Hey, I finally wrote a post for "My First Time" What? You mean there was a deadline?!

Last weeks' SurgeXperiences theme, hosted by Jeffrey MD, (excellent job, Jeffrey!) was "My First Time". As usual, I missed the deadline, partly because deadlines make me anxious, but mostly because I could not think of a single "first" that I thought was memorable enough to blog about.

Having been away on vacation for 9 days, I have been refueling my obsession and passion for the OR by reading "Top Knife" The Art and Craft of Trauma Surgery, by Dr.s Asher Hirshberg and Kenneth Mattox, actually/finally studying for my Sept. First Assist certification test, spent a few hours one afternoon hanging out in the ER near the ambulance bay and the trauma rooms while under the guise of waiting for one of the Orthopods I work with to come and examine a patient, (Discovered an ER doc I wouldn't mind knowing better!) and catching up on "Hopkins". If you have not seen "Hopkins" it is about the Johns Hopkins hospital in Baltimore. It isn't fiction, the stories and patients are real. They focus on both the ER and OR but it seems to me that they favor the OR which is awesome for me. I missed the network airing of the series(?) but all episodes in full can be found on the ABC website.
Every episode that I watch causes me to swell with pride and tear up. How can anyone not love a surgeon!? Heart transplants, brain tumors, dissecting aortas from arch to abdomen! My adrenaline starts pumping and I get all jacked up for the OR! I sit here at home, on call, and will the phone to ring with a surgeon on the other end.

My point is.....while watching the opening credits on "Hopkins" one surgeon reaches across the operating table at the end of a case and shakes the hand of his assistant. And then, suddenly I realized what "My First Time" should be about.

I used to scrub exclusively on the swing shift for the gynecology oncologist whenever he had a line. His operations were not typical gynecology procedures. While he did some simple hysterectomies and oopherectomies, they were for cancer or suspicious tumors. His big cases were modified posterior pelvic exenterations, often with node sampling, and on occasion, urinary diversions and ileal conduits if the exenteration was anterior as well. All of his cases are by referral only and so very often, the referring surgeon is there to assist. As I have mentioned before, the almost psychic rhythm between a surgeon and an assistant is magical. As a scrub, I often shared this same magic with this particular surgeon. You hand him the right instrument, at the right time, in the right manner without a word passing from either ones lips. This interpretation/anticipation becomes second nature, yet I always recognized the thrill of it.
So, on with the story. At the end of a particularly long case, the Gyn/Ong surgeon reaches across the OR table and shakes the hand of his assistant surgeon. "Wow, that was pretty cool." I think to myself. That was the first time I had ever seen anybody do that. I began to observe the actions of other surgeons and noticed that the hand shake doesn't come that often. It is reserved, it seems, for long or difficult cases, or long and difficult surgeries perhaps. A surgery where the primary surgeon is very thankful for an assistant.
As I made the transition from scrub to first assist, I never forgot about the rare handshake. I fumbled along through my provisional cases required by the hospital before I would be granted assist privileges. Just when I would think that I was getting the feel of things and feeling fairly confident, I would make a rookie mistake, or freeze when asked to hand tie a suture. I took a lot of ribbing and criticism from my main preceptor but I paid attention to everything he said. Active privileges granted at four hospitals and about 15 months under my belt later, I was assisting my F.T.S. (favorite trauma surgeon), on a somewhat difficult bowel resection. Extensive adhesions make dissection on somewhat distorted anatomy very tedious. The patient was also obese which means a lot of tissue that is tougher to retract (and keep it there) and a deep abdomen in which visualization isn't always easy. To top it off, the patient was male which translates to a narrow pelvis, making mobilization and resection of the sigmoid colon more challenging. I think I did all of the right things that day. I had finally found my rhythm. Providing traction and counter-traction was intuitive. Clamps were effortlessly being released with my non-dominant left hand. Suction was right where my F.T.S. needed it, when he needed it. Manual traction with a lap under my outstretched, slightly fanned out fingers protecting healthy bowel from electrocautery was unwavering until it was safe to move. And as we were finally closing, it felt good.
As I sometimes do, while mindlessly following the looped PDS suture as the surgeon closes the abdomen, I rehearse the procedure that has just been completed, looking for weak spots in my technique so that I may improve them next time. I am a bit in my own world as the dressings are called for, and I am brought back to reality as my Favorite Trauma Surgeon extends his hand across the table. To me! I look at his hand for an ever so brief second and it registers that he wants to shake my hand. Suddenly afraid that the moment will pass and he will withdraw the gesture, I slap my hand into his palm, perhaps a bit to eagerly, and accept the rare handshake that I have long awaited. As I blushed behind my mask and he broke scrub, I could barely contain the exhilaration of that first time handshake.

Filler and Fluff

Got distracted with this test.....hope the assassination victim doesn't pan out.

What Famous Leader Are You?
personality tests by similarminds.com

Home again.

Made it back in one piece. I drive everywhere. The highways were noticeably uncrowded this trip. It was me, truckers, giant expensive bus conversion RV's, a few u-haulers (the most dangerous species on the road), motorcycles and a spattering of mostly fuel saving cars with license plates from the state we were in or one state away. There are some advantages to the fuel prices.

I only had one OR related dream. I was on my way to the hospital. I wasn't sure what I was going there for, but I knew I was late. My cell rang and I answered it with, "I'm on my way!" It was the vascular surgeon that I was apparently on my way to assist. He ignored my salutation and proceeded to tell me all of the special equipment, thrombectomy catheters, shunts, grafts,etc. that he would need for this case. I was still driving, didn't recognize half of the stuff he was rattling off and had no way to write it down! I felt a little panicked but there wasn't much I could do but say OK and hope for the best.
Next scene I am in the OR and the patient is a male friend of mine. Not too bad except we seem to be doing a bilateral inguinal hernia repair, or so I think. I don't really want to see my friends "junk" so my dreaming psyche resolves that by having his testicles selectively draped into the field but I don't recognize them as such because they are neatly butterfly filleted! To top it off, he is awake, propped up on both elbows and conversing with me about ?? I don't remember.
Well, at least I didn't contaminate everything.

Vacation! Well sort of, away from my business of assisting for a week or so anyway. It actually stresses me out to be leaving. I'm packing about four Trauma/Surgery/Review books with me for some bedtime stories. About four days out, I'll be craving some O.R. action. On about the sixth day, I will be in actual physical withdrawals. Maybe another glass of wine on the back deck at sunset will help them go away.
I will probably dream of being scrubbed. That usually happens when I don't work for a while. I just hope it's not that horrible recurring dream where no matter what I do, I can't keep from contaminating the sterile field. That one really wears me out.
Call schedules won't come out until after I leave so at least I won't be squirming over who's trauma call I'm missing. There are several surgeons gone all or some of the same time frame that I am, so I probably won't be missing much. Still.....
When I get back, I'll work on finishing my long winded novel that "Path to SFA" has become. See y'all soon.

Meanwhile, back at the ranch...

My ortho docs are off passing their boards. The state of the economy has slowed my business. No, the surgical assisting business is NOT recession proof. Resistant perhaps, because traumas and emergencies still happen, but elective surgeries decrease and partners assist partners and my services become unnecessary. But the gods smiled upon me these past several days and I had the ultimate pleasure of working with my favorite trauma surgeon. Truth be told, he is my favorite surgeon, period. (Please don't tell my ortho docs!)
It started Sunday afternoon while he was on ER call, which means general surgical cases from the ER are referred to him. First case, a perfed (perforated) viscus at the jejunum. Fairly straightforward repair with a patch of omentum thrown over the top for added strength and healing power. He complimented me on having quiet hands. I was flattered.
Early Monday morning, 0500 early, another perfed viscus, this time of the duodenum. Another repair incorporating an omental, or graham patch. That same afternoon we had a previously scheduled case together, splenectomy. We were finished around 1700. It was an excellent case and I was honored that he had chosen me to assist. Somewhere in the middle of the case one of his partners who had been operating at the same hospital came in to announce that they were done and asked how it was going.
"Got some bleeding right now."
"Do you need a hand?"
I was concentrating on providing him with exposure but I was still aware of the conversation. I usually dread hearing that particular question because most often the surgeon will say, sure, if you want to. After all, they are peers, colleagues and there is a professional courtesy or protocol of sorts, and I sometimes feel like an accessory. Of course, I will always defer to another surgeon, especially a partner in the same group, but he has never traded me in.
He simply did not answer because he was concentrating and I was aware that his partner had left the room. When we were in recovery, he complimented me for being attentive during surgery and made a point about what a difference it makes when the assist actually cares about the surgery at hand. I knew that he was referring to not losing concentration when we had encountered bleeding. Coming from this surgeon, whom I respect so much, I was honored.
He was on trauma call Tuesday, and he asked me if I wanted to assist him on Wednesday. He had two cases, a lap chole and a small bowel resection. He forewarned me that he thought they were both Medicare patients (that means I don't get paid), but I jumped at the chance. After all, I had nothing better to do and I don't often have the opportunity to assist him so many days in one week.
The Trauma Gods brought us together again Tuesday afternoon. A fall from what and how high, I don't know, but it was enough to tear the patients mesentery, fill the abdomen with blood, and necrose a portion of the small bowel. The resection of the dead bowel would have taken less time had the patient had not been on long term steroids and blood thinners. That combination causes the tissue to become very friable and therefore more susceptible to bleeding and the bleeding more of a challenge to control. In fact, who's to say that the injury would have resulted from the fall at all, had those two factors been absent. With skill, gentle handling and the blessing of hemostatic agents, a very stable patient was delivered to ICU two hours later.
There were no more surgical traumas that night so we met again on Wednesday. Our lap chole was not so easy, a large, stone filled, edematous gallbladder and some variant anatomy made dissection tedious. Even after decompressing the gallbladder, pulling out some 45ml of dirty brown fluid resembling 30wt motor oil, it was still taut and difficult to grasp, but in the end, the gallbladder always loses.
Our final case of the week together was a small bowel obstruction. Often an obstruction is caused by an adhesion wrapping around the bowel narrowing the lumen and stopping flow. Or, the bowel may adhere to itself and cause such an acute angle that obstruction occurs. This patient had a combination of both. The bowel had adhered in the pelvis and had turned itself around so that it was twisted shut, sort of like the beginnings of a balloon animal. A short distance from that adhesion was another side to side adhesion that, despite blunt dissection attempts, refused to let go of itself. A small bit of bowel had to be resected and reanastomosed and before I knew it, my four days with my favorite surgeon were over.
There is a certain harmony between two people who work closely together for an extended period of time. As an assistant, you don't have to be told what to expect, what to do next, or what the surgeons next move will be, you already know and you act and react without thinking about it. In the operating room, it is a dance of sorts, and when you click, when you work well together, you begin to know each others moves by instinct. The choreography is perfect, flawless and smooth as silk. It is a high unlike any other.

Path to SFA Chapter Four

photo credit
prelude here
one here
two here
three
My job as unit clerk was right up my alley. They had always been without one and there was a lot of organizing to be done. With my OCD tendencies, I became the organizer. I created new charge sheets. I organized bookshelves. I rearranged the desk. I retyped surgeon preference cards. I tracked scheduling. I became the keeper of the grease board. Oh yes, and I entered surgery charges.
The keeper of the board was serious business for me. "The Board" is usually a dry erase, magnetized white board. You can write directly on it, but most often there are magnetized strips about two and one half inches tall by two feet or so long, that you write the case information on and then stick the strips on the board. Case info might include the time, patients initials, the surgeon, the procedure, and if there is any room left over, special equipment requested for the procedure. Then the strips are arranged in descending order beneath the operating room number in which the procedure will take place. Since this was a small rural hospital with a minimum of services and surgeons, our strips were color coordinated to the service. Yellow for ortho, green for general, red for the g-y-n. The board was my baby. Without saying anything, everybody knew that they were not to write on my board! If someone attempted to write an add-on strip and I spotted it, I would erase it and rewrite it. If someone had some information they wanted to write on the board for everyone to read, they handed me the info and let me transcribe it. I couldn't have mismatched handwriting on my work of art.
While I didn't really have time to observe surgeries, I would have an occasion or two to peer through the door for a brief glimpse. Thing is, you can't see a lot through a window, just blue gowned bodies hovering over a blue draped patient. If the case happened to be laparoscopic or arthroscopic, you could see what was taking place on the video monitors. As a first time spectator, what was mundane for others was way too cool for me, even though I wasn't sure what I was looking at. I knew that at least for me, surgery was never going to be a spectator sport. I kept dreaming of the day that I would become a participant.
As time went on I began to feel as if I fit right in with the crew. I was invited to the OR meetings. Okay, it was to take notes of the meeting, but it was still an invitation and I felt like an insider, no longer an outsider begging for entry. And then, on one glorious day, the pale warmth of an early winter morning illuminating the room, the announcement came.
One of the surgical techs was reluctantly relocating due to a change of venue at her husbands' job. I held my breath. The OR manager assured the remaining techs that she would search for a certified tech or at least someone with experience to replace her. My heart sank. I exhaled. I literally wanted to cry. The consensus was that they really did not want to go through the process of training another tech. It would take six months before a trainee would be ready to take call and then that would be with back-up. That meant six months of extra call for everybody remaining. An experienced new hire could be taking call in as little as six weeks. The meeting adjourned and in between the hugs and tears for the departing surg tech, I cornered the manager and begged to be trained if her employee search failed to produce any qualified applicants. I hoped that time was on my side.

Path to SFA . Three

prelude here
one here
two here
I was so enthralled with the OR that I knew I had to find a way in. I spoke with the surgical techs and found that they had been in a fast track program where they basically had to take five classes, have a certain amount of clinical cases, and then they could test to become certified. I knew what the classes were at the time, but I have forgotten them. The rules were changing anyway, and it would be too late for me to begin. Besides, the program was designed for on the job trained techs who were already scrubbing and I was not. Three of the four techs scrubbing there had been OTJ trained. That sparked my hope.
I hounded the OR manager every week to ask her if there were any positions open. I practically insisted on being the next one hired. I noticed that her trips to the business office to discuss charge issues with me were diminishing. Circulating nurse were showing up in her place. One afternoon as I leaving work, I saw her on the sidewalk ahead of me. Anxious to inquire and remind her one more time that I really wanted to fill that future job opening, I shouted her name and trotted up behind her. I swear I saw her pace quicken, and her head bow a little lower as she tried desperately to avoid me. It was then that I realized that she must have thought that I was more of a stalker than a eager prospective employee.
In the week or two that followed, the OR manager I had worked so hard on to hire me, was leaving the hospital to take a position elsewhere. I was discouraged and a little shocked. What do I do now? Who will be the new manager? Will he or she be receptive to training new scrubs, or would they insist on hiring someone with experience? Would he or she also think I was a stalker? In the back of my mind I wondered if my "stalking" led her to the decision to relocate. In the end I decided I probably didn't have that much power.
As is often the case, a setback ultimately becomes an opportunity. The new OR manager was not a stranger, but rather one of the RN's from the OR. She already knew me and my obsession. While there were no scrub openings yet, she had been working on creating and gaining approval for a unit clerk for the surgery department. Almost one year exactly from my beginnings in the business office, I transfered to surgery as the new Health Unit Coordinator, or HUC for short. It wasn't scrubbing, but it was my big foot in the door and I was overjoyed!

Path to SFA Two

prelude here
one here

It was so frustrating to get answers from the OR regarding their charge sheets, I suggested to my boss that it would sure be easier if I were in the OR when I was entering charges. If I had a question, someone might be able to answer it that day, not two or three days later, and that would ultimately keep pending claims current. I also suggested to her that if I knew just what exactly these UFOs, or Unidentified Foreign Objects, were that I was charging for, it would really help me to identify missed charges. A business office manager is all about capturing income and keeping AR current so it didn't take long before she had arranged a deal with the OR manager. I would go up there for two hours a day to input OR charges. But first, she actually suggested that I watch a surgery take place. She reasoned that if I saw the equipment and supplies being used, I would be better able to identify them and their applications. Besides, even outside of the OR, sitting at the desk, one can be engulfed in the sounds and smells going on behind the door. Even that amount of exposure is not for everyone. I don't believe she knew just how many worms were in that can she just opened.
I was elated at the chance to watch a surgery! The crew picked one out for me, a carpal tunnel release, had heard of it, not really sure what it entailed but it sounded non-exciting for sure. On this particular day there was to be another observer, an occupational therapy student. After the patient was prepped and draped, we were allowed to enter the OR. We were both given the routine instruction.....stay at least six feet away from anything blue, if you want to move somewhere else in the room, ask first, if you start to feel lightheaded or queasy, sit, or ask to sit down immediately, if you have to, sit on the floor and lean against the wall, don't be a hero, it's okay, it happens to a lot of people.
The surgeon made his incision and explained each step, showing off for his audience as some surgeons do, and all I wondered was, where is the blood? It is such a small incision, I can't see anything! Yeah, whatever, yada, yada, yada, is there another surgery I could watch later? Meanwhile, there was a commotion behind me. I turned to see the O.T. student being lowered to a chair. The nurse was standing next next to her asking her if she was sure she was okay? Did she need some water? Did she want to leave? I thought that she looked sorta' green and turned my attention back to the surgery. Yep, still no blood, still can't see, what a gyp!
Somewhere along the way the O.T. student had decided that she really did want to leave. I hadn't noticed until the surgeon asked, "What? Who left? The OT student?"
HA! What a wimp! It felt like a victory for me even though it was a very benign surgery even to my inexperienced standards. And from that day on, I was hooked.

photo credit

Path to SFA, Part one

I have always hated hospitals. My mother died in one about 24 years ago. I didn't like the smells, the perceived secrecy, even when it came to my own Mother's care. When I would ask her Dr. questions, he would all but snap at me, "Why don't you ask her!?" Guess he didn't realize that asking and answering wasn't something we did in our family. And no, HIPPA wasn't invented yet, besides, I was family. But I am getting off track.
As much as I had professed my hatred for hospitals, imagine my surprise when some 13 years later I found myself actually applying for a job in the business office of local hospital in the small wild west town I was then living in. I already had a great paying job as jobs went in that small town. I was making good money at a local auto dealership in the finance office. In fact, I was the F. and I. guy (gal). I was "promoted" from parts dept. where I had been very happy. Selling finance and insurance just felt sleazy. I was always honest with customers and never pressured them into decisions which is why selling is just not my forte'. If they say no, I say okay. It would become the end of my life long affiliation with mechanics and parts and dealerships.
I saw the ad in the local paper and applied. The hospital business office manager was new to this hospital and I found her a bit wacky. Full of nervous energy, somewhat attention deficit perhaps, but very personable and honest, she laughed at things that apparently only she found the humor in and I liked her immediately. My interview went well but I didn't think much of it. I really had absolutely no experience in all things business as it pertained to hospitals. The next day she called and asked me when I could start. I gave the dealership two weeks notice and so, in that fall of '98, began my hospital career.

Two of us were hired at the same time for the business office. On the first day we were shown to the data room which was inside the business office but it was a separate, rather large room that housed a couple of desks, computers, a long table with a monstrous printer fed by a box of folding perforated green computer paper, file cabinets, a modern copier/printer, and a good old fashioned AS400 operating system. Once we were there, the manager shut the door and we never saw her again that day. We both wondered what we were hired for. She had told us both that we would be doing data entry. We sat there most of the morning not sure what to do. We had been given no instruction. Eventually we organized and cleaned the long neglected space and found some filing to do, but mostly, we just sat in that room and conversed for almost three days before the manager actually showed us our tasks.
My office mate moved to her own desk amid the cubicles of the main office and became a Blue Cross B.S. (stands for bull shit but they hide behind blue shield) billing clerk. I remained in the data room which I now shared with the hospitals' I. T. guru. (We became and still remain great friends). I became responsible for charge master maintenance, printing daily reports, downloading Medicare claims, sending electronic claims, and doing the nightly billing backup run. Some where along the way they decided that it would be okay for me to reconcile the hospital bank statements every month. Oh the joys of a small town business!
My favorite job was entering patient charges. I would receive charge sheets from all the departments and enter them into the system which would ultimately become a patient bill. I had to be a bit of a detective and spot any missing charges. For instance, an inpatient on the floor who was post operative should have a MAR (Medication Administration Record) sheet, an OR patient who had a rotator cuff repair should have a charge for a shoulder immobilizer, and so forth. Since charges were still recorded by hand on a paper charge sheet by each individual dept and then sent down to my in-box, there was a lot of room for human error and forgetfulness. I became the charge police.
The OR became my fascination and obsession. Their charge sheets were the most complex and challenging considering the foreign language contained therein. Bair Hugger, what the heck is that? Corkscrew, really, a corkscrew? Cyro cuff? Bone plug? Insufflation tubing? Just what are they doing up there? I would have to make several phone calls to the OR several times a day to get answers to my many questions and often they would be so busy that it might be two days before anyone could get back to me. So much was my fascination with what went on in the OR, that I planted a seed in the high speed, somewhat disordered brain of my boss and sat back and watched it grow.

My path to Surgical First Assist, the long version. Prelude

I've been a big blog slacker lately. Can't blame it on house hunting anymore. Remember the house I found? Well I seem to have serious commitment issues......have I mentioned that before? After inspections I felt that there were too many do-it-yourself non-permitted revisions and add-ons that I didn't want to deal with. Truth be told though, I think it was the financial implications that subconsciously made me nauseous. Anyway, that deal is off and I've decided that now is not the time for me to buy, perhaps next spring. The economy is way to scary right now and I believe that housing will actually be even lower next year.

But enough of that. A while back someone posted a comment asking me the following, "....I went back a couple of posts .....and saw that you are not an RN, PA, MD or Scrub Tech. I was just wondering what route you took to become a first assist? "

Well, it has only taken me about six weeks to answer but here you go. I am a Surgical Technologist-Certified. That is the minimum you must be to go on to assisting. That is the short answer. Since I have long been contemplating blogging about my personal path to First Assist, what follows in 2 ?, 3 ?, parts, is the long answer.