Sunday, March 21, 2010

Heard in and Around the OR

Heard in and around the OR

In Pre-op:

The pre-op nurse will ask, “What Surgery are you having today?”

“Repair of my Hi-anal hernia” Hiatal Hernia

“Doctor is going to remove the fireballs from my eucharist” Fibroids of the Uterus

“Fix my Piles” Hemorrhoids

“Suck out my Gallbag” Laparoscopic Cholecystectomy

“Fix my Erotic Aneurysm” Aortic Aneurysm

When asked “What’s your surgeon’s name?”

“I don’t know, he’s the one with red hair and glasses.”

Before starting Surgery:

When a general surgeon says “This will only take thirty minutes.” It means “It will take me thirty minutes assuming this tumor is in the sigmoid colon where the GI doc said it’s supposed to be and not in the stomach like last time, so call Dr. Smith, who’s following my case and tell him he’ll have plenty of time for lunch.”

When an Orthopedic surgeon says “This will only take thirty minutes” it means, “We’ll fix this and then get an X-ray and then do it again until I figure out which bone is connected to what; it will be at least three hours.”

When a Plastic surgeon says “This will only take thirty minutes” it means “it will take me thirty minutes to set up my camera. The surgery will probably four or five hours.”

Things heard during surgery and what they really mean.

Anesthesiologist to surgeon “Is everything OK down there?” Translation: “The EKG is flat, there’s no blood pressure and you’d better start CPR.”

Surgeon to Anesthesiologist “We’re having a little blood loss.” Translation:

“I just cut the vena cava and you’d better call the blood bank, get the cell saver and a priest.”

Surgeon to no one in particular “that’s not supposed to be there” Translation: “Call my lawyer, malpractice carrier and my mother, I just cut the Common Bile Duct.”

Surgeon to Anesthesiologist “He’s waking up” Translation: “Put down the Wall Street Journal and turn up the gas before the patient walks off the table.”

Surgeon to OR crew “This is a new procedure; it may take a bit longer than usual.” Translation: “I’ve only seen this done once before and I was hung over at the time.”

Surgeon to assistant “This is a particularly difficult case” Translation: I haven’t the foggiest notion of how to proceed. Take over, I’m going to the bathroom.”

Circulating nurse to Surgeon “We’re out” Translation: “You don’t need that you old fool and even if you do, I’m not walking all the way to Room 12 to get it.”

Surgeon to Anesthesiologist “Put another quarter in your machine” Translation: “I’ve got at least another hour to work and the patient is awake enough to assist me.”

Anesthesiologist to Surgeon “This patient’s very high risk, but I think we can manage” Translation “We shouldn't be operating on such a sick patient, but I’ve got vacation coming up and business has been slow.”

Soft “Whoosh”… (Silence) Translation: I’ve just cut the (choose one or all) aorta, inferior vena cava, portal vein. The ‘whoosh’ is the sound of bleeding; the silence is the sense of doom. It is permissible to replace the silence with ‘Oh Shit! Or any other similar epithet.

Such utterances are, fortunately, extremely rare. When something unexpected happens the greatest effort is made to maintain a calm, workmanlike atmosphere which explains the tendency to seemingly understate the gravity of the situation. As long as channels of communication are maintained between the members of the operating room crew the patient will receive the utmost attention.

Feel free to add to the list.

Sunday, March 14, 2010

Fashion Statements

In the world of surgery where I reside fashion rarely is much of a consideration. The isolation of the operating theater does not lend itself to making fashion statements. Indeed, when I first entered private practice twenty years ago I always started my day wearing a dress shirt and tie underneath my white lab coat. Most of the time the professional look was quickly replaced by surgical scrub suits and I found myself changing back and forth three or four times a day. So, the shirt and tie faded away, replaced permanently by scrub suits.

Initially, I wore whatever scrub suit I pulled from my closet where a varied arsenal of scrubs, “borrowed” from almost every hospital I’d ever frequented, was housed. These scrubs ranged from blue to gray to various shades of green. The scrubs from Strong Memorial Hospital in Rochester, New York had a peculiar feature in that the material was 55% cotton, 44% polyester and 1% stainless steel. I always assumed that the 1% was woven throughout the fabric, but it would have been more prudent to concentrate it in certain strategic areas, given the demeanor of some of the surgical attending staff at that hospital.

The cheapest scrubs were those from Nassau County Hospital, where I did a portion of my surgical residency. White scrubs with pink “NCMC” stamped all over and pretty much see-through guaranteed that no one would ever wear a pair out in public. Actually, many did not even want to wear them in the OR, unless one wished to advertise certain assets. These have sat on my shelf for years, but were useful when I was painting our living room with the help of my kids. For some unknown reason I had several scrubs in size small which were perfect covering for my young helpers.

Surgical scrubs, until recently, were never designed to be anything but functional. Loose and drab, they could never be considered flattering. But, to the rescue, come designer scrubs. It seems there was an anesthesiology resident that tackled this problem head on and created her own line of designer (overpriced) scrub suits. As has been done with blue jeans, she added some stitching on the pockets, made them a bit more form fitting and, thus, more flattering; creating a product that has allowed her to give up medicine and become a fashion mogul. Smart move with “healthcare reform” looming large on the horizon.

The other item of surgical clothing that lends itself to fashion statements is the surgical cap. These come in quite a variety of styles. Nurses typically wear the bouffant type, billowy and comfortable. Other types are the tie around skull cap and surgical hoods. Most male surgeons favor the tied skull cap, while personnel that sport beards usually opt for the improved coverage of the hood. Many of our nursing personnel make their own head covering, adding a touch of color or whimsy to the usual drab d├ęcor. Personally, I am in the minority of surgeons it seems, because I prefer to wear the bouffant style of head covering. Besides the superior coverage which, theoretically, will decrease the risk of contaminating the operative field, these hats are more comfortable. Never sacrifice comfort for style.

Of course, there is more to surgical fashion than scrub suits and caps. Consider our patients. Certain bodily adornments are unique to the surgical patient. In particular, wound dressings, drains, scars and the ubiquitous exam gown embellish the surgical patient.

Modern surgery has evolved to its present state of ambulatory procedures, short hospital stays and rapid return to normal activity. This is all for the best and, ultimately, improves patient outcome. But, a consequence to these advances is the necessity to send patients home with freshly dressed incisions, surgical drains and sometimes open wounds that require daily care.

In the old days, circa 1980, surgical patients remained in the hospital until they had enough time to enjoy significant healing. Specifically, it was routine to keep the patient in hospital until any and all drains were removed. This could mean overnight or two weeks. Indeed, it was a frequent response at surgical conferences, when asked why a patient was still in the hospital, to answer that they still had a drain.

Times have changed, however, and patients routinely are discharged after their outpatient laparoscopic cholecystectomy or removal of soft tissue mass or breast tumor with some sort of drain. These are almost always of the class called “closed suction” drains, a fenestrated or perforated plastic end that sits within the operative site connected to another plastic tube that is tunneled under the skin and exits through an opening in the skin at a location some distance from the wound. The tunneled tube is connected to some sort of self suction apparatus; commonly a hollow bulb that is squeezed flat and provides a source of suction as it recoils to its normal state. Such a drain removes fluids that would otherwise accumulate in the surgical and wound and helps promote proper healing.

However, the patient is left with a dilemma, of sorts. How does one carry such a device in a way that is inconspicuous, functional and comfortable. At least the designers gave a bit of thought to this problem. The collection bulbs (what I call the “hand grenade” because of its shape) has a tab around its neck that allows it to safety pinned to an article of clothing. So, most commonly the drainage system is pinned to a shirt or some other article of clothing or put in a pocket, often discreetly visible but not particularly noticeable.

Some patients are far more inventive. A favorite of female patients, particularly those that are amply endowed is to stuff the drainage bulb into their bra. This keeps it well hidden, but also makes for some adventurous searching on rounds or in the office when it is necessary to check the effluent for quantity and quality. Similarly, male patients will occasionally carry it in their underwear; this works best with briefs rather than boxers.

Wound dressings generally require little attention and are rarely subject to invention. Most often they are white gauze and tape, left in place for 48 hours and simply removed. However, open wounds may require that the patient wear the dressing for weeks and sometimes months. Surgical gauze can be expensive and many patients opt for low cost alternatives. The most common is a feminine hygiene pad of some sort, sterile, absorbent and well suited to the task. Understandably, these are usually utilized for wounds that are out of the public eye.

Alternatives include cloth towels of variable cleanliness, paper towels, adhesive tape by itself and frequently nothing. It is remarkable that so many wounds heal perfectly well in spite of the lack of attention they receive; a testament to the wonderful healing capabilities that are built into our bodies.

Finally, there are exam gowns; a garment that is designed for only one purpose: to make the wearer look and feel as foolish as possible. Hospital gowns are designed with a variety of ties and snaps purportedly to make it easier to examine the patient. But, it is commonly witnessed that these gowns can cause the most learned academician’s blood pressure to rise as he struggles to undo the numerous ties which are invariably knotted and usually lead even the most rational doctor to rip or cut the offensive garment and then exclaim “I guess the hospital can send me a bill”. For the patient the gowns leave them open and exposed and many will sport two to provide complete coverage and not to reveal their “assets” to an entire ward.

In my office we have paper gowns, cheap, somewhat cumbersome but adequate. These gowns do have one unique feature. They come with a plastic “belt”. I think that this belt was designed by a runway model as it is only about twenty four inches long. Usually I find it on the floor of the exam room, sometimes the patient will be holding it with a very confused look on his or her face. Once in a while someone will actually try to put it on and one creative man tied it around his head, similar to a famous painting, a trophy to the scars he had suffered in the course of his surgery.

So the next time you watch celebrities queuing up on the red carpet, being interviewed and asked “who are you wearing?” think about the fashion statements made by the medical profession, perhaps not very glamorous, but certainly creative.