops, those dumb questions never cease when Oldfoolrn is on the case. It's time to get back on task.

Henry souttar was an engineer before he took up medicine so maybe his skull opener was inspired by circle cutting devices from other discplines. To the left is an arts and crafts circle cutting device that is a dead ringer for the Souttar craniotome.

In Souttars version a burr hole was manually drilled in the center of the intended skull opening. Burr holes were drilled using a device that resembled a boring brace and the bit was attached to a clutch mechanism that ceased the rotation of the bit when it was through the bone.

The next step involved inserting a stainless steel post in the burr hole. The post was rigidly secured in the burr hole with a set- screw activated expanding base which was identical to the manner a bicycle stem is secured in the top of the fork.

Once the pivot post was secured in the burr hole, an arm with a cutting wheel was attached. The size of the circular skull opening could be varied by sliding the cutting wheel on the arm. As the cutting wheel was moved out the radius of the circle increased making a larger opening. The pressure of the cutting wheel on the bony skull could be increased by tightening a screw atop the wheel. When Dr. Oddo demonstrated the device in action he compared it to children frolicking around a Maypole. The action was similar, but the analogy gave me the creeps. What in the world do innocent children have to do with chopping a hole in someone's skull?

The old school neurosurgeon stopped frolicking  the  cutting action just before the skull was cut through to protect the underlying dura. The final removal of the bone flap was done with a mallet and chisel.

You can count on Oldfoolrn Blog to bring you the latest in little known, esoteric, meaningless information. I Googled, Binged, and Medscaped "Souttar Craniotome" and came up dry. This post is based on memories sifted through an aging nervous system so reader beware.

Why does RN smack instrument in surgery?

Two people googled this question and were  referred to my blog. I might have made casual mention of slapping an instrument into a surgeon's hand, but never really answered it. I felt like the kid in a classroom when the teacher asks a familiar question.  I know!    I know!

One reason for the brisk slap of the instrument is to overcome what I call the trampoline effect. The surgeon has his hand extended in the open position when receiving an instrument. This action stretches his glove between the extended thumb and extended index finger creating an elastic mini- trampoline smack dab in the middle of his hand. If the instrument is not delivered in a firm manner it will bounce right out of the surgeon's hand and he might offer some unpleasant editorial comment.

Dr. Oddo, our international neurosurgeon, always had novice scrub nurses wear glasses with loupe magnifiers just to see what they were like. All I could say is kudos to  anyone with the patience to work with these things on their eyes. Your peripheral vision is blocked out and you cannot really see much of anything except that which directly in front of you. Anytime a scrub nurse works with a surgeon wearing loupes you know he is working by feel when receiving an instrument. It takes a slap and then a little push into the hand for the surgeon to easily grasp it. Don't be timid. The surgeon's vision for anything outside the operative field is nil.

Mentioning loupe magnifiers brings to mind a bit of foolishness unrelated to slapping instruments. Dr. Oddo used to tell his residents to wear loupe magnifier eyeglasses on all their cases just to get used to wearing them. When one of these eager beaver residents showed up in Dr. Slambow's  general surgery room wearing loupe magnifiers he would bellow, "We're not operating on an ant's ass in  here. Take those damn things off." General surgery cases did not really need the up close magnification and Dr. Slambow was not one to be trifled with.

When the tempo of a case picks up or something unexpected happens the instrument slapping can become a little more aggressive. I think it is a subconscious thing that goes along with the hyper vigilance when you have to move really fast and not think too much about what you are doing. It's a conditioned response.  I have never had a surgeon complain about me slapping an instrument too hard into his hand.

About the worst thing you can do when  instrument trafficking ( a slick term I learned from you bright young whippersnapperrns) is to "dangle" an instrument over the field. It's a novice mistake everyone makes. The surgeon has no idea where a dangled instrument is in space so it's of no use to anyone. To a novice, a dangled instrument does feel like a security blanket- you at least have an instrument at hand. It's really just in the way and you might miss handing off something that is needed in a hurry.

Some old school scrub nurses (to me), so it's second generation old school to you whippersnappers engaged in what I call malicious instrument slapping. If a resident was caught napping or was slow to respond they would take a sponge ring forceps and whack the knuckles with the handle end of this instrument. A sponge stick is one of the more lengthy instruments and with the leverage, capable of delivering a painful blow. Come to think of it a sponge stick is about the same length as a ruler. I wonder if this is the operating room sister equivalent to the parochial school knuckle slapping nuns. I never thought of this angle before, but it seems to make sense.  Do not attempt knuckle slapping with an attending surgeon, it would be a big mistake. I never had the guts to pull this trick on anyone, but based on anecdotal accounts, it was a favorite trick of old time scrub nurses.

OUCH!

Old scrub nurse mentors have told me, "Now that stunt deserves a good crack on the knuckles. Always have a sponge ring forceps ready to go on the residents side of your Mayo Stand." I never did this and I never talked back to any surgeon. These same old scrub nurses used to counsel me, " Don't let that surgeon scream at you like that when it's not your fault. It's bad for your soul." Maybe I should have heeded their advice.

When an instrument is passed correctly it's not really a hard smack. It's like a brisk flick into the hand followed by a very brief firm push. The surgeon then reflexively grasps it and is ready to go. It probably looks like a smack and might even sound like a smack, but I'm not sure that thinking of it as a pure smack is the best way to conceptualize it. You know a proper instrument smack when you feel it!

I suspect that with modern laparoscopic and minimally invasive procedures instrument slapping is becoming a lost art. How in the world do you slap a laparoscope?