Wednesday, September 17, 2008


Everyone in surgery and the ER has made the same joke. A young man, often African-American, comes in having been shot or stabbed or beaten to a pulp. After the patient is anesthetized, someone will ask what happened. Then The Joke starts. "He was sitting on his front porch, after coming home from church, reading the Bible when TWO DUDES, came up and shot, stabbed or beat him for no reason. And then stole his Bible." A while back we had a young man who had been shot and had horrible injuries. He was one victim of this drive-by shooting. Other hospitals in town had three more. At one point we had the state police come in to the lounge and ask we if we could look for identifying scars, so that family could know which kid was which. One of the kids eventually died. I didn't hear The Joke, but I did hear someone say, "Don't these guys have anything better to do." The Joke is funny because the sarcasm is true. It is usually assholes who are doing things that they should not who get shot, beaten and stabbed. In this case, it really was four kids, all doing well in school, one of whom was a star athlete, who were coming home from church, and were mistaken for some gang bangers and got shot.


How not to do surgery.

Hat tip to Ace of Spades

Bag of guns

Another tale from the surgery department of the big-city trauma center.

No story that begins, "My buddy brought over this bag of guns." is going to end well.

He survived.

Stupid Names

One of the joys of working in medicine or any other field in which you see many peoples' names, is the opportunity to see truly stupid names people inflict upon their children. For years I thought that the winner was the two separate women my wife found when working for the state Tax Commission named Aquaneta. But we have a new winner. This is, sadly, third hand so it is beginning to rise to the level of urban legend.

One of our fine CRNA's at work tells the story from his days in anesthesia school. It seems that one of his colleagues had child patient. Paperwork had his name as "Liam". No problem, Lee-Um, nice Irish name. Anesthesia student goes into room and starts the usual routine, "What is little Lee-Um having done today?" Cold response from mother "His name is "Yum". "Oh, I'm sorry, we have his name as Liam." "It's pronounced Yum." I'm going to interject here that this family was white. I only mention this because some of the transliteration schemes for Asian and African languages can lead to surprising pronunciations. That's not in play here. Back to the story. Stunned silence. "OK, I'm just curious, how do get "Yum" out of L-I-A-M?" "He's named after his father......William."

Scrub tech blog?

It seems that scrub techs don't blog much about their jobs. There are several emergency room and ambulance people blogging, but I have yet to find a single scrub tech blogging about the job. There are scrub techs with blogs, but they all seem to be for sharing family pictures and stories. I guess this is because the job doesn't provide the same number of interactions with a wide variety of people. A really big case will have maybe six or seven people in the room plus the (unconscious) patient, and will last for several hours. The average ER person will see dozens of people in that time. Just more opportunity, I guess, to have those unusual experiences.

Monday, September 15, 2008


Originally posted at Random Dafydd.

Doctors are wealthy. No big surprise there, but given what they do most people don't begrudge them that. You want smart, skilled people to be there when you come into the ER at 3:00 AM with a heart attack, or stroke, or injury. The only way that will happen is if you pay them well.

Not every body sees it that way though. The Tulsa World recently ran a letter from a gentlemen who refers today's doctors as "capitalist businessmen who masquerade as doctors", and hopes for the day of socialized medicine. Seems he doesn't like being asked how he is going to pay for the services he receives. He draws a comparison between today's routine office visit and the procedures during a disaster. I've been in a hospital during a big disaster. The ER saw hundreds of patients, and I bet not one was asked anything about finances.

All this is interesting, because I read the letter in the OR break room. When I was done with my break, I went and gave a lunch break in the trauma ortho room. In that room, a board certified, fellowship trained, trauma orthopedist was fixing a horrible break to the proximal humerus on a young man who had wrecked his motorcycle. He was assisted by two certified scrub techs and two certified radiology techs. There was a board certified anesthesiologist given anesthesia. The surgeon was using some very sophisticated (and expensive) plates and screws to fix the multiple fractures. A representative of the company that made the plates was in the room to make sure everything went well with his products. This is a lot of talent and expensive technology being used by this young man. Now many young men who crash motorcycles don't have a lot of insurance. This young man had several tattoos, one reading "Thug Life Bitch", and another reading "Fuck All". (We were left wondering if the thought was left incomplete, Fuck all... accountants, public employees, goats?) I may be showing bias, but I think it is safe to say the surgeon, the anesthesiologist, and the hospital are not going to be paid for this man's care. Some times life provides a nice ironic juxtaposition.

If you have the right to demand my services, and I have no right to demand to be compensated for my labor, then I am your slave.

13 years

Originally posted at Random Dafydd.

I was working on Saturday, so for the first time didn't actually note the date. It's been thirteen years since Oklahoma City. I was in OKC. I heard the bomb go off. Although, I no longer worked there, I went into St. Anthony's and scrubbed. It was six blocks from the Federal Building. Normally when I scrub a case, I never even notice the patient's name. I still remember the most serious patient's name. I called the ICU for two weeks checking on her.

13 years. I no longer think about every day, or every week, but it is always there, and always will be. When September 11 came around, I wasn't shocked. Angry and horrified, yes. Shocked, no. The world is not safe.

Another memory from that day. When the first rush was over, I went to the break room to wait. There were boxes of Sonic hamburgers. It seems that Sonic decided to send food to the hospitals. They knew there would be a lot of people working a lot of hours. No one asked, but they sensed a need that they could fill and then filled it. I will always be a Sonic customer.

There was a lot of people seeing needs and filling them. St. Anthony's, being the closest hospital, saw hundreds of walking wounded in a very few hours. Many of them had lacerations that needed stitches. They were able to get them, in part, because Luanna, the Scrub Tech who was in charge of central supply, had people tear apart all of the non essential sets, the GYN sets and the like, and reassemble the instruments into suture trays; needle holder, forceps, two hemostats, and scissors. Lord knows how many people made similar contributions.

Harvest Time

Originally posted at Random Dafydd.

This weekend we had an organ harvest. I hate organ harvests. Hate them. Will do any other case in the OR, with any doctor for any amount of time in order to not do them.

The reason I hate them is not rational, but what it comes down to, is I don't want to be part of the machinery of death. Don't get me wrong, I fully understand that these people are already dead. I accept, at least intellectually, the concept of brain death. We are not killing them. I have no problem with organ transplantation. I will happily participate in an organ transplant. (OK, not happily, but as a happy as I am to do any other long surgery with finicky surgeons.) If I needed it, I would sign up in a heartbeat to be organ recipient. If it weren't for my medical history, I would be an organ donor.

None of that matters. We bring a patient into the room with a pulse and 02 sats, and then we take out organs and turn the machines off and send the patient to the morgue. In the pit of my stomach it feels like we are causing death. I've tried, I can't get around it. It gives me nightmares.

Luckily, the other tech on my shift doesn't have these qualms. She understands my reservations and does all of them. This weekend it looked like the cases were going to fall in such a way that I would have to do this one. I was going to suck it up and do it, but man it depressed me. But my coworker came through. Thank you.

This should not have to be said.

Originally posted at Random Dafydd.

Another work weekend.

I know it is spring, because the lawnmowers are out.

For those of you who might forget, power lawnmowers have large, rapidly spinning blades underneath them. Don't stick you fingers under there.

This weekend's patient only lost the tip of one finger.


Originally posted at Random Dafydd.

Another work week(end) has passed, and I am once again reminded of a now familiar joke in the OR.

What are an Oklahoma redneck's last words? "Hey, y'all, hold my beer and watch this."

Rule #21 for scrub techs: You can't see through blood.

The grossness of surgery

People often tell that they could never do my job because they couldn't stand all of the blood and gore of surgery. I usually reply that what you see in surgery is not that gross. It's the smell.

Tedium and tragedy

Originally posted at Random Dafydd.

It is Monday morning, and I am recovering from my weekend at work. I often describe my job as "tedium punctuated by tragedy." Now, this weekend was not a bad weekend, and nothing really horrible happened. We didn't have to work for twelve hours without a break. We didn't have any crash cases. We all got lunch. None of the surgeons were assholes. It was just a typical weekend. But thinking about it can be depressing. There was the fasciotomy. A fasciotomy is done when a patient has a condition called compartment syndrome. This is when a muscle becomes traumatically injured and starts to swell. However the fascia, which is a tough membrane surrounding the muscle, won't allow the muscle to swell, causing pressure. The pressure can be so great that it can cut off the circulation to the muscle, killing it. The solution is to split the fascia, relieving the pressure. If this is done quickly enough, the muscle can be saved. This patient had been pinned under a truck for upwards to twelve hours. The surgeon told us that he had treated people with similar injuries after an earthquake in the Philippines when he was in the military. Every one of them died within a few days.

The same surgeon fixed three broken hips. I like these operations. They are technical, but I understand them well. They keep me busy and they don't last too long. There is the satisfaction in moving through a well-rehearsed dance. Underlying it all, however, is the knowledge that half of these patients will be dead within a year. Old people's health, and it is almost always old people who break their hips, is often like a spinning top. One push can destabilize it quickly and lead to its collapse. My grandfather died this way.

I got lucky and didn't have to do the PDA on the 1 Kg baby in the NICU. I hate going up to NICU. There's no space, it's hot, and there are too many people. The babies are all so small. They always run all the parents out so that we can operate and I know from experience how frustrating that can be for the parents of the other kids. There is always a gaggle of parents crowding around the door as we leave. The all seem so young, and so tired.

On the plus side we did a couple of normal appendectomies. Nice healthy people, with a single problem, that we fix. People used to die a horrible, painful death from appendicitis. We are saving these people's lives. But it is all so routine.

The weekend is over. I have the satisfaction of knowing that we helped people. We even saved people's lives. Perhaps the fasciotomy patient will survive. Perhaps all three of the hips will be in the half of people whose tops keep spinning. The appendectomy patients will hurt for a week and continue with their lives. Their surgery will a become a minor part of their past. The other patients will likewise continue. By next month I will have forgotten about most of them. Because although the job can be depressing to think about, the dirty secret is we don't. We do the job and move on. That is all.

Rules for Scrub Techs

Originally posted at Random Dafydd.

Today was a work day, and I was reminded of the set of rules I have been formulating for scrub techs. I was inspired by the Fat Man's rules in The House of God by Samuel Shem. Some of these are serious, a few are well known aphorisms in ORs around the country, and a few are just a bit cynical. Work for 16 years in an OR and you will end up that way too.

1. You can never have too many towels.
2. Pus is always under pressure.
3. There is no point in having preference cards if you refuse to believe them. (A preference card is a listing of what a particular surgeon will want for a particular case. They used to be actually on index cards. Now they are usually computer files.)
4. The preference card is always wrong.
5. It doesn't matter what the preference card says, never open an abdomen without having stick-ties open.
6. Never suck on the brain.
7. Sterility is a state of mind.
8. Give the Doctor what they need, not what they ask for. Only do this if you know what the Doctor needs.
9. Muscles are in the way. This is all a scrub really needs to know about them.
10. Know the boundaries of your circulating nurse's ignorance.
11. Sometimes it is as important to know the names of the surgeon's children as it is to know the names of the instruments.
12. A doctor who says he only needs three things for a case will need ten.
13. The patient is not on the back table.
14. Knowing why is more important than knowing when.
15. Never turn down a break.
16. Sit whenever you can.
17. Almost every time a sponge has been left in a patient, there was a correct count.
18. Every surgery, no matter how minor, is an opportunity to kill someone.
19. In a pinch, all you need on your mayo stand to start a case is a scalpel, two hemostats, a pair of pickups and pair of scissors. Everything else can be faked.
20. When setting up, the ideal is to touch everything once and only once.

There are more rules, but I can't think of them now. Maybe later.