Monday, July 03, 2006

Love Note to a Scrub Nurse

What better way to begin the surgery part of my surgical blog than with a love note to a scrub nurse? A scrub nurse is one who participates directly in the operation, setting things up, passing instruments, and, with luck, adding her (usually its a "her") thoughts to the proceedings. She can make a huge difference in the flow of things, raising it to an art-form. So here's an excerpt from my book, in which I try to make that point very clear. It begins as I find myself on the neurosurgery rotation, early in my training:


Esoteric and tedious, neurosurgery impressed but didn’t attract me. Charlie Wilson, however, amazed me. Chairman of the department, he radiated enough energy to power the place had the lights gone out. A marathon runner before it became widespread, he spent the rest of his time at the hospital, all hours, day and night. He was a superb operator, tackling brain tumors others refused, getting results far better than expected. He looked you right in the eye, drilling the truth in deep, exuding understated confidence. Patients came from all over the world, handing him their brains.

One of the neurosurgeons looked like an alien, come to Earth to help us, if allowed to breathe methane. He did all his cases with a self-designed, fully enclosed mask, dangling two exhaust hoses over his shoulders and down his back. As he meticulously
attended to bleeding, one corpuscle at a time, his operations took hours longer than anyone else’s. But they said he’d never had a post-op hematoma (blood collection), never an infection. Of course not: any bacterium that wandered into the wound would
have died of boredom or starved to death.

In a world where looks matter, kids with craniofacial abnormalities are screwed. When their facial bones and sections of skull fuse prematurely, or grow in the wrong direction, some are so disfigured you want to look away. A French surgeon, Paul Tessier, had developed a spectacular and wondrous approach to such problems, doing operations that lasted twelve hours and longer— unroofing the entire top of the skull, cutting out cubes of bone containing the eyeballs, moving them outward, rearranging entire sections of facial aberration that formerly had been set in stone. One of the neurosurgeons at UC had gone to Paris to study with Tessier and brought him back to San Francisco to put on a clinic. I didn’t have the time to watch an entire operation, but what I saw has stayed with me.

Dr. Tessier brought his team with him: an anesthetist, a tech, and a scrub nurse. It was the pas de deux performed by Tessier and his nurse that opened my eyes and dropped my jaw. As he sat, focused like a cat on his work, he’d raise a hand wordlessly and his nurse would give him an instrument, which he’d bring to the field, work for a moment, then pass it back and receive another one. Never a hesitation, never a wrong move, it flowed like a ballet, musically, the noblest art humans can create among themselves. Still clumsy, I could nevertheless recognize perfection. That, I thought, is what it can be, what it must be to do surgery. It’s a rarity. Few surgeons get to do the same thing over and over, in the same place, with the same team. Instead, it’s night shift, day shift, one hospital, two or three. You try to find the rhythm, to get a flow going, with you, your assistant, your scrub nurse all knowing what’s coming, facilitating, cooperating. In a tough spot, you want to maintain focus, not moving your head, keeping the area you’ve just exposed perfectly in view. Hand out, wanting the right tool slapped in smartly, you don’t want to fumble for it, nor lose sight, nor have to reposition the instrument; boring in, you try to keep it going, saying, “I’ll be using a long Allis next.” But instead of getting it you hear, “Sue, can you get me a long Allis from central supply?” “Geez! This is a low pelvic case. I always use a long Allis.” “Sorry doctor. I usually scrub ortho.” Screech. Nureyev drops Fonteyn on her ass.

I’ll divert to the present long enough to say that in my practice I got close. My clinic hired away the hospital’s best scrub nurse, Joanie Thompson, and I worked with her on most of my cases. When I did, we were a hell of a team. She knew. She always had what I needed. When I’d want an instrument different from what I typically used, Joanie had it before I asked. “I’ll need a longer needle holder, and mount it backwards.” Whack, into my hand, the suture perfectly placed in the jaws. “And make it snappy,” I’d say, after the fact. The pleasure from an operation allowed to flow, where every step follows logically from the last, where each move is fluid without stops and diversions, is transcendent. It restores the soul. It makes you want to sing, which I often did. Joanie told me the best thing I ever heard as a surgeon: “You make this look so easy,” she said. She became an RNFA (Registered Nurse First Assistant)—in fact, she’s a national force in making that occupation a reality; she’s just as good an assistant as she was a scrub. But I always missed having Joanie pop an instrument into my hand, the right one, at the right time, making music.

19 comments:

the granola said...

Sounds kind of like marriage sometimes, when we're talking and don't even need to finish sentences.

may said...

the surgeon and the scrub nurse...it's almost a love story huh. ups and downs, love and hate.

thanks for dropping by my blog. i linked you, i hope that's okay.

Anonymous said...

Boy you surgeons are so damn demanding!

Meanwhile, I pump my fist and scream in elation to see a temperature or O2sat documented in the vital signs part of the hospital chart.

Intelinurse2B said...

Dr. Schwab,
I am a nursing student who has learned I need to have more confidence in speaking w/ physicians. In recent comments to a post I wrote about that very thing, many comments from experienced nurses were to always be prepared with the facts when I speak with a physician.
After reading your piece, I am inspired to be an above average nurse that a physicain respects because of skills and knowledge. It seems to me that is the best way to be prepared.
I have added you to my blogroll, I think its good to have physicians, (no offense, but especially surgeons) who seem approachable and human.

james gaulte said...

I never met Charlie Wilson.He marched though Tulane Med School about 10 year before me but the profs still talked about him. In my senior year I signed up late for a surgery elective ( I always got the word late)and all that was left was neurosurgery.No one wanted it because the faculty was said to be not that student-friendly.Wilson had left by that time but a comment was frequently made in rounds and the case conferences- "what would Charlie have done?"

much maligned said...

Here's my version (from a cardiac scrub nurse):
Mr Brackenbury hated his team that came with him: an anesthetist, a tech, and a fucking scrub nurse. It was the 'pass the fucking gray turner' performed by Brackenbury and his nurse that opened my eyes and dropped my jaw. As he sat, kicking the operating table like a spoilt child, he’d raise a hand in a threatening fashion and mumble an expletive... and his nurse would give him an instrument, which he’d bring to the field, work for a moment, then throw down to the patient's feet. Never a kind eye, never a kind word, it flowed like a streetfight, vindictive, like the opening credits to a slasher flick. Still clumsy, I could nevertheless recognize bullying. That, I thought, is what it can be, what it must be to do surgery... and it's certainly not a rarity. Most surgeons haye to do the same thing over and over, in the same place, with the same fucking team. Instead, it’s night shift, day shift, one hospital, two or three.... You try to find a scrub nurse willing to put up with your costant barrage of insults and shit, to get a willing punchbag, with you, your assistant, your scrub nurse all knowing what’s coming but still willing to take it, longing for the weekend, hoping for a cancelled list. In a tough spot, you want to take it out on the easiest target, not moving your head, keeping the area you’ve just exposed perfectly in view and mumble the name of an instrument (not particularly the one you wanted). Hand out, wanting the right tool slapped in smartly without actually letting the nurse see the surgical field, you don’t want to fumble for it, nor lose sight, nor have to reposition the instrument, nor say thankyou or even consider that whilst the procedure began 30 minutes ago, the nurse has been scrubbed for over an hour and a half in setup; boring all, you try to keep the intimidation going, grunting, “long Allis.” But instead of getting it you hear, “Sue, can you get me a long Allis from central supply?” “Fuck sake! This is a low pelvic case. Are you an idiot. I always use a long Allis.” “Sorry doctor. I usually scrub ortho, I haven't got any experience in this theatre but they're short staffed.” Fuck. That fat assed nurse!!.

Sid Schwab said...

OK. And for the final paragraph?

much maligned said...

I’ll divert to the present long enough to say that in my practice I got close. My clinic, in a misplaced effort to reduce costs got rid of most of their scrub nurses and replaced them with cheaper, under qualified clinical support technicians to work on most of my cases. When they did, we were a team from hell. They knew. They always had what I needed but as they were paid only slightly more than minimum wage, they didn’t really care. When I’d want an instrument different from what I typically used, ‘unregistered and unaccountable’ Joe feigned interest. “I’ll need a longer needle holder, and mount it backwards.” Whack, into my hand, the suture slipping from the jaws as the Teflon inserts were missing, partly due to age but mostly because sterile supplies maintained the minimum wage approach... with recruitment and retention issues causing major problems. “These are useless,” I’d say, after the fact. The dis-pleasure gained from an operation allowed to grind, where every step follows painfully from the last, where each move is scrutinised by cost without much thought for the patient, is disheartening. It diminishes the soul. It makes you want to cry, which I often did. ‘unregistered and unaccountable’ Joe asked me a question one day that I never really could answer: “You make a lot of shit load of money, why aren’t you happier?,” she said. In time, Joe succumbed to SRNFA (Surgeon Responsible Nurse Felt Aggression)—in fact, Joe’s a national force in claiming unemployment benefit now; but is happier now out of scrub. But I always missed having Joe there to take a verbal punch or two.

still much maligned said...

;)

Sid Schwab said...

Yikes.

Anonymous said...

Do you know what, it breaks my heart that the abuse continues and is normalised; wouldn't you think that if a person is prepared to work at a job that most people would run a mile at the least they could expect is a modicum of decent treatment from the people around them ? I work in a very presdigious hopital in central London; with "gentlemen" surgeons; and in one week I have encountered 3 episodes of abuse, one directed at myself (luckily I am experienced and confident in my practise), I also recognise when they are projecting their frustrations and inadequacies on me. When will it end though ? We are not whipping boys; I have heard surgeons talking about how other surgeons they know "weren't happy until the nurse cried", and they have said this and laughed as if its ok. I have seen a surgeon frighten a scrub nurse who was a nun in her late fifties, so badly that she shock uncontrollabley even before scrubbing for him in anticipation of the horror to come. Where else do you encounter such normalising of abnormal behaviour ? A surgeon who I would call a friend because I have many of them; once told me sometimes he does feel as if "he's kikcked the dog", and I had to point out we are not dogs, we are human beings. Why should intelligent people in a caring profession need this pointing out ? Shame shame shame. I would never advise someone to take up the profession of scrub nurse, even though I love it, as I cannot tell them that they will be valued or treated with any dignity or repect.

ewall67 said...

To those of you posting from the scrub's perspective, I am a surgeon, recently retired from full time practice for many if not all the reasons the dr S blogs about. I have two comments in reply: first, I am sorry for the abuses you have suffered at the knife points of other surgeons (generally famous for their maladaptive behaviors) though I accept no responsibility for the ills of the profession; and second, not all surgeons are like that. You never operated with me. ;)

Anonymous said...

Awesome posting - so true! As a theatre nurse in Australia for over twenty years (predom Anaes/Recovery) I know the nurse perspective very well indeed.
My two cents:
This is a generalization of course.
How good do doctors have it? All care no responsibility in regards to many things. They perform work at hospitals with no overheads with regards to staffing, equipment, car parking, meals, you name it? Often they have rooms provided for them and other such incentives to have them operate at the facility. If they want anything they just have to jump up and down and abuse their position to get it like self obsessed arrogant children. Abuse and ridicule staff and extremely rarely face disciplinary action.If a nurse complains to management the usual course is to either stop placing that nurse within that theatre, or if the nurse is casual or labour hire nurse they often find that they no longer have any work. I have never seen a surgeon taken to task for behaviour as other staff would.God forbid that they take their services elsewhere. I could write a book myself on the garbage that I have witnessed or heard about. Heres one. Orthopaedic surgeon, small man syndrome, driving out a crapark the wrong way, smashes a visitors car coming in the right way, abuses the driver and takes off. Upon complaint and investigation, hospital management pay for the damages to the visitors car! Another one....Surgeon investigated for financial dodginess (public hospital)-other doctor does deal to provide evidence but only if other doctors at same hospital are not investigated for similar!
Nice, this is the reality of healthcare. Now, as nurses we understand the pressures that doctors face but if you cant behave yourself then perhaps you should look for another job.
Working in private facility the other day and anaesthetist pushing to go faster - production line stuff...We work very hard and are by no means slow. Wake up call to doctors - - nurses get paid by the hour, you get paid by the case. There is no incentive for us to go faster. Wheres our christmas bonus? Wheres our free parking, meals, junkets etc. Oh thats right - no room in the budget as already taken up by gifting to the already priviledged!!
Oh and while were at it lets save costs by bringing in lesser trained and lesser paid types of staff (including fleecing from the third world) to get rid of the Registered Nurses.
Sound good doesnt it??
Now there will be those that criticise the above (usually those that arent nurses) and by no means are all doctors or hospitals like this but I and millions of other nurses would vouch and contribute their own voices.

Sid Schwab said...

Thanks for dropping by. I guess we can all feel lucky not to be working down under, even though, evidently, surgeons there bear no responsibilities, which would be quite refreshing.

Anonymous said...

As a student ODP - (just finished my first year anaesthetics) - moving into the 'englightening' word of Scrub, just wanted to say thanks for the great read:))

Anonymous said...

I'm an old retired scrub nurse (In my time bovies were bovies and looked like Maytags) Anyway my specialty was working with difficult surgeons. On my last day of work, a surgeon that I had scrubbed with many times, but never exchanged words with other than criticism of me, came up to me and said he didn't know how he could continue without me. We both had tears in our eyes and I still miss him and our unpleasant times together.

Sid Schwab said...

Nice. "My" Joanie finally retired, and we stay in close touch. She's had a tough go lately, and I've visited her in the hospital many times lately.

My life would have been way worse without her, for sure.

Anonymous said...

This post makes me terrified and hungry to be a great scrub nurse. I'm starting my scrub orientation for a pediatric neuro/plastics team next month. I've worked with the docs for a few years and they are pretty friendly bunch but I'm horrified of letting them down.

Sid Schwab said...

You'll love it!