Little Blob of Fat

Keeping up a professional air can be hard at times. Patients who are wondering about their well being and are potentially very frightened sometimes just need their caregivers to be confident, and that may require a degree of acting on our part.

I once had no idea what the hell was going on with a patient who was more worried than sick, and I made her feel better by calmy and confidently telling her I had no idea what the hell was going on with her. A little while later she was fine, and the entire nurses station just shrugged and moved on.

Just the other night a postpartum mom demanded that she see a doctor before she left because she noticed a patch of dry skin on her cheek. The annoyed nurse wisely called me instead, and I proceeded to have the most in depth conversation I have ever had regarding dry skin, winter, air conditioning, different detergents, make up, skin lotion with scent, without scent. I thought the patient was teasing me. Finding myself sounding like a neutrogena commercial, I told her to "apply lotion to the area and call her Familly Doctor if symptoms persist." That is known as a "Ditzel Call".

One of the funnier moments involved a little blob of fat.

I had been assisting a surgeon with an open cholecystectomy, where the gallbladder is removed. They are usually done laparoscopically these days, but if there is a complication, the surgeon extends one of the port incisions and converts to an open case. An open case is when you actually put your hands into a patient with a big hole cut in their skin, as opposed to doing it all on a TV monitor through many little holes, or ports.

We had to open this guy because he was so big. Once open, it was still a pain in the ass getting the gallbladder out since there was so much fatty tissue everywhere. In surgery, adipose or fat, is pretty bright yellow and typically globular. Depending on how much connective tissue and vessels are in it, the globules can simply break away. During a case on a big heavy, it's not uncommon to have little blobs of fat hanging around on the field, the instruments, or your hands at the end of the procedure. When they are left in the open air for a while they get to be the consistency of, say, a Corn Pop that has been sitting in the milk in your cereal bowl for 30 minutes, then accidently pushed up and over the edge of the bowl by your spoon and is unnoticed until another 30 minutes, long after you have gotten up, put the bowl in the washer, and walked past the table. There on the table, is a mushy yet firmish fat globule, the likes of which I see every day I go to work. Same color, too.

At the end of that case there were corn pops everywhere. They can even roll over the table (fresh) and stick to your shoes (drying). That's why people in surgery where those little blue booties. People think it's for sterility. Nope - Corn Pops.

I had to retract the liver and fatty layers with a very large retractor that kept coming out. It sort of pops out, depending on how much muscle you decide to pull with. A great deal of good surgery is knowing when to be ginger and knowing when to use strength. When a retractor pops loose from fat, under force, some tissue may be ejected.

That's probably how a little Corn Pop got on one of the overhead lights. The next patient in the room was in the process of wiggling over from the transport stretcher to the OR table, when the piece of fat fell off the light and onto her right shoulder. This is a rather big No-No. I was standing on the other side of the OR table, so she was scooting towards me. She had on her hospital gown and a white hospital blanket up over her shoulders, and there it stuck.

She was looking to her left torwards me, where she was scooting to, but she still saw something move out of the corner of her eye because she sort of jerked her head to the right. Luckily, I had already raised my hand up to simultaneously flick the wet Corn Pop off her shoulder and "steady" her. It was admittedly one of the slickest, quick thinking tricks I have ever pulled. Being in midsentence at the time, I didn't even break cadence. Of course I had a mask on, so hiding my grimace was not an issue.

The problem was the anesthesiologist. (Always blame the man behind the curtains). He was standing at the head of the patient and had to duck when I flicked the glob. His reflex to avoid the glob was impressive, since it was moving at flicking speed - much more impressive than his initial reaction to witnessing the glob fall onto her shoulder - he froze. Needless to say, I am glad I didn't hit him with the piece of fat. If it had hit him in the eye I may have been suspended or fired.

The patient knew something had just happened since she saw something had fell or moved near her right shoulder, my hand was now there, and the doctor behind her had suddenly and inexplicably ducked.

She stopped scooting and asked in a slightly accusatory tone, "What was that?"
The anesthesiologist, lifting his head up to stare at me with wide eyes, also seemed to be confused.

With my hand already on her shoulder, I calmly looked her in the eye, and asked, "What was what?" The anesthesiologist's eyes rolled back to the patient, waiting for a response.

"Something just hit my shoulder."

"This is just my hand, dear, you're OK.", I lied. I appropriately held it up as if taking a left-handed oath and looked confused.

I have been married for a while now, so I can't remember the last time I skillfully one handed a bra clasp. I had just reached (almost) behind a woman who was already nervous, done something quick, slick and devilish, and was now trying as hard as I could to appear innocent and smooth to a woman who wasn't sure whether or not to trust me. My teenage years were pretty tame by some people's standards, but what evil shit I did commit has come in handy more than a few times during my adulthood. This was one of them.

"Well what the hell made him jump?" she asked, referring to the doctor behind her head. Uh oh. I almost felt like telling her the truth, but it's harder than you think finding the words to explain how someone else's guts from a preceding case fell off the ceiling and landed right on her. I continued the lie.

"I didn't see him jump. Did you just jump, Doctor?", I asked, realizing that the game could be over with his reply. All he had to do was shake his head.

"I . . . uh . . . coughed." Not bad. Could have been better, but not bad. The anesthesiologist obviously hadn't rounded third until med school.

Putting my hand on her shoulder again and bolstering his questionable explanation, I said, "I have a cough, too. Something must be going around. Keep scooting towards me, please."

That did it. She stopped asking questions and complied with me. I am not sure how confident she was with any of that situation, but it didn't matter. The Versed has a retrograde amnesic effect, so the patient typically can't remember too much of anything once they are in the room.

As soon as the incident passed, the anesthesiologist held up a syringe and said, "versed". Knowing exactly what he was thinking, I responded, "cool", and kept the oxygen mask over the patient's face. Holding the patient's hand as her eyes rolled up from the induction agent, I took a deep breath and thought about the bullet we just dodged.

We never did find that little glob of fat, even though we looked high and low for it. Other team members asked what we were looking for, and shocked by the answer, asked how a piece of body tissue could get over by the anesthsia stack.

I looked them all in the eye, and calmly told them, "Because that's where I had to flick it."

The Horror, The Horror

Every once in a while someone asks me the question, "What's the grossest thing you have ever seen in surgery?". Some people are offended by people who ask this question, others aren't. I'm not. I guess it's like asking a cop if he's ever had to shoot anyone. (Don't, by the way)

If I'm not in the mood to go into it, I'll just tell the person, "I don't want to talk about it." I've only said that once or twice, mainly because of the mixed audience, not necessarily because my own sensitivity to the incident. But what I saw that evening was truly horrendous, and sort of makes me feel like my ribs are melting when I take myself back and think about it. You've been warned.

A Shirodkar Cerclage is a pretty cool procedure. It is done for pregnant women who are diagnosed with an "incompetent" cervix. The base of the uterus (or the top of the vagina, depending on your point of view at the time) has a hole in it that comes in handy when it's time to push the baby out. This hole is clamped very tight all the time, and is actually more like a short tunnel.

If the cervix opens a little too much during pregnancy, or if the "tunnel" is shortened, a stitch needs to keep it closed. This is called a cerclage. It's like a purse string. A Shirodkar is a little more involved, as the Obstetrician must dissect some of the mucosal tissue and place the purse string stitch significantly higher up the cervix. This is done to keep the fetus inside the uterus during development. Otherwise the fetus may be lost.

Assistants in this situation are just there for exposure, that is to say, we make sure the Docs can see the cervix well enough to throw their stitches. What looked like a routine cerclage, with the woman's legs in stirrups in the operating room, suddenly became a little more serious one night. Upon retraction of the vaginal walls, I heard the doctor mutter something bad when he got his first sight of the cervix. Being to the side of him, I ducked my head in to see down the hole.

A portion of the amniotic sac, which contains the fetus floating in amniotic fluid, was sticking out of the cervix, occupying the top of the vagina. It was like a pale brown water balloon. It even had little bubbles visible. And there was a foot. The fetus' leg, 16 weeks gestation, had also poked through the cervix, and you could see the bottom of the tiniest foot in the fluid. Bad. Very Bad.

The plan at this point was to gently, very gently, push the amniotic sac back into the uterus, do the cerclage, go home, wait 24 weeks, then deliver a baby.

While the doctor was easing the sac back in, the damn thing ruptured. Very very bad. At that moment, with the sudden gush of clear fluid exploding out of this woman's vagina, the fetus was doomed, the pregnancy terminated. Not being in this situation before, I didn't realize the gravity of the situation I was about to be a part of. The physician, after collecting his thoughts, decided to abort the fetus right there.

The patient, who had a spinal anesthesia, was at that point fully conscious and aware. So when the doctor appeared next to her during the case to discuss how he could not reduce the sac and must therefore perform an abortion, she began to cry.

An ultrasound was brought in so he could see the uterus and its contents, and he went to work taking out the fetus. Usually a suction device is used to suck it out, but in this case, he decided to go after it using sponge clamps. Realizing it wasn't going to be pretty, I braced myself to see my first up-close abortion. Time after time he inserted the clamps throughout the vagina and into the uterus, and seeing where he was on the ultrasound screen, grabbed at the fetus.

The problem was it didn't come out all at once. First he pulled out a foot. Then the rest of the leg. There was a lot of blood and chunks of placenta. My menial role was to hold the open metal container directly under the bloody, dripping vagina to catch whatever he pulled out. She was still crying. At 16 weeks a fetus looks like a cross between a baby bird and a naked doll. My metal container got heavier and heavier, and I got dizzier and dizzier.

I tried not to look at the container, but just as you keep reading this, I kept peeking. Identifiable body parts kept coming out - hands, ribcage, legs. The last thing pulled out was the head, which unfortunately didn't land in my basin face down. That's what did it for me - locking eyes with a little head in bloody fetus stew.

The room suddenly sounded muffled, and tunnel vision started to set in. My knees and hips felt gimpy. I looked over at the Anesthesiologist, who was at the end of a long, brown, swirling tunnel saying in his Asian accent, "Hey! Why you look so green?" My lips felt cold and the metal basin felt heavy, and I was about to throw in the towel and ask to be excused, when Val reeled me in.

Val was the experienced Surgical Tech who was with me during that case. Realizing I was losing it, and probably not feeling too good herself, she asked what I was doing for the Fourth of July. Her voice seemed confident and loud in my left ear, and I turned my head to face her. She was very close to me, pretty much in my face, and again asked if I was doing anything for the Fourth of July.

That question kept me on my feet. We set up a conversation that invoked memories of past Fourth of July's, where there weren't any dead babies or fetus stew, or sobbing would-be mothers. Just cold beer, hot dogs, fireworks, and family. As the doctor worked, my vision started to get better, and the dizziness drifted away. When the case ended, we were talking about whether or not potato salad should contain dill.

My mind represses stuff. I know what happened in there, but I can't really picture it anymore. I only remember seeing one gross thing - the head - it's hard to forget a face.

When I tell this story to people who ask the question, they are usually a little taken aback. Once someone told me to stop talking. If they want a gross story, they shouldn't ask for one. There are certainly worse ones out there people choose not to tell. If a listener appears too grossed out or too shaken up, I'll ask them what they've got planned for the weekend.

By the way, I think potato salad doesn't need dill. Don't get me wrong. I LOVE dill in potato salad - it gives it a great aftertaste, especially if there's a little relish in it. But I've been around enough potato salad to appreciate it without the dill. I'm not a picky eater. I just love sitting outside, talking to friends, barefeet in the cool grass, holding an icy cold beer in one hand and a paper plate with a hot dog and some potato salad (with or without dill) in the other.

What's your favorite Fourth of July memory?

Wrestling With The Reaper

It's not too often that I am in a life and death struggle for a patient within a few seconds of a call. The other night was an exception.

Walking from one department to another at about 2am, I was innocently thinking about what part of my "lunch" I would eat once I got there. My wife had packed my favorite salt and vinegar chips, and my mouth instantly started watering for them. As soon as I walked into the empty surgery staff lounge, the local overhead paging system broadcast what sounded like a pretty stressed out nurse, asking for my help by name in OR #4 STAT!

What struck me as odd was the fact that I had just randomly walked onto the unit, and seconds ago would not have heard the page. I had no time to wonder about the coincidence, however, since this was most definitively a very serious problem. A couple of things about that page lead me to think the proverbial shit has hit the proverbial fan.

One, I am the OB PA at night, and everyone working at the hospital knows my position is dedicated to emergent C-sections. They can happen at any time and must often be done in minutes. Therefore I am not permitted to scrub on regular surgery. This may sound strange, but I can't be dedicated to two department's possible emergencies. I can't be stuck in an "emergency" appendectomy while a woman is crashing who needs a section. The surgical team leader must give any scrubbed-in member of the surgical team verbal permission to break scrub. Doing so without permission (say, out of anger or exhaustion) is not only grounds for termination, but grounds for losing your job license. It's a legal offense that is considered abandonment (of the patient's care). So I knew that requesting me to come into an OR for a case STAT must be for a pretty damn good reason since it is technically against my job description and could land me in trouble with administration.

Two, the 1st call surgical PA, Janeen, who was called in from home to actually do the case, was new and on her first night working solo with a surgeon. This meant what was going on in there was pretty dicey, and not within the skill set of a rookie assistant.

Three, my pagers starting lighting up, and the hospital wide overhead speakers called for the OB PA to report to OR #4 as I was putting on my mask. This to me meant that whoever called out for me initially then decided to use every possible method of summoning my assistance.

There are really only three things that warrant a distress call like that - the A's, the B's and the C's. Airway, Breathing and Circulation. A patient must have these three things or they are going to die relatively quickly. Typically in surgery the C is the culprit, so I fully expected an uncontrolled bleed as I ran into the room, or a coding patient. It wasn't.

As soon as I ran in, I realized the patient wasn't moving air. There were the signs that a struggle had taken place. Usually the start of a case looks pretty orderly, with the team members at their designated positions, arms folded, standing still around the OR table like some macabre ceremony with a lit up body on the altar. This time the routine had been broken for some reason. The 5 team members were visibly panting and in various poses as the patient lay there on the table squirming, and the surgeon was using his scalpel to cut down to the trachea cartilage. The anesthesiologist was masking him with one hand, and squeezing the bag with the other, but the air-filled mask was just cheek farting as the much needed O2 was meeting a dead end somewhere in the patient's mouth or throat, and slipping out the sides. The tech was draped over the legs, which incidentally were half off the table, keeping him from squirming. The rookie PA was holding one of his hands away from his neck while ineffectively retracting the site for the surgeon.

He had been admitted for a drainage of a pharyngeal abscess (throat infection gone bad), and had been acting strange at home. Good thing the ENT surgeon sensed something wasn't right, and decided to do it in the OR and not the ER as usual.

Apparently, I later learned, this 280lb linebacker of a man had suddenly seized as soon as they got him onto the OR table from the gurney (which was still in the room, tipped over on the floor). The circulator RN had somehow been scissored between his legs off the end of the table as he was seizing, and it took some strong-arming from the rest of the team to break her free. She then staggered to the phone and called out for me. Her two words for me when I barged in were, "GLOVES!! HELP!!", as she pointed to the surgical site. These words were actually all she needed to say.

I just put on some nonsterile gloves and took over for Janeen, who was understandably a little stunned and out of breath. The Anesthesiologist kept saying, "I don't know what happened! I don't know what happened!", and was pushing Diprovan into the IV as fast as he could. The patient, I should mention, did not appear conscious or reactive to the pain of surgery, but still had positive (and strong) muscle tone. It was pretty obvious he was in laryngospasm, where the muscles that can close off the top of the windpipe decide to clamp shut, just as if you were drowning. He was trying very hard to breath on his own to no avail, as the chest and abdomen kept contracting violently.

I asked the tech for another retractor, and pulled the hole wider for the surgeon. I had one L-shaped retractor called an Army/Navy in the hole on one side and another Army/Navy on the other side. The distance from the skin surface to what we were hoping would be the trachea was about 2.5 inches deep, and about an inch and a half in diameter. Needless to say we were working on a big fat neck in a little deep hole. It kept filling up with blood, too. Working with the surgeon and giving Janeen a few instructions on what to hold, we finally got a relatively clear view of the bright white tracheal cartilage. I am not sure the surgeon knew exactly where we were on the trachea, but it wasn't the time to explore. His pulse ox (a finger monitor that measures oxygen saturation in the bloodstream) had stopped it's baritone beeping and gone silent.

He asked if we were ready and I instinctively crouched to the side of the patient while still holding exposure, and waiting for the stab. Judging by this guy's thoracic retractions, I anticipated some pretty forceful breaths coming out of that little hole once the trachea was cut. As I got as low as I could while holding the two retractors, I came face to face with the patient's shoulder tattoo. In plain black ink on his massive shoulder was drawn a sinister image of the Grim Reaper, with skull face, black hood and scythe. How coincidental, I thought, that this man was currently dying, and all I really know about his history was that once upon a time he decided to have death scarred into his left shoulder.

As I thought about that, there came a surprisingly loud hissing and spurting sound from the surgical field. I glanced up to see a fine pink mist geysering up from the man's neck, with drops of more blood flying to the ceiling. The face of the surgeon was covered in little red polka dots and his eyes squinted through the red haze. Janeen had her head turned, but every surface with an unobstructed line to the the surgical site was hit with bloody splatter. My bare forearms got hit, and the vaporized blood formed a pink fuzzy coating on all of my arm hairs.

With the sudden rush of oxygen, the patient's muscles sprang to life again. I had to forcefully resist the squirming man's neck in order to allow the surgeon good visibility. The tired circulator had to get back into the game and start keeping the patient still.

The sound was impressive. We had to talk at a yell in order to be heard over the loud whistling and hissing coming from the new little hole in the trachea. With every massive inhalation, there was the snake-like hiss, and every exhale there came the rough whistling, interrupted by violent spasms of coughing and sputtering; the blood from the incision trickled into the new tracheostomy and then ejected into the air as droplets and mist. At some point during the case, the cartilaginous tissue of the trachea began to actually honk under the forceful passage of air. It was sort of like cutting a slit into a reed or a piece of thin bamboo then blowing as hard as you possibly can through it, making a loud and offensive goose call. It was a barrage of honking, hissing and whistling.

We eventually had to use a little pediatric tracheotomy tube since the adult size wouldn't go in despite the surgeon's best effort to mash it into place. I remember there was a point when it didn't look like a tube was going to fit, and the case sort of hit a standstill. We weren't getting anywhere in our efforts and were starting to genuinely fatigue, but the RN produced a little pediatric tube, and things started to work. Once the tracheotomy tube was in place, things were able to calm down considerably. I took that moment to get out of there. The patient was getting good general anesthesia, and the tube just had to be sutured into place - I left Janeen to assist.

After attending my duties elsewhere that night, I learned that the patient spazzed out again on wake up. He shot up like a jack-in-the-box and immediately thrashed about, clawing at his throat. This time the Anesthesiologist was ready, and sedated him well enough for an uneventful recovery.

When younger people start to circle the drain, they usually do so with effort. It's almost like a 100% attempt to die, or perhaps 0% effort to fight - so drastic things must be done to save them. You don't see that with old people. Old people fade into death, often times surprising health care workers in their prolonged descent despite horrendous numbers that seem impossible. I knew somebody quite close to me who lived on for 6 good months at 10% ejection fraction. Our hearts empty 60% (if I remember correctly) of its blood volume with every beat, and the books say anything below 15% is noncompatible with life. But the body adjusts to survive if given enough time.

We still don't know why this guy seized the way he did, but he certainly seemed like he had a mission to die. Everything the anesthesiologist did was to no avail, every attempt to keep him still was met with forceful resistance, and the surgical site was a messy, hazardous combat zone with sharp instruments and blood on the field and in the air. When I left the room, I glanced back to see the weary circulator nurse tucking his huge tattooed left arm back onto the table at his side while the team worked - it had of course broken free and was laying limp over the edge for a while.

That's the last I saw of that patient - an ugly tattoo of the Grim Reaper himself, complete with the scythe and the black hood. In the space of ten minutes I had become sweaty, bloody, tired and stunned. And that hideous, grinning skull was staring back at me with empty eyes as I walked out of the room.

Drunken Stitches

At the time, hiding in a cornfield to scare an approaching group of friends seemed like an absolute no-brainer.

Who wouldn't? It doesn't matter how old you are; if you are of the male gender, it's at night, and you are presented with this opportunity, only an unimaginative snob would decide against it. It surprises me that when I tell this story orally, people actually roll their eyes when I describe how my friend and I ducked into the adjacent cornfield, waiting for the right moment to scare the living crap out of our approaching buddies.

I have to admit at this point, the idea was all David's. He was a little drunker than I was, his passion for quality spirits having become evident well before sundown. I wasn't far behind, since the switch to my beloved gin and tonic from the relatively steadying effect of Guinness started at sundown. Nevertheless, after quickly stating his proposal he all but vanished from my side. Knowing the idea was irresistible and well-timed, I heard a whispered, "WELL?" from about 5 feet into the dark rows of corn. Glancing over my shoulder and seeing our two fellow drunks stumbling down the side of the road, I pushed through the tall stalks and practically tripped over the patiently crouching David.

Seeing as how this was sort of David's show, I patiently waited next to him, listening to the voices getting louder. To our disappointment, they weren't quite as inebriated as we were, and were talking about where we had hidden. I was in the process of whispering the question of where David had put his scotch glass when he decided to spring his trap. I should have known this, since David, able to more acutely regress to adolescence than I, understood that the element of surprise was partially lost and could only be saved if done immediately. He had even anticipated the necessity of his actions requiring two hands, as he had thoughtfully put his scotch glass into one of his large side pockets. Whether it still contained alcohol when he did this has been lost to the mystery of history. What is known, was that I was trying to keep corn leaves out of my gin and tonic when I realized I was alone again - this time in a claustrophobic dark corn row, listening to the nearby commotion of David attempting to salvage a scare with the effort of an inspired athlete.

He had leapt from my side with catlike reflexes and a tiger-like growl, only to find that his two prey were still a considerable distance off. What he managed to find was that the ruts made in the corn field were extremely hard to negotiate under these circumstances. Off balance and probably pre-occupied with his roaring efforts, he very quickly stumbled his way out of the cornfield and onto the ground, changing from the loud roar to the sound of a man wearing a tuxedo and slowly falling into a pool. The instant laughter of his would be victims revealed his plan had fallen apart alongside him.

Pushing my way out of the corn, I was met with the sight of my friends doubled over in laughter and David getting up and cursing that he had broken his glass. He walked out into the empty country road to empty his pocket, and broken shards of scotch glass fell out of his shorts and onto the pavement. He told us he thought he cut his leg on the glass when he fell on it, and there was warm liquid dripping onto his foot. A flashlight displayed dark blood all over his lower leg, down onto his foot, and dripping off his flip-flop. Instantly fearing the glass had cut into his femoral vein or artery, I was already thinking of how to convince him it was necessary to stand on his groin after forcing him to the ground again. I wouldn't have hesitated to do that if his artery was hit, since death is minutes if not seconds away without proper pressure. His vein would have been less serious, but still potentially life threatening and very messy.

I took one look at the laceration, which was thankfully on the lateral aspect of his mid thigh, and saw a very small amount of bleeding from a 2 inch long full thickness cut. Subcutaneous yellow fat glared back at me in the shine from the flashlight. He would need stitches. The laughter had very quickly changed to curses all around. We were in the middle of a 4 day sailing trip and away from home, making a drawn out ER visit more than just a hassle. David, the captain of our expedition and an enthusiastic sailor, was dreading not his leg, but the delay of a well-planned sailing expedition. His demeanor of drunken adolescent to concerned drunken captain occurred the moment he felt hot blood on his foot.

Because we were on land partying at a friend's parent's place, the idea of waiting in an ER all night for a couple sutures was dreaded by all. Until Jim had a great idea. It was he we were visiting, at his parent's house, and his dad is a doctor. Being out in the country, his dad's little office actually had suture material complete with lidocaine. We all batted around the idea of waking him up to sew David's leg, when Jim asked why I couldn't do it, afterall, I sew skin practically every day I go to work. So I did.

Getting there would be a problem, since all of us were in varying stages of drunken stupor. Urging Jim to wake up his little sister, who happened to be a co-ed home on vacation, I assessed the situation. I had no idea what the office would be like, whether it would be too dark, too dirty, definitely no back-up if the bleeding became uncontrolled. I was starting to get nervous. Then I thought of what might happen if everything did go well. Would it get infected later? Would it reopen on the following days at sea? I was getting pretty nervous. At one point David rather tentatively asked how often I suture skin, and I gave him an honest answer - pretty much every day I go to work. I didn't tell him that work was made up of unquestionably sterile procedures, a 10 million dollar inventory of possible instruments and material, and available help within talking distance. I needed a drink.

I knew from experience that anxiety is contagious, and if everybody realized that I was uncomfortable, the mood of the situation would go into the crapper.

Asking one of the guys to fix me a quick gin and tonic for the road, I watched him disappear into the house while I re-examined David's leg. A little while later he re-emerged empty handed with a face smeared with tomato sauce. We were all piling into the car when I asked him what happened to my much needed crutch, and he guiltily told me he fixed himself a bowl of spaghetti instead. I realized at that moment we were all too drunk to be doing this.

When April opened the door to the dark office, I half expected to see the sterility and cleanliness similar to the hospital in which I work. An entire department of cleaning staff disinfects every floor and surface every night of the week at the hospital. This privately owned office evidently did not have a cleaning staff. Lighting up each room, I was disappointed to find a disorderly array of equipment randomly placed in different rooms. Rummaging through drawers with the help of our volunteering co-ed, we found expired suture packs. Most of them had been torn and the suture inside was dry-rotted or something. There were a few sutures that seemed alright, so I grabbed them, along with the instruments which were surprisingly in peel-packs and evidently sterile.

I found a small fridge in the corner, and pushing aside somebody's old lunch and a half eaten apple, I spotted a half bottle of lidocaine next to the Snapple. Crap - it had already been used, and it could have been double tapped with a dirty needle. In a hospital, you aren't allowed to restore open meds - you have no idea if the last person was using sterile technique or not. In a privately owned doc's office, the money used to buy new lidocaine bottles comes right out of the bank account of the solo practicing physician.

I figured the cold temp of the fridge destroyed any existing bacteria or virus, so I decided to use it anyway. It was clear that my hospital standards would be challenged throughout the procedure with the more field-quality standards of a country doctor's office. I would simply have to adapt.

David lay down on his side on an exam table in one of the most dimly lit exam rooms I have ever been in. The rest of the office was dark, and there were 3 of us huddled over david's bleeding leg. I had him pull down his pants and instructed Clarissa, the young co-ed, to dab his wound with a sterile 4x4. I collected a small amount of alcohol from about 10 disposable swabs and cleaned out the incision with the liquid and my gloved finger. There was no glass in there.

I drew up the lidocaine and realized how nervous and sober I had become waiting to sew him. I caught the attention of everyone in the room as I was visibly shaking while preparing to inject. The next step was to numb him up and go to work, and here was the patient, my best friend, staring at the quivering needle held by a drunk man. Although there was a generous supply of adrenaline floating through my veins, I still felt the effects of a full night of drinking. It was now about 1 am, and as I pushed the needle into his laceration, I had to strain my eyes to focus and spread my legs to keep from wobbling. Clarissa stood next to me and assisted, going along with her brother's drunk idiot friends in their moment of action.

I hate to think of the details regarding what I did, since they weren't done under the best of conditions, but in the end his leg was sewn shut. I pushed more than 10 cc's of lidocaine into his skin (although he probably could have taken none), and then threw in about 4 or 5 interrupted simple sutures. My hands started to come under my control a little more after I was finishing, but the irregularity of the laceration combined with the irregularity of my pickled brain made for one of my lesser proud suture lines. David was happy he didn't have to use insurance or delay the trip, though.

I dressed the wound as though we were exiting surgery, going so far as to tape seal the edges of the gauze. I was well aware of the dirty and close quarters on a multi-day sailing trip, and was petrified his leg would infect. Since the night was still young, and we were all able to stand up straight without having to apply pressure on a bleeding wound, we decided to have a drink. Down the block happened to be a busy bar, and we left the dark office and walked into the bustling establishment to rehydrate with a few more beverages of choice.

The next morning I awoke with a headache wondering if I should confess to Jim's dad that we had commandeered his office for a little meatball surgery; but I ended up not having to worry. Everybody else had already told him, and he was not only interested in the goings-on overnight, but seemed happy about them. He even inspected my suturing, congratulated me on the job I had done, and redressed the wound to his liking. Which incidentally involved a single piece of gauze and 3 strips of black electrical tape.

The rest of the trip was great, and David's leg never got infected. It was probably a little sore the next day on the way home, but since he was in the middle of a sailing trip, he never once complained about it, true captain as he was. He even took the sutures out himself a week later, still grateful for my services, despite the uneven traintracks I had put into him.

Sometimes while I am sewing a surgical site shut at work I smile to myself, remembering the night I nervously stitched my best friend's leg closed in a dark office at 1am, while a college girl wiped blood off his naked leg, drunk off my ass.

Maybe hiding in a cornfield to scare the hell out of your friends wasn't a bad idea after all.

The Great Mixin' Bowl

The hospital where I work states somewhere (I remember ponderously reading it), that cultural considerations must be weighed when interacting with and administering healthcare to patients. There was nothing more.

Without wanting to get slammed for profiling or racism, the statement is just sort of thrown out there, leaving the reader to wonder whether a patient from Pakistan will want to kill you if you do something like wipe their skin with an alcohol swab. The statement does seem to encourage a personal bias based on experience when attempting to help our patients. To my analytical mind, it confronts the negative connotation Americans have linked to that charged word, RACISM (thanks to the whole slavery debacle). If bias is used to determine how to help and not harm a person, should it be called racism or cultural awareness? How about cultural sensitivity?

Labor and Delivery is unique in that it combines healthcare with a very, very cultural phenomenon. There usually are no cultural or religious ramifications involved in, say, an appendectomy, or IV antibiotics for the treatment of pneumonia, but when it comes to the act of labor and delivery, culture and religion can be a governing force in the decision making process.

Sometimes funny, sometimes disturbing, the following are simply observations of cultural behavior I'll just throw out there for you.



1. Chinese - High pain threshold. Hard to read when they are first generation and there is a definite language barrier. Very unemotional compared to other ethnicities - even on the mother's part, even a first child. The father sometimes doesn't want anything to do with the process, and the woman's mother is in the room as support instead of him. Sometimes the staff acts happier than the couple, and that's always awkward. There seems to be a heavy favor on boys, to the point of absurdity. I have witnessed a Chinese man groan in despair and hold his head in his hands when they found out the baby was a girl.

2. Asian Americans - Usually really supportive and introverted emotional with one another regardless of infant sex. Nurses coming into the lounge after their Asian American couple delivered will say, "My people were so cute when the baby came out." What a difference a country makes when compared to #1.

3. Germans - I have witnessed two German women and one Scandinavian woman push out a baby, and each time, they were absolute power-houses. I admit it's too small a population for anything more than anecdotal evidence, but My God, it's like they had roid-rage.

4. Indians - The dad is not in the picture insofar as being supportive during labor. Standing five feet away from the bed is very common. If he is even nearby, he will say something to his wife in Indian, and she often becomes more distressed. I have no idea what kind of stuff they say, but it's not warm and cuddly. The women are notorious for "crapping out". This means they are basically wimpy at childbirth, hitting a point where they are too tired or in too much pain to continue pushing - sometimes they just stop moving and lay thre like they're waiting to die. Often the father is not in the room at all, but a mother or mother-in-law is. These women sort of act as Doula's, and "baby" the birthing woman ad nauseum. The synergy of two people panicking or screaming can be a huge obstacle when motivating a woman to push. "I'm paining" is (for some reason probably involving the syntax of their native language) the catch-phrase for Indian women when they crap out. If you say "I'm paining" to an L&D nurse in a diverse area, you can bet the house they will know EXACTLY what you are talking about. L&D nurses never seem to want an Indian couple for a delivery.

5. American Whites - Runs the gamut, but this is the population where you can run into a "princess". Nurses can assume the role of RN, waitress, psychologist and concierge if they aren't careful. Nurses will communicate to their patients that they are under stress and need to help with someone else's care, and a princess will still ask for a warmer blanket, more ice, more tea, an outside line, a cordless TV remote, more nurses, more visitors in the room, a different room, a radio with a CD that plays relaxing music, please scratch my back I have an itch, and oh could you take pictures of my delivery for me? (instead of monitoring my health and possibly administering life-saving procedures to my infant child). Pretty unbelievable sometimes.

6. Homosexual couples - Young liberal nurses get these. Surrogates are sometimes involved when they are a male couple. The donor is sometimes present when they are lesbian. They are typically so happy that science is allowing them an experience they previously thought impossible, they get pretty overcome with joy. The family dynamics are not typical and often a little confusing, so young and obviously open-minded nurses do better than the battle-axes when it comes to communication and the staff-to-patient relationship.

7. African Americans - Runs the gamut like whites (#5), including the occurrence of the occasional princess. I've noticed that African Americans often have good senses of humor throughout the whole ordeal, even if the shit hits the fan. The women can be "jumpy" when getting epidurals or spinals, however, making it difficult.

8. Red-heads - It's said they tend to bleed more than any other patient. This is more a myth than a statistic in my opinion. Maybe a low hematocrit in an already pale person leaves more of an impression - I don't know. But I have asked experienced doctors and nurses whose knowledge and decision-making process I respect beyond my own, and they all say it.

Red-heads bleed.

9. Africans - Extremely vocal, and usually pretty emotional. This can swing both ways; when it's your basic happy couple having their first baby, the reaction of joy is awesome to see, but when things go bad*, ho-ly-shit. Nurses think they are tough with pain, but often finger-snap during contractions. No kidding.

*It's unfortunate that I see so many Africans when things go bad. The reason for this is simple - if you were a relatively wealthy African with relatives in the U.S. and happen to have a complicated pregnancy, you would probably arrange a visit at or around your due date. American hospitals are generally better than African hospitals.

10. Latino couples - High pain threshold, similar to African women. Also can be more emotional than whites. Often finger-snap through pain, also.

11. Jehova's Witnesses - Only experienced teams get these unique patients who are typically friendly cute couples/families. They are not allowed to get transfused. Women can lose a shitload of blood during a delivery, C-section or not. Last year a JW lost a significant amount of blood and became unconscious. She needed blood because she was going into DIC - a terminal condition. Her husband, who was power of attorney, was also a JW and decided to forgo transfusion and let her die. The team administering her care needed counseling afterwards.

12. Brazilian - I throw this one in because the C-section rate in Brazil is over 55%. It is considered unclean or lower class to push a baby out vaginally. There is a gigantic emphasis placed on the sexiness of the female body in Brazil (breast implants are very common sweet sixteen gifts among the upper class) and I guess the vagina must be saved from potential trauma at all costs. If the staff here at the hospital suspects the patient prefers a C-section over a vag delivery and gets her way, we call it a "Social Section".

13. Native American - Apparently the highest pain threshold of anyone. I have no experience with this population, but for some reason they are used in all the textbook examples of a person's culture playing a part in the determination of pain level. The word people use when describing their reaction to pain is "stoic".

14. The Indigent Population - You'd be surprised what kind of people are making babies. Think Jerry Springer Uncensored. These folks can be mindful of the free care they're getting and be quite polite, but when they are immature and ignorant, it's a mess. Sometimes seeing an Obstetrician for the first time on delivery, surprises abound with the "walk-ins" and the "no pre-natal care's". Staff must stifle negative attitudes when a pregnant mom smells like an ashtray, lies about her Hepatitis, or pushes out a baby addicted to heroin. The underprivileged always leave quite an impression on the middle to upper class staff of a hospital, myself included.

Apart from this brief list, I have witnessed strange chanting, incense, constant praying, and impressive singing that I fail to recognize as an actual demograph.

Whether it is just maternal behavior or a religious ritual, we in healthcare have privately laughed, frowned, shaken our heads, or been inspired by the actions of different types of people pushing out a baby. It's just one of the things that keeps me on my toes and one of the reasons I love my job.

Cast Cutting

The other night at about midnight I got into a genuine wrestling match with an ankle cast on a senile old lady's leg.

A patient needed her ankle cast taken off before she went home in the morning, and the nursing staff here at the hospital didn't get around to calling the PA until midnight. When I walked into the patient's room, I realized an all too frequent situation. The patient was senile. This one was practically catatonic, complete with the "O" sign.

The "O" sign is when the mouth is permanently held wide open and the lips are slightly pursed, imitating the letter O. It's only one level of health better then the "Q" sign, which is the same thing, except the tongue is hanging out to the side. Strangely enough, healthcare workers think that when the patient has the "Q" sign, death is knocking. For more on this interestingly insensitive topic and others, read The House of God in it's entirety.

Anyway, this lol (Little Old Lady) stared wide-eyed at the TV above my head during my whole introduction and explanation of what I was about to do. She was 100% unresponsive. You still should explain everything and remain polite in these situations, since you never know how much is actually sinking in. I left the room and came back in with the cast cutter, noticing she hadn't moved an inch, continuing her dedicated coverage of the CNN channel.

The 1950's cast cutter on the orthopedic floor is known as the Green Dragon. It's an ungainly contraption on two wheels that can be dragged around like a golf bag, and looks like it has tubes and cables coming off it at every angle. At the end of a large vaccuum tube is a small hand held circular saw that looks pretty intimidating - except the saw doesn't spin, it vibrates with such force and speed that it cuts into brittle stuff like plaster or fiberglass, while just tickling your skin should you punch all the way through. The vaccuum tube is to suck up the dust and crumbs while you cut. And of course it's green. Bright green. Who knows, maybe it was once used in pediatrics. With the suction and the vibrating saw on, it doesn't come across as a delicate piece of machinery.

After plugging in the dragon, I stepped back to assess the situation. I chose my cut lines carefully, knowing how easy it is to find yourself upside down and left-handed after "cutting yourself into a corner." I noticed how thick the cast was down around her ankle - there must have been 15 layers of cast there. Never the less, I flipped on the cutter, then pressed the foot pedal for the vaccuum and went to work.

Starting at the top of the cast, I pressed the rattling blade easily through the stiff fiberglass and inched down to the ankle. Once there, I realized the blade wasn't going all the way through. The fiberglass was too thick. I'd have to come back to it. I pressed on after making a 90 degree turn at the ankle and finished up by the toes. Now for the next side. Things were going well, when she suddenly jerked her leg.

I tell patients to raise their hands if they feel pain at any time since I can't hear over the saw, but this lady either didn't understand me or didn't act like she understood me. So when she jerked her leg, I turned everything off and asked her if she was alright. No response.

Sometimes the vibrating blade gets hot from the friction and can touch the patient. It happened to me while cutting a little cast off a squirming 2 year old, and we all thought he was squirming and screaming because that's what little kids do when confronted with the green dragon. When I pried off the cast there were little red tracks where the blade went through the cast padding. I had been burning him.

Needless to say, I was gunshy when it came to using dull hospital cast blades on unresponsive patients. I questioned her until I was sure the blade was cool and she just stared at the news anchor on CNN. Going back to work, she flinched again. I again turned everything off and asked her if she was OK. Nothing. I finally finished cutting my lines on the inside and outside of her cast, and reached for the cast spreaders.

Finally able to insert the tips of the spreaders into the crack lines after considerable effort, I pulled. Nothing. I pulled harder. The spreaders came out of the groove and popped open in the air. I had to cut deeper into the cast.

What happened for the next 15 minutes was horrendously tiring. I would alternate trying to saw with using the cast spreaders, slowly building up frustration and starting to sweat. Managing to cut down through the cast on one side using a combination of saw, spreaders and trauma shears. The other side was hopeless, as it was just too thick. Plus the manipulation of her broken ankle would probably cause more pain than the side I had just done.

I stepped back and thought. Maybe I could open up the cut side of the cast with the spreaders like a clam and wiggle her foot out. I tried over and over, getting the swollen old foot about halfway, then losing strength and needing about two more hands, gave up and let the cast close again with the foot inside. I was getting pretty hot and tired.

After starting off with a gentle introduction and careful manipulation of her foot, my actions had descended into a tortotous debacle of pulling and shoving, sweating and cursing. Although the patient was calmly watching TV, I couldn't help but wonder how much pain she was feeling.
At times practically forgetting there was a person attached to the foot, I had to keep reminding myself to slow down and think.

It had turned into a simple problem of physics/mechanics, with little medical involvement. I simply had to get the cast off her foot. While not hurting her. While not hurting myself. It reminded me of a home improvement situation where you get involved with a difficult task you've never done before, hitting a point where you must make a decision to forge ahead, possibly making matters worse, or call in a contractor, admitting defeat. Around the house, I am usually pretty lucky fixing things, but this was different since a patient was involved. Plus it was a goddamn cast - I have removed tons of casts. It wasn't brain surgery.

Standing there in the room, trying to simultaneously cool down and think for a minute, I heard a nearby voice say, "Things aren't working out for ya, are they?"

At last - a sympathetic, overworked nurse had arrived to lend a hand - I immediately said, "No Goddamnit". But there was no one there. It was still just me and the old lady.

But she was looking at me.

Realizing she was having a moment of clarity, and realizing I was at the end of my rope, I surprised myself with a totally unprofessional thing to say;

"What should we do?"

Without skipping a beat, and recognizing my problem was also hers, she began to offer incredibly accurate suggestions that made evident she was in fact paying attention for the past 30 minutes. I felt no pride lost in working with her suggestions, determining what hurt, and what didn't, as she pulled her foot out and I managed to wrestle the cast open further. It was still a considerable struggle, though. We both should have felt a wave of releif when her foot was finally free of the evil cast.

I asked her if her foot still felt OK, expecting an exuberant "YES!", but she was gone again. Her eyes were glued to the TV screen, watching CNN. She didn't look at me or answer any more questions that night. I stood there frozen in disbeleif, holding the broken and defeated cast at my side.

For just a breif moment in time, she was there as clear as day, and not at all grumpy. Usually old sick people are a little touchy when it comes to inexperience - I've been asked how old I am, How long I've been a PA, whether my mother knows I'm out - you name it, old folks can be pretty bitter people when they are sick or in pain. But she wasn't, in fact, she was encouraging me a little here and there, even joking around. I have to admit, after her initial surprise comment we got along as well as two people can when dealing with a problem.

When you go through something difficult with another person, there is a sense of bonding, whether it be fighting in war, climbing a mountain, or in this case, cutting a poorly wrapped cast off an old lady's broken ankle. Especially if success is the final result.

I have received more than a few "thank you's" for cast removals since it feels so good to get them off, but that night was the first time I thanked the patient; I can't be sure she heard me, but I like to think she did.

Good Vibrations

This patient had a vibrator up his butt and couldn't get it out.

Everyone in the OR had heard about this procedure before it was even put on the board, and the rumor started a domino effect of story-telling. It seems everybody working in healthcare has the crazy sex accident patient involving a foreign object up the butt. There's the shampoo bottle, the rose, the flashlight, the wedding ring, beer bottle - almost every object that pushes the limits of sphincter physics has been lost in the butt. The stories always come to a disgusting finish with some over the hill nurse with inner city experience talking about the hamster craze in the late eighties.

Just so you know, rarely is there a problem with an object stuck in the vagina. It's because that hole is relatively shallow and has a bottom. But the hole in the bottom doesn't.

This guy, according to his history, accidentally sat on a vibrator naked while it was turned on. It's amazing how many people will lie about something as obvious as losing a vibrator in the butt. In truth, it doesn't matter how it got in there, it must come out. Because it's a socially awkward situation, the whole healthcare team apparently goes along with the lie, since it helps the patient preserve the last shred of dignity he or she thinks they have.

The reason this problem is so common is because it's easier to lose something up your butt than you may think. Once irritated, the sigmoid colon can go into reverse peristalsis. Peristalsis is the wave-like action than moves food through your system, and if it were to go in reverse, an object that may seem right behind your sphincter one minute can travel halfway to Wichita the next. Have you ever had to take a crap really bad, and then the feeling suddenly and thankfully goes away? Reverse peristalsis. The mechanism that prevents the embarrassing occurrence of crapping your pants may also cause the embarrassing occurrence of sharing your anal endeavors with an entire hospital full of people.

The patient that day was just laying on his stretcher and staring at the ceiling. I have to admit I was delighted to be part of the team to take it out, since it was the talk of the town. The procedure was to cut open his abdomen, and then try and milk it by hand down his large intestine and out his butt. The poor guy didn't say a word to anyone, but followed instructions quickly and without discussion while getting anesthesia. The vibrator must have been close to the surface, because as Donna the circulator nurse was scrubbing him, she felt the vibrations in his belly.

We were all very lucky to be wearing masks, because although we were able to suppress outright laughter, grinning was irresistible. After gowning and gloving, we were ready to go to work. The vibrations were just palpable as the skin was cut, but became louder and more noticeable once we were in the abdominal cavity. Then we found it.

Inside the descending colon, near the splenic flexure, the surgeon and I could feel a solid object vibrating away. Feeling it through the large intestine, it was obvious the base of the vibrator was sort of wide, and pushing it down and out of the butt might cause worse damage than cutting open that spot. So he did.

With the anesthesiologist peering over the drape, the tech leaning practically into my field of view, and the circulator hovering over my shoulder, the surgeon asked for the scalpel. He made a small incision in the large intestine and I squished out what looked like an 8 inch purple vibrator. It was wet and slippery, and before we could grab it, the damn thing slid off the belly and onto the floor, where it bounced around like a fish out of water.

The circulator nurse had been quite close to the field, wanting to be one of the first people to witness the birth of the much talked about sex toy, so when the vibrator unexpectedly landed at her feet, she yelped something and jumped back. She careened into a stainless steel table on wheels, knocking it over, and continued lifting her feet away from the bouncing vibrator, which seemed to be chasing her. Her squealing was almost immediately drowned out by the instant and raucous laughter of the four others in the room, who stopped to watch the nurse act out what resembled a Jerry Lewis segment.

After gaining her balance, her semblance of fortitude, and probably realizing the humorous and legendary situation she was about to enact, Donna began her dance with the dildo. She donned her gloves and assumed an attack position as though she were a gladiator facing an 8 inch opponent. As the vibrator rolled and bounced its way under tables and equipment, she kept shifting around, facing her little nemesis. We were dying with laughter.

Finally she made a grab for it, but the slippery little phalus eluded her grasp, and immediately thudded to the floor again. At this point, the rest of us began calling out suggestions and taunts akin to a county pig wrestle.

When she had it again in her grasp, she shouted the question we all were waiting to hear, "How do I turn it off?" Of course being a politically incorrect operating room, every possible joke was made regarding Donna pretending not to know how to turn off a vibrator.

"I'm sure you have no problem turning it on, Donna."

"Do they always turn purple on you?"

"Keep it where we can see it, Donna."

And so on. It's pretty amazing how much dirty humor you can get away with in the operating room behind closed doors. I have to watch myself when talking to coworkers on other units; their brand of humor is much tamer. More than one of my peers has been "written up" for inappropriate comments.

Alas, the phalus was switched off and dropped into a bag. So ended our adventure with the vibrator, but the laughter kept on overtaking us as we closed, getting softer and less frequent until we were done. Then we were ready to tell everybody about it at lunch, complete with re-enactments. (of Donna, not the patient)

Don't think for a minute the sanctity of a hospital will shield you from being the butt of a self-induced joke. It's my personal opinion that hospital employees seek out and over abuse funny situations to lessen the impact of sad or stressful ones. So if you are ever in a hilarious compromising situation for whatever reason, and you need medical attention, I recommend you drive for a long time before you stop at a hospital.

Strangely enough, the guy wanted to keep the vibrator. That must have broken Donna's heart. The patient was probably afraid we would frame the thing and hang it up in our lounge as a centerpiece for discussion and laughter. Anyway, I had a great deal of fun that day, and I hope I'm working the next time somebody is naked and accidentally sits down on an upward pointing vibrator that's turned on.