16 years.

Today is the 16th anniversary of the Oklahoma City bombing. I wrote this a year ago.

Today I'm going to eat at Sonic.

Fifteen years ago I was lying in bed reading when there was a loud noise and the house shook. I initially thought that a car had hit the house. I lived in Oklahoma City and I was three and half miles away from the Murrah Federal Building.

Within a couple of hours I was scrubbed in surgery at St. Anthony's. I was no longer an employee, having parted ways with the hospital almost a year earlier. I was part of three separate teams working at the same time on the most seriously wounded patient. I've been scrubbing for almost twenty years. I remember two patient names. This woman is one of them. (The other shared my first and last name.)

At one point I went to see if I could help in instrument processing. St Anthony's was the nearest hospital to the federal building. (Close enough that the hospital building itself had minor damage.) Hundreds of walking wounded had found their way to the St. Anthony ER. Almost all of them had severe lacerations. The average hospital stocks maybe thirty suture trays. Luanna, the scrub in charge of processing, had her staff opening every tray we wouldn't being using that day, the GYN instrument and the like, and reassembling them into suture trays: Two hemostats, a needle holder, a pair of scissors and some forceps.

When I came out of surgery, I was surprised to find bags full of Sonic hamburgers. Someone at Sonic had figured that there would be a lot of people working a lot of hours at the hospitals who would not have much chance to eat. They made and sent thousands of burgers to every hospital in town without being asked.

Today I will say a prayer for the souls of the departed and a prayer for the continued health of the survivors and families. And I'll eat at Sonic.

Classical surgery.

The surgeon gave me the specimen, said it was ileum. A bit later the circulator asked me what we calling the specimen. I told her ileum, or Troy, her choice. She said "Oh".

Nobody gets my jokes.

Tying me up.

Dear Circulator,

I have timed myself. It takes between 20 and 25 seconds for me to put my gloves on. I have also timed you. It takes about ten seconds for you to fasten my neck and tie the waist tie. You must wait at most 15 seconds for me to finish gloving so that I can turn. So why do you walk away every time and make me chase across the room. Can't you wait a few seconds or is tucking the patient's arms really that urgent.

Lawyers Suck.

This isn't really about surgery, but it is medical.

If you have a heart attack in public, what is your chance of survival? It depends. If there is not a defibrillator near by, 6%. If there is one, 50%. Modern defribillators are marvels. It takes five miutes of training to learn how to use one. Actually, since they are designed to talk the unitiated though the process it doesn't even take that. The user needs to be able to figure out how to turn it on, get two pads on approximately the right positions on the victim's body, and hit the shock button when the machine says to. The machine's computer makes the rest of the decisions. They are also relatively cheap.

The key thing is that they must be used as early as possible. Within minutes, the patient will pass beyond the point where any medical intervention will help. If a paient has to wait until EMS arrives, it will probably be too late. These marvels were designed with the idea that they would be widely available in the community, at stores and churches, in parks, in apartment buildings and the like. Then the lawyers arrived.

Many states offer some form a immunity to owners of difibrillators. If a local convience store owner buys own, and has to use it, and the patient dies, then the store owner can't be sued, even if the store owner used the device incorrectly. California offers qualified immunity. The store owner only has immunity if they jump through several hoops, including training employees in the use of the devices and monthly checks of the equipment to for good working order, and developing a written plan for their use. Failure to jump through every hoop looses the store owner immunity and exposes them to liability. Of course, standing there and watching the customer die exposes the store owner to no liability at all. Given his legal environment, many business owners rationally choose to not buy defibrillators.

A state senator proposed a bill to sweep all of this away and give owners of defibrillators unqualified immunity. Without the fear of liability more places would buy these life saving devices, more people would live who would otherwise die. Who oposed the bill? Lawyers. Without liability there could be no lawsuits, and that would be bad for lawyers. Who else oposed the bill. An EMT who runs a company that provides the training required by the current law to avoid liability. These people suck.

15 years

Today I'm going to eat at Sonic.

Fifteen years ago was lying in bed reading when there was a loud noise and the house shook. I initially thought that a car had hit the house. I lived in Oklahoma City and I was three and half miles away from the Murrah Federal Building.

Within a couple of hours I was scrubbed in surgery at St. Anthony's. I was no longer an employee, having parted ways with the hospital almost a year earlier. I was part of three separate teams working at the same time on the most seriously wounded patient. I've been scrubbing for almost twenty years. I remember two patient names. This woman is one of them. (The other was named David Stapleton.)

At one point I went to see if I could help in instrument processing. St Anthony's was the nearest hospital to the federal building. (Close enough that the hospital building itself had minor damage.) Hundreds of walking wounded had found their way to the St. Anthony ER. Almost all of them had severe lacerations. The average hospital stocks maybe thirty suture trays. Luanna, the scrub in charge of processing, had her staff opening every tray we wouldn't being using that day, the GYN instrument and the like, and reassembling them into suture trays: Two hemostats, a needle holder, a pair of scissors and some forceps.

When I came out of surgery, I was surprised to find bags full of Sonic hamburgers. Someone at Sonic had figured that there would be a lot of people working a lot of hours at the hospitals who would not have much chance to eat. They made and sent thousands of burgers to every hospital in town without being asked.

Today I will say a prayer for the souls of the departed and a prayer for the continued health of the survivors and families. And I'll eat at Sonic.

The Sound of Surgery

I've mentioned elsewhere that the smell can be the grossest thing about surgery. Smell is not the most nerve wracking thing, though. Sound is. Not the sound of surgeons bellowing, but rather what is normally a quite normal sound, the pulse oximeter. For those not familiar with it, the pulse oximeter is a machine that measures the amount of oxygen carried by the blood. It does this by shining a specific wavelength of red light through a relatively thin body part, usually a finger. It then measures how much of that light is absorbed. From this it is able to calculate what percentage of the red blood cells are oxygenated. The best possible "score" is 100 (unless you are a member of Spinal Tap). Numbers above 96 are considered normal. Numbers below 90 are worrisome. The machine is also able to measure the pulse by measuring the time between each wave of freshly oxygenated blood. It has become one of the basic tools of anesthesia.

It has also has the best designed sound I have ever heard. It is the modern version of Monty Python's "machine that goes ping". Every time the curve peaks the machine makes an electronic "ping". Its the background noise of every OR. Most of the time it doesn't register on our consciousness. The genius in this sound is one feature: as the oxygen saturation decreases, the the tone of the "ping" lowers. A drop of 10 points will drop the tone over an octave. Since a decrease in saturation is often accompanied by a slowing of the pulse, the machine begins to sound like its battery is dying, which is the perfect metaphor, because that's what the patient is doing.

Believe me, a serious drop in the tone of a pulse ox will get everyone in the rooms attention.

This video shows the tone change in minor way. These tone changes wouldn't grab anyone's attention but they give an idea of what I am talking about. (Tone changes about 0:27 and 1:25)

Just do it.

This is a bit of a rant.

I work weekends, hence the title of the blog. I have to be able to do just about any case that comes along. I understand that the wimps fine scrubs who work during the week are stuck in their specialties and don't have a lot of exposure to other specialties. I don't care though. There are certain cases spread through all of the specialties that every scrub working in a large hospital must be able to do. (I may make a list of these someday.) If you can't do them, go work out an outpatient surgery center, or L &D, or specialty hospital and let your position be filled by a competent scrub. Even if you don't see them every day, you gotta be able to day a crani for subdural, a thoracoscopy, an ORIF and other procedures in the "scary" specialties of ortho, CV and neuro, even if you a GYN, or Plastics or General scrub. You just have to be able to do them, or get the hell out of here.

There, I feel better.