Just like what you see on T.V.? No, I think not.

A real OR is not like what you see on Grey's Anatomy. We don't spend hours in between cases sitting around chatting about our lives or hooking up in On-Call rooms. Our job is not that much different then yours. We have scheduled surgery's that we try very hard to complete on time. Our turnover time between cases is short-we have maybe 15 minutes to clean the room, pull in the supplies and equipment for the next cases and get setup. It's not a gravy job by any means.

This past week has been particularly challenging for me. Maybe it's because this is my last week of being on the morning shift. I'm not at all a morning person so getting up at 5am to be at work at 6:30 is not exactly ideal for me. Next week I start working the 3pm-11pm shift which I'm very much looking forward to. So it very well could be that I'm just done with these early mornings and it's making me drag a little knowing I just have a couple days left of it. Or maybe the stress of working two jobs for the last six months has finally caught up to me. Either way it's been a difficult week.

Every day I've been in a different service and most of the procedures have been fairly new to me. That in itself is pretty stressful for me. But I've also been with some pretty demanding doctors. Don't get me wrong, they're great doctors. But they've been very fast paced and very particular. Normally I'm really good with these kinds of doctors. My attention to detail is always on point, I'm very organized,and my technique is very good. All things doctors like in a tech. But it's all just added to my stress level so I've been pulling my hair out a little.

Yesterday I spent the day in ortho. My first case of the morning set the tone for my day. It was a knee arthroscopy which is a pretty simple procedure. The doctor makes a small incision in the knee and inserts a trocar into the knee.

A scope connected to a camera that transmits the video onto a tv screen is inserted into the trocar so we can see what's going on inside.

This is much less invasive to the patient and we can fix a lot of problems without having to open their leg up completely. When I've previously done knee scopes it's been with a doctor who has a PA (Physicians Assistant) with him so there wasn't too much for me to do. Yesterday I was working with a new doctor and it was just me and him. This meant that I had to perform my job and the job the PA usually does.

What does the PA usually do? They have to hold the leg in very awkward and unnatural positions so that the doctor can see in all the nooks and crannies of the knee. It's a labor intensive job under the most ideal circumstances. Yesterday was not under ideal circumstances. The patient's leg was pretty big and the doctor was having a hard time seeing the problem area. Which meant I was holding this leg very high and pulled to one side very tightly for a good hour. My arms were shaking by the time we had finally finished and I was exhausted. It was only 9 in the morning. And for the rest of the day he was moving so fast-I don't think I sat down until 1pm. By 3 my arms felt like Jello.

On Tuesday I was on GYN service. I really like GYN surgery so I was excited. The doctor I was working with is pretty great but he likes to move very quickly. So for him it's important that you plan ahead as much as you can and have all the equipment and supplies at your fingertips. This makes for a tiring day simply because you don't have any down time. But all was going well until around 1pm. That's when a newer doctor came into the room to assist him. The surgery was routine and towards the end the newer doctor put in a Foley catheter and asked me to hook up the drainage bag. "Of course, no problem." A couple minutes later she says, "Oh, I have to unhook that drainage bag for a second." Um...okay go for it. I wasn't paying too much attention to what she was doing because I was trying to keep the table running smoothly.

I looked up just in time to see her struggling with the bag. Instead of just unscrewing she was trying to pull it apart. Then she figured out to unscrewed but she was still pulling so when it came apart pee flew EVERYWHERE. Including in my face and worse, it got behind my eye protection and directly into my eye. Oh yeah, pee in my eye.

I freaked. And yelled (but only a little). And as I'm breaking scrub to run to flush my eye out the original doctor says to me, "Lisa, you better hurry up and flush that out! You don't want to get a UTI." (Get it? UTI. U-T-EYE) Yeah, he thinks he's pretty funny.

They don't show that on Grey's do they?

Always,
Lisa Marie

Rules- made to be broken or good to follow?

Before I write my next full length post I wanted to take a second to share with you guys something I think is pretty important. So here's a  short post to tide you over.

Every patient that comes in for surgery gets a list of things that they need to do to prepare for their procedure. Depending on what the procedure is it might be to temporarily stop taking certain medications, they may need to bathe with a special soap, or do a bowel prep (drink some nasty tasting stuff so that they poop alot). But there is one preop rule that you can count on being there. If your procedure requires general anesthesia you will be require to be NPO (nothing by mouth) for at least eight (sometimes twelve) hours before your surgery.

NOTHING by mouth. Nothing. No food or drink (not even water), no chewing gum, you're not really even supposed to brush your teeth. Why? Because whenever you put things in your mouth that sends a signal to your brain that you need more gastric acid in your stomach to aid with digestion. That's a bad thing when you go under general anesthesia because there is a real risk that the breathing tube could trigger your gag reflex and cause you to aspirate (breathe in) the contents of your stomach. That's bad news folks.

We don't tell you can't eat or drink to be mean or to torture you. We tell you that to save your life. So it's important that you follow the rules and even more important that if you break them you come clean about it. Yeah, it's probably going to delay your surgery for a few hours and you still won't be able to eat but at least you'll be alive.

Yesterday I was working in pediatric dental surgery. The kids that come through are very young, a lot of times under six, and need to be under general anesthesia so that we can fix or pull their teeth. Because the patients are so young we have to rely on the parents to make sure that the rules are followed and we trust that they will be honest with us.

We had done three cases and was about to start our fifth when a preop nurse called into the room with some news. She had caught our next patient drinking out of the water fountain. Uh oh! So the doctor went to talk to the mom and tell her that we would have to postpone the surgery. The mom was outraged and said "Why is the water such a big deal? I mean, he had a bag of chips on the way here!"
Oh really? Well in that case the surgery is cancelled. And the mom just couldn't understand why we were being so strict and mean. I'm sure it must be hard to not feed your kids when they're hungry but eating before general anesthesia could kill them. We don't just tell you not to eat because it makes our job easier.

So please listen carefully to all the instructions your doctor gives you before surgery. And if you slip up, come clean before hand. It could save your life.

A Lesson in Pallative Care

~Warning- some pictures in the following post may be considered graphic~

When you really enjoy what you do for a living it doesn’t always feel like a job. Sure, the early mornings can be killer and there are some days that you just wish you could go home and never come back. But if you have a real passion for your work the majority of your days are filled with a sense of accomplishment and pride.

Being a surgical tech is one of the most rewarding things I’ve ever done. It’s not glamorous and it’s not full of recognition. But every day I know I helped make a difference in someone’s life. Maybe I helped relieve their pain. Maybe I assisted in giving them back their range of motion so now they can play with their grandchildren. Or perhaps I helped perform an emergency surgery that saved their life. The patient often has no idea who we are and the only part of our face they see is from the eyes up. But that’s okay because when they wake up from their surgery they can hopefully look at the faces of the people they love and know that they’re going to be just fine.

Sadly though, that’s not always the case. Sometimes we can't cure what ails them. And the only thing left for us to do is to try to improve their quality of life and give them the most pain-free time we can give them.  This is called palliative care.

 I first heard of this back a few years ago when my grandfather suddenly got sick. My family and I waited for days in the hospital waiting room praying that the doctors would be able to give us good news. But it never came. We had two options. Keep him on life support or realize that he lived a full life and let him pass away peacefully with no pain. I can tell you that it was the hardest decision our family has ever had to make. You never want think that there is no more hope. You never want to give up because what if……..but we knew it was the right thing to do.

What television and movies don’t tell you is that when you take a person off a ventilator they don’t die instantly. By any means. So the doctors told us that they were going to move my grandfather to the palliative care floor. There he would be given a practically endless supply of pain medication and they would simply continue to care for him but no live saving measures would be a part of his care. It was the right choice.

In surgery palliative care means that we perform a surgery or surgeries that will alleviate a patient’s pain or will give them a better quality of life until they die. We can’t cure whatever is wrong with them, usually cancer. When you find out that you’re performing a palliative procedure on a patient, your heart sinks because you’re used to fixing people. The prognosis is usually good. But in these cases you know better.

Recently, I had a patient coming in for an exploratory laparotomy. This means that we make a long midline incision in the patient’s abdomen to expose the bowel.

Then we basically look around (not always knowing what we’re looking for) and try to find the source of the problem. For this patient it was gastrointestinal cancer.  In this case the cancer had metastasized to other organs and there was nothing else that could be done to cure it. The patient had already had a partial gastrectomy (removal of part of the stomach) but the original tumor was in her bowel and had grown large enough to cause an obstruction (blockage) and was causing her considerable pain.

Once we located the tumor (which turned out not to be too hard…it was the size of a softball) it was just a matter of deciding how best to proceed. 

The surgeon decided that the best outcome would come from a Roux-en-Y procedure. This is named after the surgeon who developed it, Cesar Roux, and the way the final product looks (the letter Y).

After clamping the bowel on both sides of the tumor we used a stapler to both close the bowel and cut it.

Bowel surgery is very delicate because the contents of the bowel are highly contaminated with bacteria and it’s very important that we don’t let it spill out into the abdominal cavity. Once both sides had been stapled shut and were cut we were able to remove the diseased portion with the tumor. Then it was just a matter of reconnecting the remaining portions of the bowel to what remained to her stomach and to each other.

All in all the surgery took about four hours to complete. It wasn’t easy and to be honest, I wasn’t entirely sure I was ready to scrub on it by myself but I tend to underestimate myself and did just fine. As a team we did exactly what we set out to do. We took out the source of our patient’s pain and gave her a little more time to spend with her family. That’s all we could do. But at least we did something.

Take the Good With the Bad

I’m going to start this post on my soapbox. Feel free to skip down a couple of paragraphs if you’d rather not hear it. But I feel like as a medical professional I have a duty to educate and warn people of the dangers of smoking. Since smoking ties into this post, I’m going to do it now.

Now it’s no secret that smoking is bad for you. We’ve known it for years. It even tells you directly on the package. However most people think that all those warnings and dangers are greatly exaggerated. I’m here to tell you that they are not. I’ve seen the damage that smoking does to a person’s body and it is NOT pretty! Here are some fun facts that I found at quittersguide.com:

90% of lung cancer cases are caused by smoking.

30% of all cancer fatalities are caused by smoking.

Lung cancer is the most common cancer associated with cigarette smoking but you can also get cancer of the mouth, bladder, kidney, stomach, esophagus, larynx and pancreas. Some of these cancers can be treated and others are 100% fatal.

Cancer isn't the only disease that smoking causes - either directly or indirectly. 75% of all fatal cases of emphysema and bronchitis are linked to smoking. Both of these diseases cause extreme breathing difficulties and emphysema in particular is an extremely nasty disease as your ability to breathe on your own slowly vanishes.

Smokers have dramatically shorter lives than non-smokers. On average a smoker will die 15 - 20 years before a non-smoker. This is truly shocking when you think about it. That's 7,300 days deducted from your lifespan. Look at what you can achieve in a single day and then imagine what you might be able to achieve in over 7,000 days.

Okay, I’m done with the lecture. On with the show.

The other day I started my rotation in ENT (ear, nose, and throat) surgery. To be honest, I wasn’t very enthused about it because in my little experience I found it to be a little on the boring side but also kind of difficult because there are thousands (okay that may be a slight exaggeration) of specialty instruments. But I want to be able to do as many surgical services as I can so I was determined to master ENT.

The bread and butter of ENT surgery is myringotomys (insertion of ear tubes to assist in the drainage of fluid) and T&A’s (removal of the tonsils and adenoids). Both of these procedures take less than twenty minutes and are not considered sterile procedures. These are called “clean” procedures. The instruments and equipment are sterile and we wear our sterile gown and gloves but the mouth and ears are not sterile areas of the body so our sterile technique is more relaxed.

So I thought that a day in ENT would be more stress free than what I was used to. And if it had just been ear tubes and tonsils I would have been right. But nestled right in the middle of my day full of children with chronic ear infections and sore throats was a man with a tumor running down the entire left side of his throat. This is where my day turned really, really bad.

The patient was a 44 year old male who smoked at least a pack and a half a day. The cigarettes had really taken a toll on his body. Like I said, he was in his forties but he looked easily sixty or seventy. His skin had aged prematurely.  His teeth and fingers were stained with nicotine and he had a chronic cough. He also had trouble breathing due to the enormous tumor in his throat. We didn’t know yet if the tumor was benign (not cancerous) or malignant (cancerous) but we suspected it was cancer caused by his many years of smoking. The tumor was growing and the bigger is grew, the less he could breathe.

The plan for him was to snake a scope in his mouth and down his throat so we could do only get a good look at his tumor but to also take a biopsy of it to send to pathology so we would know what we were dealing with. In addition, if we felt it was necessary once we got a good look at the tumor we were prepared to perform a tracheotomy. The patient wasn’t thrilled with this possibility but the surgeon had told him on numerous occasions that it was just a matter of time before we had to do it anyway.

 A tracheotomy (also referred to as pharyngotomy, laryngotomy, and tracheostomy) consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea. The resulting stoma can serve independently as an airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe without the use of his or her nose or mouth. Both surgical and percutaneous techniques are widely used in current surgical practice.

I had never done a trach before so another nurse came into the room to assist. And it was just my luck that it was the one person I’ve come across in the hospital that I’m not fond of. This woman always has a bad attitude, her words just drip with sarcasm, and it seems her sole job is to point out everything I do wrong. Yay!

We never even got to the scope part of the procedure. When the anesthesia provider tried to intubate the patient, she ran into a huge problem. The throat tissue was so friable (easily broken into smaller pieces) that wherever the breathing tube touched fell apart and started to bleed. It also caused the throat to swell.

Our patient wasn’t getting any oxygen. Normal O2 (oxygen) stats are between 95-100%. His stats quickly fell to 80 and continued to drop. We needed to trach him and very fast. This is where things in the OR get scary. The surgeon quickly went to work.

There were three of us scrubbed in so there wasn’t too much for me to do but I was ready and willing to help out in any way I could. So every now and then when that favorite (or not) nurse was busy I would hand up an instrument or two as they were needed. But because of the state of the patient’s throat the doctor was having a very hard time getting the tube in. As a matter of fact, even he was starting to panic and told the nurse to run out to the desk and find ANY available surgeon to come in and assist. The patient’s O2 stats fell to 20%. This is when brain cells start to die. NOT GOOD!

There is one instrument that is crucial in this procedure. It’s the trach hook. You can’t do a trach without one. So when the surgeon looked at me and asked for the hook I reached on the mayo stand and picked it up with no hesitation and was ready to pass it…..

Until that fantastic (or not) nurse tried to grab it out of my hand. When she did she pushed the hook through my glove making the most important instrument contaminated. Our patient was in danger of coding and the one hook we had was now hanging off my hand. She started cursing and yelling. I stood there not knowing what to do. The surgeon (who is fantastic by the way) asked if it had cut me. I told him no that it had just puncture my glove. So he grabbed it and quickly completed the trach. At this point, the fact that he could have introduced any resident bacteria that was on my hand was the least of his worries.



After about five minutes of trying he finally got the trach in and it was hooked up to oxygen. His O2 stats finally started to rise and we were out of the woods. By this time though, I was so shaken that I broke scrub and just stood in the back of the room trying not to cry. I was just beating myself up. Why didn't I just stand out of the way? Why did I even scrub? Why didn't I just let that great (or not) nurse do all the work while I just stood there? I mean, in my head I could have been the cause of that man dying. Let me be the first to tell you that it's not a great feeling.

After the patient stabilized they ran the scope down his throat and did the biopsy as planned. We sent the specimen down to pathology and waited patiently as they examined it. They called into the room with their diagnosis- squamous cell carcinoma. Throat cancer.

After the case was finished the surgeon came up to me to ask if I was okay. I told him I was, just a little shaken. He pulled me aside and told me that I had done everything right. He asked me for the hook because the other nurse had solely decided that I didn't need to learn how to do one of those cases and that just wasn't the way it should work. It wasn't my fault and that I shouldn't take it so hard. Thank God for nice doctors!

I learned a lot that day. I learned that not everyday is going to be fun and that there will be days when I feel like all I did was mess up. But tomorrow's another day. And another day brings more cool surgeries.

Busy, Busy, Busy

Yes, I'm still here!! I know it's been a little while since my last post and I just wanted to take a second to assure you that there is more on the way. Between the job at the hospital and the one at the college I've been pretty swamped the last few weeks but I've been taking notes and writing down ideas for new posts. I am in the middle of writing a new one now so you can expect that in just a few more days.

Thanks for being patient and I promise the wait will be worth it!

Always,
Lisa Marie

Microbiology and Sterile Technique Part 3

Now let’s go back to the operating room. Like I said before, when our instruments and supplies come to us they are sterile. It’s now our responsibility to make sure they stay that way.

A surgical tech is the person who sets up all the equipment so we have to learn how to do that and keep it sterile. It’s called sterile technique. And commonly we are the only person in the room when we set up. So if we accidentally touch the sterile field before we’ve scrubbed, gowned, and gloved no one knows it but us. It would be easy to contaminate the field and just act like it didn’t happen. But that exposes our patient to infection so we develop something called surgical conscience.

Surgical conscience is what tells us to break down that setup and start over rather than risk infecting our patient. Our motto is “When in doubt, throw it out”. We don’t play when it comes to sterility because that could cost someone their life. So if we suspect something has been contaminated, if someone else tells us there’s been a break in sterile technique, or if we just aren’t 100% sure we will consider it contaminated and we will get a new one or start all over.



Our sterile technique starts before we even go into the operating room. We put on clean scrubs when we get to the hospital, we cover our hair with scrub caps, and before we open the sterile equipment we put masks on.



The first thing we open is our back table pack (which includes the drapes we’ll use, gowns, towels, and other sterile equipment) touching only the outside of the package leaving everything on the inside sterile. We open all our instrument sets, other sterile supplies, and our own gown and gloves the same way.



Once everything is open, we scrub. One of the first skills we learn in school is how to scrub. Scrubbing renders our hand and arms (up to two inches above the elbow) surgically clean. Not sterile. that’s important because it’s impossible to kill and the microorganism on and in our skin. That’s why we have to wear a gown and gloves.




We use sterile scrub brushes that are impregnated with either Chlorahexidine or iodine and we methodically scrub our hands and arms for five minutes. We are very careful to keep our hands about our elbows so that the soapy lather and water runs off our elbows. This keeps our hands and the cleanest part. We make sure we don’t bump against anything which would contaminate us. We rinse and back into the O.R. make sure our arms remain above waist level.





Then it’s time to put on our gown. The gown is folded so that when we pick it up we only touch the inside of the gown. This keeps the outside of the gown sterile. Our hands remain inside the sleeves of the gown while we glove ourselves. And if it sounds difficult it’s because it kind of is. It’s gets much easier with practice though.

Once we have our gown and gloves on we are considered sterile from waist level to nipple line and from our fingers to two inches above our elbows. Only the front of our gown is considered sterile because we can’t properly monitor our backs so we consider them unsterile.



Now we can touch all that sterile stuff that we opened before we scrubbed. But we can only touch that sterile stuff. So then it would be time to organize our back table and put all our instruments out. We also will be gowning and gloving all the surgical team members who will be participating in the surgery.

From here it’s just all about monitoring the sterile field we just created. It’s my job to constantly be aware of how close nonsterile people and things come to my field. And any extra equipment I need also need to be sterile. And this keeps up until the surgery is over and the patient has been stitched up and has a dressing over the incision site. Every patient, every time.

We don’t do this because it’s fun. We do it to protect our patients. So before you starting reading this blog you may not have ever heard of a surgical tech. But if you’ve ever had surgery you can bet you had a surgical tech looking out for your health and well-being. My job is a lot of fun and I get to see some really cool things, but I also have a lot of responsibility

MIcrobiology and Sterile Technique Part 2

Hopefully by now you all understand why it's our number one priority in the operating room to make sure all our equipment and supplies are free of microorganisms. And if you are ever a patient in the O.R. you'll really appreciate the work we do to ensure your safety. In this post I'd like to share with you the many processes we go through to ensure sterility.

Let's start with all the work that gets done in the Central Sterile department. Obviously when we get the instruments they've been sterilized already. We use them on a patient and send the now dirty instruments to Central Sterile (C.S.). The first step in the journey back up to the O.R. is obvious.....the instruments need to be cleaned. So they go straight to decontamination.

In decontamination each instrument is thoroughly cleaned using FDA approved cleaners, brushes, and specialized equipment like an Ultrasonic Washer. This is the most important step because if even one instrument isn't properly cleaned and there is bioburden (dried blood, bone, ect) stuck in a crack or crevice and it is put in a set and sterilized...the entire set is contaminated. If it isn't caught and that set is used on a patient, we are exposing that patient to all those nasty bugs we talked about.

This is an Ultrasonic Washer. It's filled with water and a detergent is added. When the washer is turned on it sends shockwaves through the water. This causes bubbles to form on the surface on the instruments and the bubbles lift the bioburden off the instruments.

After the instruments are hand cleaned they are put through a washer sterilizer. It's basically a big dishwasher and it cleans the instruments enough that they are safe to handle without gloves. From here, they go to processing.

This is a washer sterilizer.

In processing the instruments are double checked to ensure that they are 100% free of bioburden. After they've been checked, they get reassembled and put together as a set. They are either put into an instrument tray, peel packed, or wrapped. Then those packages are sterilized.

This is an example of an instrument tray.

This shows supplies being wrapped.

It's important to note that not everything can be sterilized the same way. Depending on the type of instrument, material, and other factors it may require steam, gas, or chemical sterilization. It is the responsibility of the people who work in C.S. to know which sterilization process is required.

Those are wrapped instruments that are being loaded into a sterilizer.

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After the sets have been sterilized they are stored until they need to be used again.

There are usually at least five people who handle the instruments along this journey back to the O.R. Don’t let this post fool you, it takes a good amount of time to get things through these process and the people who do it go through a lot of training to ensure that everything is done correctly. Chances are patients never see these people and they never think of what goes on behind the scenes. But I’m here to tell you, we would never be able to do what we do in the O.R. if it wasn’t for the work being done in Central Sterile.



I know I orginally said this would be a two part post but after I started writing this part I realized how much I had left to talk about. So there will be one more post to follow in order to finish up.