Just a Matter of Time

photo credit
Well, it finally happened. It was just a matter of time before it happened. But it was a Thursday afternoon, a scheduled case. It's not like it was a sultry trauma rendezvous in the middle of the night! Just a simple, standard double incisional hernia repair with mesh. Booked for an hour and a half, but I knew from experience it would take longer. So why did I optimistically fudge the time when *FTS called to have me come meet him at 1530? I knew I would be later but I told him it should be about 1630 before I would be done. "Not a problem." he says. "Just come over when you're done and see where I'm at."

We finally made incision at 1445'ish on our hernia patient. I calculated in my mind that we would not be done before 1700 but I hoped for the best. The clock was on the wall behind me, and while time usually has no bounds for me in the OR, this day I could feel each passing moment. The (other trauma) surgeon even asked me, "What time is he starting his case?"
"Supposed to start at 1530, but you know what that means, start time will probably be closer to 1600." Even as I said it, I didn't feel it to be true. Somehow I was sure they would start on time at the other hospital.
"You'll be done by five, don't you think?" I asked. To which he enthusiastically shook his head yes.
First hernia (at an old ostomy site) reduced, cleaned up, meshed and closed, we moved on to the second, a smaller peri-umbilical, mid-line, incisional hernia. I resisted the urge to look over my right shoulder at the clock. As is often the case, the area of defect was larger than anticipated. Well, I anticipated it, but that's more akin to Murphy's law than medicine.
After placing the mesh, tacking it down in four "corners" and sewing one side of it in, we switched places and moved to the opposite sides of the patient. Although I already had resigned myself to missing the sigmoid resection with my FTS (he was on ER call this day, not trauma), I couldn't resist a peek at the clock. Almost 1700. As was expected, we would finish close to 1730.

As soon as the wound was closed, I broke scrub and called the other hospital. I asked to be put through to the room my FTS was working in. The phone was, as usual, on auto-answer so when I identified myself and asked if he was still working, the room could hear the conversation. While the nurse was trying to explain to me that he was closing, I could hear him in the background. "Tell her she's fired! She missed my case and I'll never, ever work with her again."
This is a running joke with us because he knows that I can't say no, and when, or if I do miss a case or call day, I get anxious fearing that he (or they) will stop asking me to assist. Of course I know that this is not true, especially with him. Still he knows I always have that sliver of doubt so he likes to tease me.
"Tell him not to say that! He knows I'll believe him!" I yell through the phone with a smile.
"Nope, it's too late, she's fired. Well, right after this open appy I have to do next. She can help with that if she wants. Then she's fired."
I tell the nurse I'll be over shortly.

After I arrive and change into scrubs I seek him out in the ER. "I came to beg for my job back!" I tell him.
He almost seems hurt when he asks what took so long on the hernia case and tells me he really could have used my help. I didn't have an answer for him except that the defect was larger than expected. Even as I spoke the words, it felt like a weak excuse. He turned to the chart he had in front of him and I told him I would wait upstairs. Before I turned to go I told him, "It was just a matter of time before I got caught cheating on one trauma surgeon with another!"

*favorite trauma surgeon

Slowly coming back to life.

photo from freephotos.com
I have had an extended vacation it seems from blogging. I've barely been lurking. I do actually feel sort of rested and ready to work my way back into posting. A few things have happened since my last entry.
I did, in fact, take my first assist certification test. I took it over three weeks ago and I still don't have my test score back. I have been told that they had the preliminary results and "I should be
pleased.." I am assuming that it means that at least I passed. I was
told that I would have my certification card in the mail by the end of last week, but that hasn't happened yet either. So here I sit, still waiting.
I bought a BlackBerry. My Razor was dying a prolonged, painful death as the result of one too many falls to the O.R. floor. It was fond of blacking out for no apparent reason and periodically begging me to check it's SIM card. I think it was trying to tell me that it's heart was giving out. I took the hint. I don't have a clue regarding the full extent of BlackBerry capabilities yet, but what I have discovered so far, I like.
I have assisted on 46 cases since my last blog entry.
I missed the last two SurgeXperiences, edition 209 and 210. I was supposed to host 211 but many, many thanks to "M" for stepping up. I was starting to panic because it is due to be published on November 23 and I will be spending November 22 in house and on call for trauma. (Have I mentioned how deadlines make me anxious?) It could always be a mellow night of call but it is Saturday night and the weather has been super mild for this time of year. In fact, I am on call for trauma 6 nights this week. The seventh night is ortho call. I don't know how students and residents can keep up so well with blogging and their careers/studies. I think I am horrible at time management. I know I am great at procrastination. I think that is why I like surgery so much, as an assist, I don't have to plan it, it plans itself and I just show up. I don't decide what time to allot to it and there are no excuses to put it off, they call, I go. Muddling through my billing paperwork is another story.
I have become a 1099 employee (a bit like contract labor) for a large local orthopaedic group. I actually started about two months ago. Sounds like a big deal but I only really work with three of the orthopods there. They were surgeons I already worked with and now it is just a different pay and billing arrangement.
I did a quick peek at what search phrases brought visitors to my blog, and I have discovered that there are some men out there worried about their hand size. "depressed size of hands", "what is a small hand for a man" and "man with small hands" all showed up as keyword searches leading to my post. I hope the size of my hands hasn't pushed anyone over the edge.

I'll be back....

My apologies to my two (!) faithful followers, my assorted lurkers, and those whose email I promised to answer in the form of a new post. I have exactly six days left to "cram" for my first assist certification test, and for the last month or so, I have been procrastinating on other events in my life. You know, like paying bills, exercising, cleaning house, creating posts, etc.
All I have left to do is review anatomy by drawing structures I am unsure of, reviewing the 200-300 index flash cards I have created, and retaking the practice test one last time. I've had a pretty lax call schedule of late but I have been crazy busy with scheduled cases. This coming week is just the opposite, six call days but a light surgery schedule. Barnes and Nobles has reserved a seat for me to study in.
I love taking tests, I just hate being unprepared!

Customer Loyalty Program

Quite a while ago, I posted about my Trauma Hopes and Dreams . Almost a full year later, and nothing has come about as far as a position with Trauma Services. There is constant discussion among them as to how to change the way things are currently done , but no solution has been reached. There was talk of reducing the trauma shift from 24 hrs to 12, but that just means twice as many call days. The latest suggestion was to hire someone to handle the critical care of patients in the ICU. This made sense to me until one of the docs explained it as if the trauma surgeons would be the ones taking critical care call. ? I'm sure I don't understand any of it. All I know is that my FTS recently threatened to give up trauma next spring if something didn't change. Say it ain't so!! I practically pleaded with him not to give it up for purely selfish reasons which, of course he understood, but it seemed his mind was made up.

As I mentioned in my post last year, my FTS has come to depend on me. The bond has strengthened throughout the year. He's thankful when I am there for trauma because he says, "You calm me down." He jokes with me that I cannot desert him when he is on call. I plan my "life" (as if I really have one!) around his call schedule. There are two other trauma surgeons who have remained loyal to me (my group of five down to three) but on rare occasions, I have been known to tell those two that I am not available.
A few weeks ago I jokingly, or not so jokingly, told FTS that they should just give me a trauma pager and I would stay in-house when he is on call. Subconsciously I guess I was hoping that if I could make his call nights just a little but easier, maybe he wouldn't give them up. He really liked that idea. I really like the idea. In fact, I'm excited to implement the plan but he is gone for two weeks. It will be near the end of the month before it happens. Of course, while he is gone, I can see how it goes with the other two surgeons. Schedule permitting, I can stay in-house on week nights. Friday and Saturday nights will be easiest, and in fact may be all I need to commit to because those are historically the busiest trauma nights. With winter coming on soon, being in-house is a lot safer than me trying to get to the hospital in a hurry from home. Yeah, the more I think about it, the more I like it!
Friday, while assisting FTS on a right hemi-colectomy (he also uses me when he is on ER call and for scheduled cases during the week), he mentioned that due to some new financial obligations, he would NOT be giving up trauma call anytime soon. I made him repeat it twice. I'd like to think it had something to do with me, but I know better. No matter, I am just psyched that he will be remaining on the call schedule!
All three of these trauma surgeons still promote me to the chief. I know they are trying to find a way to compensate me when assisting on indigent and sum dood trauma patients. And while I may never have a paid position with Trauma Services, I know that I will always have a job with at least one of the trauma surgeons.

Take a look at these hands.

These aren't so manly, are they?

I wear a size eight glove. Only a few of the male surgeons I work with wear gloves as large as mine, and I'm not aware of any other females who do. Often times, when I finish scrubbing first and enter the room before the surgeon, the scrub tech will try to give me the smaller pair of gloves, assuming that a female must wear the smaller size. This stereotypical division of size according to gender also occurs in restaurants. If I am out with a male friend and we both order the same item, whether it be steak or dessert, the larger portion will always be given to the man. This recently happened with a dessert and when I pointed out to the server that my friends portion was bigger than mine, she suggested I trade him. Since the plate had already been set down in front of him, my food compulsions (oh yeah, they go way beyond simply not allowing certain foods to touch each other!) would not allow this.
A good friend of mine recently began calling me "Man Hands." Anytime we give each other a ration of shit he says "O.K. M.H." While I was out of the room, one of the surgeons finally asked him what M.H. stood for. My friend informed him that it meant Man Hands and suggested the surgeon call me that also. Well, as you can imagine, size eight hands don't belong to a demure, petite, fawn-like Barbie. I'm a full six-foot-zero and while I'm not heavy, I'm big enough to take care of myself. When he told the surgeon to call me Man Hands, the surgeon replied, " I guess it's O.K. to call her that, as long as she doesn't mind!"
The funny side of the nickname is that famous Seinfeld episode, Bizarro Jerry where Jerry dates the woman with Man Hands.



The practical side of the nickname is the fact that large hands are often a blessing in surgery. In ortho I assisted on a proximal humerus fracture just last week and I was able to hold two hohmanns under tension by spanning the wound with my left hand, thumb on the right hohmann, pinkie and ring finger on the left hohmann, while providing suction with my right hand. In a difficult trauma splenectomy earlier this month on an overweight male with guts that insisted on getting in the surgeons visual field, I was able to use my left hand backhanded to sweep guts out of the way while temporarily holding the tail of a suture placed on a stubborn bleeder between my left thumb and forefinger. Meanwhile, my right hand was occupied with maintaining traction on a large rich. I think the surgeon (my F.T.S.*) even made a comment about my hand span(?) though I don't remember it now.
There are occasions where size eights are a hindrance. In vascular surgery where 6-0 and 7-0 suture is often used and one must follow suture (maintain slight tension on the suture as the surgeon sews) with just the right amount of tension so as not to tear through the vessel, I feel like the proverbial bull in the china shop. When trying to provide traction on tissues deep in a narrow male pelvic cavity, my size eights are sometimes in the way of the surgeons field of view. If anyone has been wondering if I like the nickname or not, I do. All in all, I think my Man Hands are pretty handy.

*Favorite Trauma Surgeon

Path to SFA 6 Ortho rules!

five here
Training in the "real O.R." was much more stressful, but the cool factor was significantly elevated. In the beginning, you do a lot of work on opening supplies for the case, setting up the back table and mayo stand, and then observe as the primary scrub passes instruments. It is sort of like grunt work with no glory but a valuable lesson none the less. You may be surprised at how easy it can be to contaminate the field if you aren't careful. Do it once or twice and have to explain to the surgeon why you have delayed the case, and explain to the OR manager why you have wasted supplies and you become more vigilant.
Scrubbed in as the observer during those early cases, I would use an empty glove wrapper and a sterile marking pen and take notes of the procedure in sequence. After the case, I would transfer my notes to a sheet of paper and use it for reference the next time the same procedure came along.
After observing as second scrub for about a week, you begin to first scrub and your preceptor gets to sit back and observe. With the pressure of knowing that I would have to take call in about four months I became anxious to scrub everything. The crew was more than happy to oblige me. If there was only one line that day, I scrubbed it all. If anything got added on during a slow day, I scrubbed it.
The influx of information was often overwhelming and I thought that I would never be able to retain it all. Ortho cases, particularly total joints, have a high volume of instruments. You may have as many as six instrument trays in addition to your basic setup. In fact, you need to use two back tables to accommodate them all. Being slightly (yes, just slightly) obsessive compulsive, the clutter from total joints was frustrating for me. It was also hard to retain the sequence of surgical steps and instruments during the case. I would take whatever notes I had been able to gather and tape them to the wall behind my back table so I could "cheat" during the case. It was too difficult to turn away from the procedure long enough to squint at my notes trying to find my place again in the sequence. I longed for a better way since I didn't have a better memory.
Then my hero came along. The girl from central sterile processing, that I had spent a week with back in the beginning, had discovered that if you use a permanent marking pen on a 4x6 index card, put it in a peel pack and run it through the autoclave, it comes out sterile and still readable. Hallelujah! I soon had a collection big enough to require it's own space in the supply cabinet. Total knees went from my most frustrating case (I am a perfectionist), to the most satisfying and fun. And, bonus! The orthopaedic surgeon was the most fun to scrub for.
The general surgeon was very high strung, and the Gyn doc was a bit of an ass, but in a clever sort of way. More on that later.
prelude here
one here
two here
three
SFA four here

What I learned Today

Today I learned that when the trauma surgeon recounts his last trauma call shift and says, "Trauma was dead last night." He doesn't mean that it was slow.

The "Arte Y Pico" My First Award!

Oh my gosh! My first blog award! Thank you Oystein of The Sterile Eye for choosing me to be honored with this award. And thank you for your compliment,

The blog of the Surgical First Assistant that calls herself makeminetrauma. To her “surgery junkie” is a compliment. Her love for anything surgical shines through in all of her posts. I envy her hands-on access to the human anatomy, and I love her blog.

Now I pass the award on to five other blogs. The rules are as follows:

1.You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.

2. Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.

3. Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.

4. Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.

5. To show these rules.

Buckeye Surgeon. His posts are well written and always interesting with some great case presentations. He is very representative of the human side of medicine and his compassion for his patients is obvious.

Mother Jones, R.N. at Nurse Ratched's Place . I love her writing style and the nostalgic pictures she finds. Her captions and interpretations of the pictures are as entertaining as the posts themselves. She has a very clever sense of humor.

Bongi author of Other Things Amanzi. He is my hero of the blogosphere. His posts are an insight into another world that most of us will never experience. From the "sink or swim" style of surgical training to the roadblocks of dealing with the Government, his dedication to his country and his patients is unwavering. He truly loves his craft.

Addicted to Medblogs. Here is a loyal medblog addict. She is very creative. From her monthly (pretty close to monthly, as time allows) series Calander Doc, to all of the goofy cool stuff she finds to incorporate into her posts.

Someonetc at Orthopaedic Residency. He cleverly incorporates everyday challenges and situations as a mirror into the challenges of training ortho residents as their attending . He is constantly striving for more creative, motivating and successful methods of teaching.

Path to SFA five. Training begins

SFA four here
After placing ads and interviewing candidates, of which, if I remember correctly, there were only a few, none qualified as certified or experienced. Surgical techs were still a scarce commodity at the time. The fact that the town was so small and basically in the middle of nowhere was also to my advantage. With no local employee base to draw from and relocation an issue for anyone else, it was announced just two weeks after the search began, that I would start my on the job training as their new surgical technologist. I had made it at last! My patience and perseverance (harassment ?) finally paid off.

My training began by spending the first week in central sterile processing. This is where the instruments are brought after they are disinfected with enzymes that remove gross contamination.The sets are brought here to be reassembled and placed in their containers or peel packs or wrapped in blue wrap and autoclaved for sterilization. Central sterile is a great place to begin learning the names of the instruments, a vital bit of knowledge for a surg tech. You also learn proper sterilization techniques and how to identify something that has not passed sterilization parameters. There are checks and triple checks performed to insure sterility of instruments.
Before you can begin doing the fun stuff, you must first know the proper way to scrub, gown and glove, and learn sterile technique. With the help of a timer, scrubbing was easy enough. Gowning yourself if fairly simple, but learning how to closed glove yourself takes a little more practice. You must keep your hands safely within the end of the sleeve of the gown and not extend beyond the cuff. Then you pick up a folded sticky glove with your mittened hands and lay it on one gowned wrist, usually right hand first, upside down and backwards with thumb to thumb. The long cuff of the glove is folded over about halfway. With certain brands of gloves, the cuff is often quite sticky and hard to separate. With your other mittened hand you peel the folded cuff of the sticky glove forward around your fingers while holding the other cuff end of the glove with the enclosed hand you are currently gloving. Then, as you wrap the glove around, you are able to slide your hand forward through the gown sleeve and it should end up enclosed in the glove. Sounds easy enough! The good news is that after you perfect this move, you get to smirk under your mask at residents, PAs, med students and even some assistant surgeons who have no clue how to glove themselves.
Sterile technique is something tangible that can be taught. Sterile conscience is a little bit different. Part of sterile conscience involves recognizing a break in the sterile field, reporting it, and taking steps to reestablish sterile field. It is about being the patients advocate. As a tech, one very important part of my job is to protect the sterile field. It also became my pet peeve. If anyone non-sterile gets too close to my sterile field, I let them know. And they don't forget.

When it was finally time to start learning procedures, the girls who were precepting me decided that I should begin my training in the Procedure Core. The worst duty one could have was in the Procedure Core, which was their title for the Endoscopy Suite, aka GI Lab, aka any other title that makes what goes on there seem more glamorous. Well, let me tell ya' there is nothing glam about EGD's and colonoscopy's . Especially if it is your own. For the first week , they stood right there with me, instructing me on the proper way to handle a polyp specimen, how to give proper sigmoid pressure to help the surgeon maneuver the colonoscope through this redundant section of colon, care and cleaning of the endoscopes, etc., etc. By the third week, they would sit just outside the room at the nurse's station, within a shout's reach should I need help. Week four, I was on my own. Not a problem, I felt pretty confidant. However, I began to wonder just when I was going to be allowed in the OR to learn "real" procedures. Two more weeks had passed and I realized that they were very content just to leave me up there because that meant less poop and drool for them. I had to throw a little hissy to finally let them know I was on to them!
prelude here
one here
two here
three

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/Onc 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.