Off the Subject

After being threatened and coerced into filling out the US Census form, why is it that the US Postal Service still can't figure out who lives here?

1 Sick Day a Year

My Favorite Trauma Surgeon gave up regular trauma call about one year ago. Since then I haven't been involved in assisting on many traumas which in part explains why I haven't had any regular postings for the same time frame. Well, with two sons fast approaching college, my FTS has come back on board the trauma panel if only to fill in on occasion, generally once a month. Last month we had no surgicals. This month his call day was Monday the 13th. I was stoked and so looking forward to it. As luck would have it, without going into too much detail, I was totally incapacitated with painful symptoms and unable to cover call with him. What did I miss? Only three, yes three, exploratory laparotomies resulting in one liver resection, one kidney repair, and one bowel resection.

Doo-doo-doo doo. Doo-doo-doo-doo. "You're traveling through another dimension --"

I've always hoped that my particular involvement in the health care profession was recession proof. Not so, it seems. Unit clerks are getting laid off, scrubs and nurses are being called off and instead of reporting to work, they are being put on call (much, much cheaper to pay call pay that an hourly salary-the hospital plays the odds that the crew won't be called back in at time and a half pay), or just told not to come in to work. I haven't worked on a call night since I can't remember when, and, my cell phone hasn't rung for two days now. It all feels so odd and Twilight Zone-ish.

Not for the Queasy

In one of the local hospitals high school kids from various programs frequent the operating room (they never had cool stuff like that when I was in high school!). During turn-over the other day, one such student was hanging around while the crew was cleaning the room between cases. As one of the orderlies was picking up bits of bone and tissue off of the floor he looked over at the student, opened his palm full of tissue and said, "Hmm, almost enough for a sandwich."

Space Camp (first drafted Nov 2009)

Wednesday was supposed to be a light day. I had enjoyed sleeping in for the first two days of the week, but Wednesday was a 7:30 start which means I have to get up at 0530. I am not a morning person. No matter, a light day of two ortho cases. One, a hallux valgus correction, which is a fancy way of saying bunionectomy, though to be fair there is a little more to it,( my foot and ankle doc would probably argue that there is a LOT more to it!) and the other, an achilles repair with FHL transfer (flexor hallus longus-the tendon that flexes your big toe) . Both cases are kinda fun and not too time consuming so I'm looking at getting done by 11:30. Yes, it was my day with the ortho foot and ankle weenie. Don't worry, I have called him a lot worse to his face, and he to mine. In a lot of ways he is my "work husband" and we are sort of the comedy team of the OR but that is another post entirely.
At 1800, sorry 6 pm, I have a dinner to go to. A general/vascular surgeon that I have recently begun assisting has invited me to dinner along with his office staff. They are invited for getting his Medicare paperwork through for him (finally!) and I, for assisting him with multiple no-pay Medicare/indigent cases.
As predicted we finish with our ortho cases and I am off the hook by 11:30. Although he still has a simple hardware, ie. screw removal and a foot puss......pus ......how do you spell that?..... washout at a different surgery center, he has an eager PA student with him that day so off I go.
Now I can: Print off some op notes, go to the credit union, fuel up my truck, spend some time with my horses, shoot off some claims and some emails, and next thing I know, it's time to get ready.
Dinner was amazing. The food was great, the company was spectacular. The only way it could have been better is if I hadn't been on call and could have enjoyed a glass of wine. Or two.
So, home by 8:30, in my jammies, comfortably stuffed and watching my dvr shows in the leather recliner with a blanket and a cat on my lap. Life is good, life is comfortable. Until my cell rings at 10 pm with a familiar ring tone. It's my FTS. Oh wait, he used to be my F avorite T rauma S urgeon, " til he GAVE UP TRAUMA CALL!! No matter, he is still my favorite all time surgeon. He has a small bowel perforation due to go to the O.R. in about half an hour. He gives me the option to say 'no' because he knows that I have a case the following morning. I tell him 'yes'.
OR times at night, or almost anytime really, are not exact. It is after 1130 pm before we even get in the room. Fixing the small bowel perforation for this patient is the easy part. The hard part is meticulous and tedious take down, or lysis of adhesions, before one can even examine the bowel to find the perforation. Not all patients have these adhesions, which are typically the result of previous surgeries, but tonight our patient does. If you ever hear a surgeon dictate one of the procedures as "Extensive lysis of adhesions." you can bet that is just what happened. Doesn't mean they get paid any more for it, but I think it makes them feel just a tiny bit better to dictate it with emphasis! Somewhere in the middle of miles and miles of adhesions, I start to zone out a little. Mind you, the surgeon is doing all of the "fun' stuff, blunt dissection with his fingers , sharp dissection with a pair of metz, while my only job at this time is lifting two kocher (clamps) that are attached to my side of the patients abdominal fascia, straight up in the air in order to provide the surgeon better exposure. As I stand bored and daydreaming, I almost startle as I see a spider run across the drapes. In my mind my first thoughts are how odd it is to have a spider in the OR. Then it dawns on me. We're in the OR! Break in the sterile field! I must point it out! And just as I'm about to open my mouth and spill my guts, replacing them with my foot, I realize that what I actually saw was nothing more than a bead of dark blood "running" through the suction tubing on it's way across the patient towards the suction canister at the head of the bed.
When it is all said and done, the leak is identified, the damaged bowel is removed, everything is put back together, the abdomen is irrigated copiously to decrease contamination and the patient is sewn back up. By time we hit the PACU it is 2:20 the following morning.
I make it out of the hospital by 2:45. I'm home by 3:15 and in bed somewhere this side of 4 am.... wide awake, and starving, and wondering if I am going to dream of spiders.

Speaking of pet peeves....

For all of you up and comers to the sterile field, I present you with some not-so-sterile techniques that I pray you never choose to follow. Now I know that there are those who shun the "old" ways. If you look long enough you will find a study to support any theory you choose, often contradictory to what you may have believed for years. I know one anaesthesiologist who jokingly asks why I bother to scrub my hands. "You're just going to put on two pair of gloves anyway." I hear that there is a study that proved that it makes no difference if you take a ring off before you scrub. Yet I have only ever seen one surgeon wear his ring under his gloves.

There is a tech who, in her efforts to see into the belly, will actually lean her face on my arm. She happens to be short and I happen to be tall. Now, I know that your sleeves are only considered sterile to a couple of inches above the elbow, and her non-sterile face is plastered just below my shoulder, but in my opinion, my sleeve is now contaminated. Period. "May I have a sterile sleeve, please!?" She doesn't seem to think that it matters. While many of these things may be benign when it comes to creating an infection, why take the risk? Don't get complacent. Don't be lazy. It is your job and duty as the scrub to be vigilant over the sterile field. If you see or cause a break, tell the surgeon. Ninety-nine percent of the time the surgeon will thank you for letting them know.

Sometimes you may have to physically keep or take something away from the surgeon so that it won't get used again. Then, they'll just have to wait. I work with one orthopod who throws the bovie down on the field instead of trying to put it in the bovie bucket when we are doing total joints. I cannot count the number of times that I see the bovie tip burn or rip through the drapes. I know that he has this habit so I often spot the hole long before the scrub does. I grab the bovie, remove the tip with a hemostat, notify the circulator to come take the contaminated tip, open a new tip, and ask for a medium tegaderm to cover the hole in the drape. The whole time my surgeon is standing there gritting his teeth and holding his hand out in the I wanna' bovie! position. In all honesty, there are three drapes down and the tip has probably only gone through the top one, but it would be remiss of my duties not to point out the break and correct it. Maybe one day he'll make it to the bovie bucket!

Women scrubs, oh wait, I guess this applies to men now too, don't wear earrings when you're scrubbed in!! This rule isn't meant to punish you, it's meant to protect the patient. Consider the following scenario: A first assist to the surgeon is questioned halfway through the procedure about the fact that she is missing one earring. No one can find it before the case is over and the patient gets an x-ray. Fortunately, no retained foreign body. Facilities have become far too relaxed in enforcing this standard in my opinion.

From the scrub sink:
If your facility allows alcohol foam or alcohol gel scrubs. Your first scrub of the day should still be a standard six minute scrub with a nail pick scraping out the gunk under your fingernails. You should also do a complete scrub again after eating meals. If I go from one hospital to another I scrub again. I was taught that if we left the OR suite for any reason upon returning you start over with a complete scrub.

Now that you have finished your six minute scrub and your neatly trimmed, UNPAINTED fingernails are squeaky clean, and you walk from the sink to your gown, KEEP YOUR HANDS UP! I see so many dudes (yeah, sorry, I've only seen males do this) walk in like they think they're a gunslinger with their hands down and "dirty" water rolling down from their "dirty" elbows to their used-to-be clean hands. When did this become okay? I must admit though that I do struggle with the concept of religiously scrubbing properly and then rinsing off with some tap (:^O water from the scrub sink.

If you are opening a room, keep the O.R. doors closed. Ever hear of positive ventilation? It's not very efficient with a big gaping hole leading out to the hall. And if you are opening a total joint please be even more compliant and limit the amount of traffic in the room and have team members enter through a sub-sterile area if possible, not the common hallway. I often see rad techs at one facility I go to prop open the OR doors to an already open room and then wander off down the hallway to retreive the c-arm and roll it into the room. Then they wander back down the hallway and fetch the monitor all the while leaving the doors wide open. NOT OKAY! A better technique would be to roll all of the equipment to the OR before opening the door and then push both pieces into the room at once. Of course the best technique would be to have the equipment in the room before sterile the supplies are open, but this isn't always possible.

The surgical techs that I have mentored were all taught to pull up their back tables and mayo stands up (closer too but safely away from the undraped patient) when they begin to drape. This solves two issues that I commonly see. Number one, walking back and forth across the room to retrieve each drape. The sequence goes something like this: Grab the first down sheet, walk across the room and lay it on the patient, walk across the room and grab the blue towels, cross the room and hand the towels to the surgeon, walk across the room again to get the laparotomy drape, cross the room and hand the drape to the surgeon, walk across the room one more time and bring up the mayo with suction and bovie. While the suction and bovie are being thrown off, the back table is still across the room.

Now the tech has created two sterile fields instead of containing the field in one area. Issue number two, Walking between sterile fields. I see this infraction more than anything and it irritates me the most. If you create a space like this you are inviting axillary staff in the room to walk between sterile fields. Even though most of them know better, very, very few of them will go around the head of the patient or ask you to pull up your back table. I have seen x-ray techs take this opportunity to wheel the entire C-arm and monitor between fields because they realize they are on the wrong side of the room. This is unacceptable! Circulators, DON"T DO THIS! Scrubs, DON"T LET THEM!! I have been to so many places and there are so many nurse and techs who have, in my obsessive compulsive opinion, become way to complacent on this standard.

Well in the interest in getting this posted-I started it in July- I am going to end here for now. I'm sure I have insulted somebody, but I feel it's both my obligation and my hope to make others vigilant.

Off again, on again.

Everybody that knows me knows that I like to work. You can usually count the number of days that I'm not on call in any given month on one hand. Every now and then (today for instance) one of my ortho docs uses a PA when he's on call. The local trauma center employs a PA from 0700- 2000 every day but Sunday for Ortho trauma. On those occasions when the orthopods tell me they are going to use the PA, I'm fine with it. In fact, I kinda like the break when I regain one more precious day for myself. What's a little bit annoying is when I think I'm off and then get called in anyway because the PA can't stay. Like last night, and like this morning.

Another Surgery Addict

This email comes from Jackie. Jackie craves surgery as much as I do.

I'm a 21 year-old pre-Med student from Phoenix, AZ. I'll be graduating in May, and due to economic and personal concerns, I will not be able to pursue my medical education at a 4-year Medical School.

I ran across your blog while looking for alternative, and I found that we are very much alike - I am also addicted to surgery, using my internship with a Kidney Transplant surgeon as an opportunity to get into the OR at every turn. I believe that a career as a 1st Assist is something that I would greatly enjoy!

However, I have had difficulty pinpointing the best way to go about this. I have found that the best way to go would be to become a CST. However, what is the quickest route to 1st Assist from there? Do I need to take more courses, or simply amass enough cases to qualify? Is it necessary to become certified as an assist, or can I be a CST and, with experience, become recognized as an assist without additional certification?

I am by no means interested in the "easiest" way, I would just like to get back into the OR as soon as possible after school, as well as possibly begin working, so that I can, in the future, accomplish my goal of medical school.

Any tips? I find your writing and blog inspiring, and I am looking forward to your insight!

- Jackie

Jackie,
First let me say that while I respect your concerns, it's unfortunate that you will be unable to pursue med school at this time. If I knew then what I know now, as the saying goes, I most certainly would have pursued med school and a surgical (trauma?) residency while I was in my youth. It seems as time goes by and our lives becomes increasingly full of responsibilities, it becomes harder to devote such an enormous amount of time and money to such an endeavor. If it is truly what you want though, you will find a way.
In the meantime..... the quickest way back into surgery would certainly be as a surgical technologist. You can complete a certificate program in about 9 months, sit for your certification upon graduation, and off you go scrubbing as a certified tech. In fact, the clinical portion of your school will be spent scrubbed in. From there it is simply a matter of taking a first assist course. Most programs consist of didactic, usually offered by distance, a 6 day (min) hands on skills workshop, completion of a suture and tying course, and completion of 350 supervised clinical cases in a variety of specialties. There are several schools out there but I would say the average time of completion is 18-24 months. While there is nothing that says you must become certified as an assist, I would highly recommend it. Legislation is always changing and soon it may be required. Best to sit for the test while it is fresh rather than waiting and having it forced upon you several years later.
I'm not sure what your long term goals are but if you enjoy the whole gamut of patient contact, from clinic to surgery to post op, why not look into P. A. school? If you are graduating pre-med, I believe you would have the pre-reqs out of the way. The tuition is much less than med school and there are (were anyway) certificate, Bachelor's and Masters PA programs. A little more time to dedicate (2 years?) but if you land the right job, you will be more valuable to your surgeon, eligible for Medicare reimbursement ( as minute as it may be) , and hopefully still get to go to the Operating Room two or three days a week.
RNFA is another option. You are probably looking at four years, if I remember correctly- two year BSN, 2000 hrs of circulating (for CNOR eligibility) , and an RNFA program. If I don't have those facts straight, I apologize. I do remember being faced with the same dilemmas when I decided that assisting was the way for me and, next to med school, I remember RNFA was the longest route. If you decide on RN, I would also recommend continuing on to APN for reimbursement and advanced knowledge though I don't have a clue what attaining those titles entail.
I will say this about what I do. For me, it is the best job in the world. I do all of the fun stuff and don't have to deal with any of the not-so-fun stuff. That is, clinic, pre and post-op, phone calls from the floor, etc. All I do is OR all the time.
What I find missing from what I do? Knowledge. I crave more medical knowledge. The pathophysiology of trauma, diagnosis, in depth pharmacology, anaesthesia, what it feels like to put in a chest tube. OK, I'll never know the last one. I am self educating myself as best I can from books but it's certainly no substitute for an organized formal education. Heck, I can't even get lab values memorized!
Well Jackie, I hope that gives you some answers or at least a general idea of what to expect. If you do choose surg tech, be sure to go to a CAAHEP accredited program or you will run into roadblocks for certification. Generally, you must be a certified ST in order to be approved for hospital privileges which you will need in order to be able to assist.
Thank you for enjoying IntraopOrate and feel free to ask any other questions.
Best of luck to you,

MMT

Q and A

Went and dusted the cobwebs out of my in-box and found this letter from Ryan, a prospective student of surgical technology. While I have already replied to him via email, he was kind enough to allow me to post his questions on the blog. So, an entry for me, and perhaps answers for others with the same questions.
--------------------------------------------------------------------------------------

I have been reading thru your blog and I love it. Thank you for much for writing it.
Thank you so much for reading it!

I have some questions about becoming/being a surgical tech. I have been researching several health care related careers including surgical tech, RN and respiratory therapist.

Since you are a surgical tech I will focus and this field and my questions for you:

First, let me clarify that while I will always be a surgical tech, I'm currently a self employed first assist. I did scrub for seven years.

Have you found being a surgical tech rewarding?
I loved to scrub. If you have a touch of OCD (obsessive compulsive disorder!) I think it's helpful. I found it both rewarding, especially the first time I was involved in a surgery that actually saved someones life, and challenging. I constantly challenged myself to set up faster, anticipate better,know the anatomy involved, count an entire set of instruments with the circulator and still keep up with the closing suture, etc. I liked to identify the patterns of certain services, mark-inject-cut, drill-measure-tap-screw, clamp-clamp-cut-tie-tie, heparin in for two minutes-eleven blade-potts scissors, clip-clip-clip-scissors, right angle-vessel loop-hemostat, the list goes on and on and almost never varies....did I mention OCD?

How is the job market for surgical techs right now? ( I have read contradicting things about this some say good some say bad)
Since I have been out of the market for a few years, I'm not sure I know the answer. I would say that some regions, and even different hospitals within certain regions, prefer to use RN scrubs. I would definitely research your region before jumping in. Perhaps look at the on line job openings with your local hospitals, that should give you an idea. I will say that in my experience, there always seems to be a shortage of Certified techs.

Did you find the schooling/program difficult?
I did not find any of my school or training difficult. I did a combination of OTJ and an Associates program (2 yr). My interest was so great in the subject matter that it was fairly easy to grasp. I will say that clinicals can be very stressful depending on your demeanor. The OR is most certainly NOT for everybody. Unfortunately, some students don't discover that they are not able to handle the environment until they are doing clinical cases in the OR. There are various programs available, the shortest route would be a certificate program. Word of warning....be sure the school you choose in CAAHEP accredited or you will find it very difficult to get your certification.

How is the pay?
The pay can vary greatly between regions and hospitals. I started at $9 something an hour (way too low!) and when I quit, $24 an hour with an additional $2 shift differential. Trauma centers typically pay more and some hospitals will pay an extra percentage if you become a specialty tech for one of the services, say General or Ortho. If you need extra money, someone is always willing to give you their call. Call pay can be anywhere from 3-6 dollars an hour, and if you get called in, you receive time and one half.

I see on your blog that you work a lot of call hours, is this the norm for this position or do you choose this? The call hours I work as a first assist are excessive because I take call with so many different surgeons. The most call I've had to take as a tech was 176 hours every month. More typically, in a large hospital with more than one shift, call should average about 48-72 hours a month. Plus, as I've said, you can almost always find someone to who is willing to take it from you.

I am 34 and changing careers is this to old to start training for surgical tech?
I began scrubbing when I was 40! You can complete the course in 18 months or less depending on which one you choose (certificate programs are typically 9 months), sit for your certification at the end of the course and off you go. Once you start working, you can take that career anywhere in the country and find a job. You may decide to become a traveler, go into nursing, or assisting, or, you may even decide to go to med school. I find it very exhilarating to work at a major trauma center. Others are more suited to out patient surgery centers where there is typically no call required and you don't work holidays or weekends.

I am sure I have a million more questions, but these are the basics.
If you have any more questions, feel free to ask.

Thanks in advance for your insight.
Ryan
You're welcome. Thanks for enjoying the blog and look for more frequent entries as the weather gets colder and I get back on track!

MMT

Neglected!

I have been badly neglecting my blog. So many excuses I could give to you. In a nutshell, I'm gonna blame it on summer. Imagine my surprise to finally log in after two months and see that the faithful have actually increased! Talk about feeling guilty!
I find it hard to blog about actual cases because I am paranoid about the Hippa police. I suppose it is just as easy to change the gender and age, I would never give a name, although I suppose all males could be Joe's and females could be Jane's. I could give age groups, 0-18, 19-30, 31-5o, etc. I'm quite sure patients don't read my blog and when they are asleep I'm sure they don't appreciate the details of their surgery. We'll see how it goes.
I have been considering a change of direction for the blog, perhaps gearing it more towards future surgical technologists and/or first assistants. I do love to share what I know and feel about surgery. Perhaps some sort of question and answer format drawing from emails through my gmail address?
My love affair with trauma may be dwindling to a trickle. My beloved *FTS is giving up the call rotation. We have only a few days left together! It feels like the end but he will be still be taking ER call and on a rare occasion, a trauma call day. Whenever I lament to the other surgeons about MY (!) loss, they look at me funny and remind me that he's still going to have regular call. But we all know it's not the same......seldom is there that urgency from non-trauma patients. The other trauma surgeons think they are being considerate. I cannot seem to convince them that even if it's 0230 and the sumdood with knife stuck in his chest or the bullet lodged in his flank isn't gonna pay me a penny, that I want them to call me! I WANT to come in!
There is a new trauma surgeon just starting. I have asked the others to pimp me out! He is still being mentored. I am trying to get to him before the cowboys do. I call cowboys the trauma docs who, #1- don't think they need any help at all, and #2- only call for help when they feel the case is technically challenging enough to require another surgeon. I fully understand #2 but come on guys, an extra pair of hands to help provide exposure and free up your scrub isn't going to help you? That's really all I'm asking, I don't need to do anything fancy, just want to bo part of the team/experience.