Oh, oh...

My c-spine film circa 1985
Well, I woke up Sunday morning With no way to hold my head that didn't hurt.
-Johnny Cash
I had undiagnosed, untreated whiplash somewhere back in the early eighties. They had me move my head through a range of motion, said, "Yup, you have a still neck." Gave me some valium and sent me on my way. The next morning I remember that I couldn't lift my head to get out of bed. About five years later, the chronic headaches started. Everyday, without fail. When I finally sought treatment films revealed a reverse curve in my c-spine. All these many years later I still have a fairly straight c-spine with just a hint of normal curve.

For about the last 5 weeks, I have had localized muscle aches and spasms along the right side of my neck annoying enough to interrupt my sleep several times each night. Monday morning I went out to feed and slipped on the icy packed snow, I didn't fall, but did a sort of chicken strut with my neck. By Tuesday morning, my entire neck was fairly stiff and sore. The case I posted about on Tuesday started at 1500 and we finished around 2200. Still I was no worse for wear. Wednesday had morphed into a full day, starting at 1100 with a laparoscopic right colectomy and ending at 1930 with an ORIF of a left ankle. The entire day my neck was killing me. Range of motion was now greatly decreased and pain and stiffness greatly increased. A "helpful" rad tech running the C-arm, poorly I might add, decided to adjust the OR light to help us see better. Unfortunately he is about 4 ft tall ( I am 6' o) and drug the light down to his level so as I stepped away from the field to switch places with the surgeon, of course I rammed the light with my head sending the jolt right down my already tortured c-spine. Lucky for him I was scrubbed in because my impulse was to pick him up by his neck and toss him across the room. I grabbed the light and sent it up to my arms length and focused it on the field from there. I made a very theatrical production out of it so that maybe he would notice? No, about ten minutes later the little bastard did it again! This time, at least I was aware of it. I ended the night with a raging neck ache and now unable to determine if the pain was muscular in nature or skeletal.

Thursday I had only one case at 0900 and we were done by 1030. My neck still screaming in agony. I had some errands to run before I could go home. I purchased a soft cervical collar. It hurts to hold my head up. One naproxen sodium the day before didn't touch the pain. One Daypro (okay they are about two years expired) the next day gave me about 1 hour of barely noticeable relief. When I got home I alternated ice and heat, ice bringing much greater relief than heat. I took two, 200mg, ibuprofen when I went to bed. I managed to sleep until 430 am when my neck would not quit screaming. I took two more ibuprofen and fell back asleep until 0930. Thank goodness I don't have any cases today.

The pain is a little more localized but no less intense this morning. It starts at the occipital on the right and travels all the way to the right shoulder at about the level of C-7, T-1. With a frightening trigger point at about c-3-4, or 4-5. My range of motion is limited to flexion and extension with discomfort. Lateral flexion is extremely limited more so to the left, and rotation to the left or right is barely a few degrees.

The good news is that my (self) diagnosis is most likely cervical strain. The differential DX is cervical spondylosis or herniated cervical disk. Regardless, both may be treated conservatively. I doubt either of the latter because I have no neurlogic symptoms in my arms, though I'm not sure how to give myself a neurologic exam ( the more I dwell on it the more I imagine weakness in both arms). I may have reached a therapeutic dose of ibuprofen as the two I just took seem to be working fairly well.

The bad news is that acute pain may take up to one week to subside I have a full week next week. I need to get hay today. Our Christmas party is tomorrow night. I have a three thousand dollar deductible I just as soon not use until 08. I have a dying dog who needs daily meds and two hungry horses so I can't do hospital time. I have no established PCP. I am a self confessed BAD patient.

I find it very frustrating and annoying to be in this position. I can't work on muscle relaxants, can I? Are there any varieties that would not impair my function? If I can just complete next weeks surgical obligations, the following week is the week of Christmas and so far nothing is scheduled, I only have a shitload of call. Perhaps I can heal. Or better yet make to 2008 when I can commit to some down time and that 3k deductible.

It's not always about the money.....

Yesterday at the scrub sink I am scrubbing with one of the trauma surgeons who also uses me for scheduled general cases. We are getting ready to do a mastectomy. I mention that this is a slow week. I only have this one case today , one on Wednesday, and one on Thursday. He tells me he has a case tomorrow but I'm not on it. I ask him what it is. It's a trauma patient from last year who had been shot from posterior to anterior and the bullet transected the vena cava, took out the hilum of the right kidney, (may have nicked the liver, I stopped listening when I heard transected the vena cava) went through the duodenum and out through the abdomen. He now presents with various fistulas, yada, yada, yada.....I quit listening again as I daydream about what a rush it would have been to be there for the original surgery.
"Do you have help?" I ask.
"No, (my partner) was going to help me, but he decided to take some time off this week."
"I don't have anything scheduled, I'll help you!"
"You don't want to scrub it." He says. " This is a Medicaid patient."
"I don't care, I always want to operate." I assure him.
"You don't get paid by Medicaid. Besides, it may keep you from something that would pay you."
"Well, if something paying comes up then we'll have a change of plans. Otherwise, plan on me being there."
What is he, nuts? Did he really think I would want to miss this case?
He knows I'm a junkie. Just last weekend he acknowledged that I was a trauma slut. Of course I immediately corrected him and told him I am a trauma whore. In retrospect I think teasing me with this case was a test to see just how far I am willing to go for free. Hey, wait a minute, I guess that does make me a slut.

The Things You Learn in the OR

Here's how naive I've become. A gay man of average weight made the comment..."Thank god I found me a chubby chaser." I thought this was a new name for gay men. I have since been set straight (snicker) and was informed that a chubby chaser was someone, particularly a man, who chases chubby women.
I visualized the wrong chubby. I thought it meant chasing after The Little Chubby.

Love, Trauma Style

One of our beloved trauma surgeons just happened to turn 60 yrs old the same day he was on trauma call. As expected the trauma pager went off for a trauma blue sending him to the ER. When he arrived he found the ER team already surrounding the patient, but he thought it a bit odd that there were no monitors or IV, no law enforcement officers, no paramedics or flight crew giving report, very odd. As he made his way to the head of the patient to begin his assesment he understood why. Gazing serenely back up at him with an inviting smile was none other than......a blow-up doll.

He carried the joke on by delivering his critical patient to the ICU. They were poised and ready to assume ventilations when little miss dolly arrived.

I don't know if he has given her a name yet, but I bet she has a home in the trauma on-call room.

Slowing Pains

My on call dry spell continues. Another week gone by and nothing. This week I had three days with no scheduled cases and call of one persuasion or the other Monday thru Friday. I've figured out part of the problem. It's hard to find work when your hospital is one divert status or another. The town I live in had a rapid growth spurt which, in my opinion, has destroyed the clean air, open spaces, water supply, traffic flow, cost of living and overall quality of life in my home town - but that is a whole other rant. There are four major hospitals here, a 538 bed level II trauma center which is in the completion stage of expansion, another similar sized (380 bed) hospital, and two smaller hospitals with a combined total of 165 beds, all with "full service" (the latest advertising phrase) ER's. (photo credit)

Here is my impression of how the game goes...keep in mind, I am talking about patients arriving by ambulance only. Patients arriving by private vehicle or on foot can still come in and join the party. The trauma center ER usually fills up first. People without insurance that don't express a preference seem to end up there. Once all the ER rooms and hallways are full, the ER informs ambulance dispatch that they are on ER capacity divert. This generally shifts the flow to the next largest hospital until they too end up on ER capacity divert. It doesn't take long for the two smaller hospitals to join in on the fun and now all four are on divert. So where does the ambulance deliver at this point? Well, this is where the game gets fun! Since all four hospitals are on divert, they all have to be considered open again. I think there is some sort of time frame that they have to honor, say 2-4 hours (?) before they can reclaim ER capacity divert. This seems to be the most common divert status, however there are more options.

Critical Care Divert means that all of the ICU beds are full. I believe this includes all ICU's, trauma, general, pediatric, cardiac, the one exception may be neonatal. Sometimes surgeons on general ER call love to hear this. When I am on call, I hate to hear this! Even though the trauma center may be on critical care divert, a patient meeting trauma criteria and an appropriate trauma score still comes to the trauma center. So where would this patient go after surgery if there is no ICU bed? If you can't go to the ICU, sometimes the ICU comes to you. Qualified recovery room nurses and an ICU nurse (more than likely one who has been called in) will manage an ICU patient in the recovery room overnight or until an ICU bed becomes available. Nobody likes to play this game.

And the final divert status I have not quite figured out yet. It is the coveted Closed Divert. I imagine that it is just as it sounds. Closed. Period. No ICU beds, no ER rooms, no floor beds, no room at the Inn. Fortunately this status doesn't happen too often and I have never heard of all hospitals being closed. I believe that when the trauma center is on closed divert, and it always seems to be the trauma center, patients are shipped to the next regional trauma center. When the OR staff walks by and see's CLOSED DIVERT written on the grease board, you can almost hear an audible sigh of relief. It means the case load you see, is the case load you get. No add on's unless the hospital re-opens or it's an emergent inpatient. When I hear closed divert I also utter a sigh but it holds a different meaning.

The rapid growth has obviously exceeded the hospital capacities. I can't wait for the trauma center expansion to be up and running so I can get back to work.

None

Nothing exciting to post because nothing exciting has happened! I had the free institutional turkey dinner at the hospital on Thanksgiving and hung out in the lounge 'till midnight waiting for some trauma to come in. There was one pediatric trauma blue which thankfully turned out to be nothing. Other than that, people seemed to be not driving drunk, or at least not crashing, and not assaulting each other. All things to be thankful for in reality.

"If you love what you're doing, why would you go to school to do something different?"

I have come to a dilemma in my career. To PA or not to PA? That is my question. I am currently a Surgical Technologist (certified) and a Surgical First Assistant. I had the notion in my head to go to PA (Physician Assistant) school. For the first time in this life of survival on my own, I will have the financial means to pay for tuition and go to school full time. PA school is very intense and no amount of time can be spared for a j-o-b.

But for those of you who don't know (!). I love surgery. If I go to PA school I will have spent approximately $50,000.00 in tuition and my best bet at a position after graduation will be in a clinic. Maybe an Ortho group or General Surgical group sure, but everyone knows that PA's generate more income in clinic than they ever will in the OR. Of course there will be days that I actually get to assist but most of my time will be filled with H and P's, (physical exams actually touching the outside of patients, argh!) and patient teaching and follow up visits and rounds and fielding phone calls and all sorts of other patient contact chores that I have absolutely no desire to do. The only way cool thing I can think of in this position is diagnosing. I would love the investigative portion of medicine. I even think I have an intuitive aptitude for this, but beyond that, why would I want to change my current situation?

Emergency medicine might be a venue to explore. I am unsure what a PA's duties might be there. The ER is the only other place that intrigues me as much as the OR, but I fear I would constantly be yearning for surgery.

I had originally thought that being a PA in the OR would make me more valuable. Surgeons often have a hard time finding an assistant for Medicare patients. Go figure. Right now, I do it for free because Medicare does not recognize an SFA. Medicare reimbursement is minimal. How long would it take at Medicare pay rates to compensate for 50k in tuition and two years lost income? My guess is a very, very long time. If I don't want to do all of those PA things, why spend the money and "waste" the education?

In the innocent words of my sister, "If you love what you're doing, why would you go to school to do something different?"

Why indeed. I believe that I have the best job in the world right now. It allows me the financial stability to be self employed. I get to do all of the fun stuff and none of the horrible. I don't have a lot of emotional interaction with the patients. I try to be comforting and reassuring when they enter the OR before induction. After the surgery my follow up consists of inquiring about their condition from the surgeon. This is all the patient interaction I care to have. It sounds callous, but I have had to admit that I have come to realize that this is self-defense, protecting me from the emotional roller coaster of being involved with sick and/or dying patients and their families. I cry at Dove soap commercials. I have become softer as I age, I used to only cry over animals.

I have heard legend that there are surgical PA's that only do surgical assisting and related post-op activities. Is this true? Can anyone reading confirm this? Now that might be a dream job.

To all of you ER, or if you insist, ED Docs, are there PA's in your department? If so, in what capacity?

I could sure use some help on this one.

Uncalled Forth

Apparently I have become the white cloud. Even worse, I seem to have turned the Trauma Surgeon with the biggest black cloud into a white cloud also. I'm sure he appreciates it, but I am having physical cravings for some trauma surgery. Hell, I'll even settle for any open general surgery. Nothing laparoscopic thank you, it just doesn't fill the void like actually getting your hands on some organs. (photo credit)

Last week's call for me.

Monday- Ortho.

Tuesday-Trauma and Ortho.

Thursday-Trauma.

Friday-Ortho.

Saturday-Ortho and ER (with the same doc I take trauma call with).

Sunday-Ortho.

Total number of cases, 0, that's zero, zilch, zip.

Last night I was on Ortho call again. Nothing. Tonight I will hopefully have better luck, I'm on ER call again with the trauma surgeon.

Tomorrow I will be available for trauma with a different trauma surgeon, maybe he will be the new black cloud.

This week I assisted one of the general surgeons on Monday morning, three scheduled laparoscopic cases, he mentioned he was on ER call this Friday and Sunday. I volunteered my services. He programmed my number into his phone. A good sign.

Free Cell?

One of the Ortho surgeons had given me a coffee card for all of the free assists I do for him. He's a great guy. Today I had an hour in between cases so I went to Starbucks. As I got out of the truck a street person approached me and asked if I could spare 50 cents. I told him when I came back out I would give him my change. Standing at the counter, I gathered up two one dollar bills as I waited for my hot beverage, with full intentions of giving them to the "dude". As I walked back out to my truck, he was still standing there but his back was to me and his attention seemed to be on a group of three girls approaching the store. I opened my truck door assuming he would hear me there and come to collect his free money. When I looked back at him I realized that he was not soliciting the three girls that had approached but rather he was talking on his cell phone! I got in the truck fully expecting him to tap on my window, but as I started to back out I saw that he had taken off across the street pushing his empty shopping cart ahead of him. Apparently street people are now networking.

Very Superstitious?

I am normally not a superstitious person. A black cat lives with me (the feline variety), the mirror on my locker is broken, and I love the number thirteen. Give me a Friday the 13th and I feel lucky. But in the operating room, there are several superstitions that must be strictly adhered to!

Many OR's have a large magnetic dry erase board on which to display the days schedule. Individual magnetic strips about two feet by two inches are used to write the individual cases. Start time, patient initials, procedure and surgeons name are the typical information written. Then the strips or cases, are arranged on the board by room number in chronological order. Anaesthesiologists, Techs and RN's have their own little magnetic strip with their names on them. When you are assigned to a room your name magnet is placed next to the corresponding case.

When a surgery is complete and the patient is transferred to recovery, the individual strip comes off the board and the information is erased. Different story if a patient dies in the operating room. Should this unfortunate incident occur, the magnetic strip upon which the procedure was written is left in it's place on the board and turned upside down. This informs everyone, especially those who may be wondering why their case to follow is delayed, what has occurred without anyone having to say a word.

What is the superstition, you ask? Never, ever, let someone turn your name magnet upside down! If you see it is so, immediately upright yourself and any of your friends. If you have enemies you may turn their name strip upside down, but I shudder to think what Karma may have in store for you

.

Another strip superstition. If it is the last case of the day, and the patient has long since gone to recovery, maybe even been transported up to their room, under no circumstances should you remove or erase that strip. Unless of course you want to bust open the flood gates and have several add-ons rain down upon you. Typically three at a time.

Emergent procedures come in threes. If you do one lap appy, you can bet two more are to follow in the same evening. Same with hip fractures. Some procedures like Crani's and AAA's may occur once a day for three days. If you exceed five in a consecutive time frame, you just have to plan on doing six.

When you are scrubbing a case all instruments that have been opened for that case MUST remain sterile on your back table. If you are sure that the surgeon won't use a particular instrument, or set of instruments, or any item of any sort, and you hand it off to unsterile territory, the surgeon will immediately request said item.

If your instrument string has an uneven number of like instruments, for instance, three Kochers or seven hemostats, you must either remove or add one Kocher and one hemostat to even up the numbers. If you insist on tempting fate, and remaining unbalanced, your case will not go well for you.

There is no OR number thirteen.

If you are on call and you don't want to work all evening and night until the sun comes up, then never, under any circumstances, utter the words "Quiet" or "Slow." If you use them in a sentence such as, "It sure is quiet tonight." Or, "It's been so slow lately." You will invoke the jinx pixies and you will not see sleep's bliss until tomorrow night.

These are just a few of the superstitions I know of. If anyone out there in the medical world have any I missed, I would love to hear them!