Piggy Sniffles, Tread Ye Not Here

I’m officially all H1N1-ed up.  Vaccine in the left deltoid, and hopefully no swine flu will come my way.  Sorry for the no-post thingamajig goin’ on lately, but I had a difficult patient the last few days, and wasn’t quite sure how to blog about it.  Maybe tomorrow I’ll figure that one out.  For now, the weekend is here, good food awaits, I finally got a winter coat after like, 10 years (well, it’s technically a shell + inner lining, but who’s counting?), and I’m ready for T-giving to arrive.  Bring on the mashed potatoes.

The Kidneys

So far, out of all the body systems (except GI, of course), I’m finding the kidneys pretty incredible.  We’ve studied some amazing things, but the past week we’ve been discussing renal, and I’ve found my jaw dropping more than any other day.

The kidneys are pretty special little buggers, and I’m super thankful they work well in me.  I don’t really know a whole lot yet about what it takes to be a dialysis nurse, but it’s one of the careers that has jumped out at me this semester.  Not sure why, but the kidneys are just so fascinating and so important, too.  Good times.

Religion? Ummm …

Today in Intro to Nursing class we had a lecture on “spirituality in nursing,” which, inevitably and assuredly, turned into a discussion on religion.  Even though the professor tried to differentiate between spirituality and religion, the chatter invariably turned to religion.  Nothing super-duper contentious or anything, but there was certainly an air of tension in the room this afternoon.

Conversation then turned to dealing with death, and the mood became somber.  Ugh.  And this after a long morning lecture on kidney disease.  A very, very tired day today.  I’m headed to bed early.

Open Mouth, Insert Foot: Vol. I

SCENE:  Patient’s room.  Patient is blind.  RN and Student Nurse Kenny are examining the patient’s mouth ulceration.

 

RN:  Let’s just grab a tongue depressor here.  Ok, open up and stick your tongue out, Patient.

Kenny:  Oh, let me just turn this exam light on so we can see better.

RN:  Good idea.

Kenny (to patient):  I’m sorry, Patient, I know this overhead light is so bright, it’s like the sun … it must be blinding!

The Famous “Nasal Cannula Whip”

So, it wasn’t my patient, but another student had a patient tonight who was quite … ornery.  Understandable, given her condition (lung cancer spread to the brain).  But this patient had quite a time with the many folks who came into her room to help her:

• Trying to bite the instructor.
• Kicking the student when she came near.

And my personal favorite:

• Using her oxygen nasal cannula as a whip on the people coming near her bed.

In other news, my patient the last 2 days was a real sweetheart.  Older woman with quite a history, and who was in the hospital because of a stubborn little wound that wouldn’t heal.  She was in the hyperbaric chamber to promote wound healing, but had to have tubes put in her ears (bilateral myringotomy) because of the pressure of the hyperbaric chamber.  She didn’t have a whole lot going on, but was mostly blind, so I got to assist her with a lot of daily activities, such as helping her figure out where things were on her dinner tray, or helping her to the commode, or just generally sitting with her and getting her what she needed.

I really enjoyed these 2 days of helping her, because I felt like I was really aiding someone who needed it.  She was mostly self-sufficient, but it was nice to help her out whenever I could.  I also got to give her meds twice today, and didn’t even mess up once (unlike last time, where I forgot to ask the patient his name and birthday before I gave him his meds).  I’m becoming awfully familiar with doing the Accu-Chek as well (checking the patient’s blood sugar).

It’s also time to start thinking about a summer externship for 2010.  I’m asking my instructor for a letter of recommendation.  Not sure what I want to do yet — whether it’s just a general med/surg floor position or something more specific.  We shall see.

We Have a Winner!

Congrats go out to my 2,000th visitor, Ms. Fay Kreeder, of Doubtful, Ohio.  Fay has been a faithful reader since this blog’s inception.  Fay won an autographed copy of my new book, A Million Ways to Make Things Up and Not Fool Anybody.

Zweitausend?

If you’re the 2,000th person to visit my site (most likely to happen sometime today), you will receive a fabulous prize!*

*Restrictions apply.  Limit one per visit.  Prize has no monetary value and cannot be exchanged for money at any local WaWa, 7-Eleven, Sheetz, or Piggly Wiggly.  Owner of this blog has no way to tell exactly who will be the 2,000th visitor, and as a result will never actually give that visitor his or her prize.

H1N1 … What’s Up?

Some interesting factoids and numbers tossed out to us recently from the University.  I should mention that none of this is my own — it ALL comes from the university, not just the factoids.  Situation analysis comes from them as well.

PHILADELPHIA STATUS REPORT — Week of October 25-31

• 101 hospitalized (for a total of 234 cases since 9/1/09)
• Median age of hospitalized cases is 17

U.S. STATUS REPORT — Week of October 25-31

• Influenza activity remained elevated in the U.S. with 17,838 laboratory-confirmed influenza associated hospitalizations and 672 laboratory-confirmed influenza associated deaths reported to the CDC since August 30.
• Doctor visits for influenza-like illness (ILI) decreased very slightly after four consecutive weeks of sharp increases.
• Over 99% of all subtyped influenza A viruses reported to CDC were 2009 influenza A (H1N1) viruses.  Eighteen influenza-associated pediatric
  deaths were reported.  A total of 129 deaths in children associated with 2009 influenza A (H1N1) virus infection have been reported to the CDC.
  Forty-eight states including Pennsylvania reported geographically widespread influenza activity.

WORLDWIDE STATUS REPORT — As of November 1, 2009

• More than 199 countries have reported laboratory-confirmed cases of pandemic influenza H1N1, including over 482,300 cases and 6,000 deaths
  (up from 5,700 the previous week and 5,000 the week prior).  Many countries have stopped counting cases, particularly of milder illness; the overall case count is likely to be significantly lower than the actual number of cases that have occurred.

SITUATION ANALYSIS

There continues to be no indication that this disease has a higher case fatality rate than seasonal influenza, which is usually less than 0.1%.  However, the young age of H1N1 cases and deaths compared to seasonal influenza will continue to garner national attention.  Fortunately, the vast majority of cases are mild and do not require hospitalization or antiviral medications.

For the first week, we are seeing some evidence of a leveling off/decrease in the number of cases regionally and nationally.  Hopefully this trend will continue as vaccine becomes more widely available and the current pandemic wave runs its course.  However, there is concern that, even as the current wave shows evidence of waning, this virus will reemerge in the winter.  We will benefit from lessons learned in the current wave as well as a population with more widespread immunity from vaccine and natural immunity (for those who already contracted the disease).  Surveillance continues worldwide to look for any changes in the virus that may make it more severe.  We should continue to follow good infection control practices.

The Thigh Bone’s Connected to the … Hip Bone

###WARNING### — this post will contain very graphic description of surgery and operating room stuff.  If you’re not cool with reading that, stop reading now and go here.  This means you, S, J, R, M, and Y.*

*I totally made these people up, by the way.  Unless your name starts with S, J, R, M, or Y, and you’re easily skeeved by blood and guts.

Let’s try writing in the present tense for this entry.  Change it up a bit.

So.  Let’s see.  Friday morning I wake up at 5AM.  This is early.  Normally I’m dreaming about car fires or delicious little impossible cupcakes at this point.  But I wake up to my alarm (set to 93.3 WMMR, because it’s the only station I receive clearly on my 20-year-old clock radio), shave, shower, eat some breakfast (per my instructions … don’t wanna be passing out in the OR), and make my way to the hospital.  This time I am in the main hospital building, which houses some 30 or 40 operating rooms, I believe.  I take the elevator up to the floor with some of the ORs.  I knock on the door of the OR nursing suite.  “Hello?” I say to no one in particular.  It is 6:45AM, and I don’t see anyone here.  Finally, a woman sees me and says, “Ok, grab some purple scrubs (yes!), put them on in that bathroom, lock your stuff in the locker, and wait in that room over there across the hall.  Someone will come to get you.”

Hmm, ok, I think, this isn’t so bad.  I change into my sweet purple scrubs, lock my stuff away in the locker, put the key around my ankle, and turn the corner into the OR lounge.  Yikes.

There are about 40 people in here.  All wearing either teal or green.  All drinking coffee and eating danish or donuts.  All talking to each other.  I stick out, but people ignore me.  I sit down on a couch and wait.  To my left is a bug zapper.

Wait, a bug zapper?

To my right is another bug zapper.  I can only assume, given the vast amounts of food and drink to be seen in this lounge, that they’ve had a little problem with lil’ critters.  Hence the bug zappers.  I assume.

At precisely 7:01AM, all the green- and teal-clad folks begin checking a master sheet, file through a door, and disappear down the hall.  I take it that these people are all nurses and techs and have disappeared to start the day.  I am left alone in the lounge, watching the sad news from Ft. Hood.  I am tempted to stuff my hole with donuts, but I resist.  At 7:30, another student comes in and we chat.  She changes into her purple scrubs, and we sit together for a while.  At around 7:50, a nurse comes over and introduces herself, saying she’s sorry, but someone called out sick, and she’s been tasked to take care of us.  For the next 15 minutes, she goes over the “house rules.”  This includes things such as:

• Do not talk to the surgeons unless they talk to you.
• Do not touch anything blue or clear plastic.
• If you feel faint, sit down immediately and tell the circulating nurse.

So after these rules are hammered home, she says, “Ok, let’s go, follow me!”  She gives us booties for over our shoes and a hairnet/cap.  She is perusing what looks to be a master list of all the surgeries scheduled for that day, and is trying to figure out where to put us for the morning.  We follow her downstairs and to the next building (which is connected with a bridge).  And then we finally enter the OR suites.

At this point we are standing in a very long hallway, with ORs on either side.  The nurse gives us a duckbill mask here, and instructs us to wash our hands.  As I’m stepping toward the giant sinks they have for the surgeons to scrub in, I hear the following:

WOMAN #1: Oh man I gotta go wash my eye out!

RANDOM MAN:  Why, what you get in it?

WOMAN #1:  Oh, just some blood.

Our friendly nurse says we should always wear that mask inside the OR.  She also gives us a flimsy-looking coat of some sort, because it gets very cold inside the ORs.  Lastly, we are told to wear disposable plastic glasses to protect our eyes.  We follow this nurse down to OR #5, at which she drops off the other student.  She wants me to go into OR #3, and we enter through the door.  Five people turn around and stare at me for a few moments, then turn back to the patient, who is lying on the table, completely under anesthesia, with her abdomen exposed.  They’re about to start a laparoscopic resection of the colon.  Cool!  I think this is my lucky day.  Then things turn sour.

The surgeon seems upset.  He’s going on about some machine that isn’t working properly, and they can’t start the operation.  The nice nurse who’s been taking me around says, “Ok, let’s find you another room — this one’s quite ornery.”  She then says, “I think there’s some ortho surgeries going on, let’s go down there.”

We knock on OR #36, which seems to already have a surgery going on.  I’m allowed in this room, introduced to the circulating nurse, who will be taking care of me here all morning, and then the charge nurse disappears.  Ok, this is it.  I’m alone now.  On my own.  Gotta keep it together and be professional.

I’m introduced to the people in this OR.  Right in the middle of their surgery.  From left to right:

1. Circulating Nurse, who is the only one not in the sterile field.  She wears a mask and cap, but normal scrubs.  No gloves.
2. Scrub Nurse, who is in the sterile field.  She seems to be standing next to the instruments and handing them to the surgeons.
3. Scrub Nurse, who is in the sterile field.  He seems to be manning the hooks and retractors.  That seems to be his only job.
4. Chief Resident, who is in the sterile field.  His job seems to be opening the case, making the incisions and getting started.
5. Registered Nurse First Assist (RNFA), who is in the sterile field.  She is manning the suction and other tools.
6. Patient, who is in the sterile field (duh).  He doesn’t seem to know what’s going on.

I should mention here that this OR is different-looking.  They do only “joint” cases here (involving joints and bones and such).  Because of this, they use some sort of strange air-flow system.  All the people in the sterile field, which is represented by a giant box drawn on the floor (I was instructed to never step over this line, by the way), are wearing these futuristic-looking helmets with battery packs.  Over these helmets they have what appear to be space suits.  They really look like the scary government guys from the movie “ET.”  Hilarious.  Apparently these draw the air up and into the ceiling or something.  I never did figure out what that was.  There is a giant apparatus attached to the ceiling, to which they have taped plastic sheeting in front of the patient’s face.  Only the anesthesiologist, who is not in the sterile field, can see the patient’s face.

This first case is a bilateral total hip replacement.  As I arrived, they had just finished this man’s right hip.  They are ready to start the left hip now, and I have arrived just in time.  I’m told to stand where I can see what’s going on (which is still about 6 feet away), and this is pretty much where I stand for the rest of the morning.  They have a giant flat-screen TV, which is showing a close-up camera view of the operation.  I sneak a few peeks at this from time to time, but it’s much more interesting to look at the surgical field.  There is an iPod hooked up to a miniature speaker system sitting on the floor to the side, and this is pumping out some tunes at a reasonable volume.

So, onto the first surgery I witnessed.

As I mentioned, this is the left hip replacement.  The patient is a man in his 40s, and has severe degenerative joint disease, which has rendered both his hips in pretty crappy shape.  This patient has a spinal epidural in place, and is under only conscious sedation — Versed and Demerol.  So the anesthesiologist talks to him from time to time, and the patient answers back.  Amazing.

At this point they’re ready to get going.  The chief resident and the RNFA seem to be doing most of the prepping — they have shaved this patient’s left hip and leg down to just below the knee.  Then the circulating nurse applies liberal amounts of betadine to the patient’s leg.  Then the Chief and RNFA wrap the hip and leg in some sort of yellow material from 3M.  I think they call it Ioban.  It wraps skin-tight and stays on throughout the surgery.  They actually just cut right through this material when they make their incisions.  The chief asks for the scalpel, and starts his incision, which runs about 8 inches down the outside of the left leg.  As for the surgery and operating room … some observations:

• There is a giant drape/blanket sitting on the floor in front of me (between me and the operating table).  The chief and RNFA, who is in charge of soaking up the blood with sterile sponges, throw their trash onto this blanket.  Sometimes when this trash lands on the drape, it splashes onto my lower legs a bit.  I don’t mind this.
• At the beginning of the surgery, the scrub nurse and circulating nurse write down everything they are using for this surgery (25 sponges, 2 scalpels, etc.).  At the end of the surgery, these nurses go over this list again, and ensure everything that went into the patient has also come out of the patient.
• The circulating nurse does a lot of paperwork during the surgery.  Every now and then she is asked to get something from the surrounding cabinets or outside the OR, and she gets this, opens up the package very carefully, and extends her arm into the sterile field, where the scrub nurse grabs it from the package.  The circulating nurse also calls over to the PACU to let them know the patient is almost ready after surgery.
• After prepping the patient for surgery, the 1 scrub nurse, the chief resident, and the RNFA all go out to scrub in for surgery.  The other scrub nurse remains behind to continue prepping the room, and when the other 3 come in, she and the circulating nurse help them get their gowns and gloves on.  It’s really a well-oiled machine and team.
• The anesthesiologist has an interesting role.  A lot of the time during the surgery he is just sitting there looking bored.  Other times he is hanging some blood on the IV pole or monitoring other numbers.  During the entire surgery, he is often chatting with the other members of the team.
• Speaking of chatting, there is rarely any silence.  They talk often and loudly, about many topics including vacation spots, the Phillies, and dinner plans.  I’m sure they’re concentrating, but you couldn’t tell from the mood in the room.
• The chief resident starts the surgery, and opens up the patient and does most of the work.  Then, in the middle of the surgery, the attending surgeon walks in, takes over, does the actual implanting of the titanium hip the patient will receive, and then walks out again.  The attending surgeon is there for, at most, 15 minutes.  The surgery lasts about 75 minutes in total.
• During the surgery, lots of random people (all wearing scrubs, of course) walk in and out of the OR.  Some of them start talking to the operating members, and some of them just watch for a while, and then leave.  Apparently these are other nurses from other ORs who just feel like visiting.  I didn’t know this happened during surgeries.
• The attending surgeon and the chief resident are both triple gloved.
• It is astounding how much the surgeons manhandle the patient.  After the hip is implanted, the RNFA and attending take this patient’s leg and turn it every which way, sometimes appearing to discolate his hip.  They are doing this to ensure he will have proper range of motion, as well as to ensure he won’t dislocate his hip when he walks on it.  However, they aren’t exactly gentle when they do this.
• Once the thighbone is exposed, the chief and attending break out the big tools.  They have to attach the new hip to the hip and thighbone, so they basically just take out this giant chisel and hammer, and WHACK WHACK WHACK WHACK away at the bone.  It seems almost barbaric, but I suppose there really isn’t any other way to do it.  Then they take out this extremely loud bone saw and just saw away at precisely measured places of bone.
• The smell of burning bone is one I will never forget.  When the chief is burning some of the areas, and chiseling away at the femur, there is that distinct smell that I can still remember.
• Even standing about 6 feet away, the chiseling of the bone makes some blood and bone marrow spray on my glasses.  But only a little bit.  The chief and RNFA have liberal amounts of it on their face shields.  From time to time they take a sterile towel and wipe it off, like surgical windshield wipers.

Some other thoughts about my experience:

• Some other nurses and HCPs talk about something called “Imposter Syndrome.”  This is especially true in my OR observation.  How is it that I, a little old nursing student in my 2nd month, am allowed to just wander in and out of rooms where they are performing major operations on people a few feet away?  It’s crazy!  Such trust!  It’s amazing to me that I’m still allowed to do these things and be given access to these ridiculously cool scenarios.
• Orthopedic surgeries are super bloody.  The patient has given 2 units of his own blood to use during surgery.  Cutting into bone is very messy.  Lots of blood and marrow and other gunk.  Because of this, the blanket in front of me is filled with bloody sponges by the time the surgery is done.
• After the total hip, I get to stay for a 2nd operation, which turns out to be a total knee replacement.  This is less bloody because they use a tourniquet on the patient.  However, it’s infinitely cooler, as I get to see the entire knee exposed 4 feet in front of me (I lean in a little closer by this point).  All the tendons and ligaments they talk about on TV — all right there.  Incredible.
• Patients fart a lot during surgery.  At least my 2 patients sure do.
• After the range of motion is confirmed and the titanium hip implant is secured, the chief and RNFA measure the length of each of the patient’s legs.  I can imagine it would be a bad thing if the patient’s legs were two different lengths, right?

The soundtrack for the surgery (iPod edition) includes:

1. The Killers:  Somebody Told Me
2. Matchbox 20:  3AM
3. Nickelback:  Rockstar
4. Maroon 5:  This Love
5. Modest Mouse:  Float On
6. 5 For Fighting:  Superman
7. Radiohead:  Karma Police
8. Weezer:  Beverly Hills
9. Sublime:  What I Got
10. Third Eye Blind:  Jumper

I wonder who gets to pick the songs.

After seeing the total knee, it’s time for me to leave.  I go back through the doors into the lounge, where I see … 25 people eating lunch.  There are pizza boxes everywhere, and people are digging in for the lunchie munchies.  I change back into my regular scrubs, return the purple scrubs to the charge nurse, and leave the hospital.  My back hurts from standing.  My feet hurt from standing.  But my mind is spinning with intrigue.  I love the OR.

Did I Just Get Hit in the Face With Marrow?

Stay tuned for a looooooooooooooong entry tomorrow about my OR experience today.  I might just have to write 5,000 words.