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ctsurgeryscrubrn

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  1. Background: I wrote an article a little over a year ago about what 'Being on the table taught me about treating on the table'. I was diagnosed with Marfan syndrome as a child and required an AVR in September-2016. I am a scrub nurse on our high-risk cardiothoracic surgery team, and chose not to have that procedure done at the institution where I work mainly because of the privacy I sought. Flash Forward: The AVR replacement has started to fail and symptoms have returned. Further scans have indicated an aortic arch aneurysm, requiring a very complicated open aortic surgery for total arch replacement. I am very scared given my own experiences scrubbing these cases - they tend to be some of our worst outcomes due to extensive bleeding often requiring Factor-7, and the need for long DHCA pump-runs. Having had previous aortic surgery only makes my surgery more complex due to the adhesions that are likely hindering the surrounding tissue. Putting Faith in "My Team": Given the complexity of this surgery, I wanted to be operated on by my very own team. We had the consult this morning and it felt like it was the first time meeting everybody. Terms and concepts that are second nature to me as a practitioner suddenly became foreign: How long will I be on bypass? What temperature will you try to cool me down to and why do you need to pack my head in ice? Why would that be a complication associated with this procedure? Feeling HELPLESS and HOPELESS: Even sitting at the table with a team that I have operated with on some of the most complex cardiac cases in the world - working miracles every day, I felt helpless and hopeless. There was a natural barrier that they established and I could feel exactly where it began - a barrier of objectivity, the unknown, the risks, the things we all know about and can't control. Cardiothoracic surgery is not an easy specialty - I've lived it - I've seen the fear in the eyes of our patients; I've seen patients whisper their last words before passing on our table; I've seen the promising do poorly and the unlikely do amazingly well. I've always wondered what is going through the patient's mind while they sit through a consult where they are told, in no uncertain terms, that we will crack open their chest with a saw. I thought having my colleagues walking me through all of this would make it more palatable, but I felt like 'another case'. I could feel their unease knowing it would be 'me' on their table. I looked for the little signs - a gentle smile, a reassuring 'don't worry', an outreached hand to calm mine - I found no such signs. The lead scrub is a nurse I precepted when she joined our CT team - she is a friend and when we work together, we are seamless. Today, we felt world's apart. I can't imagine the additional pressure they feel, and perhaps that's why having one of the highest risk CT surgeries with your own is not the best of ideas. But, I know that they'll bring their very best to that table (just like they do every day)...and then some. I am vulnerable and I am ok to admit it. Have you operated on a co-worker before? Did you treat them differently and with more compassion, or did you maintain an objective presence? The Case: Date of Procedure: 2019-Nov-19; 0700 Patient: ________________ Age: 32 / F Presentation / Dx: Aortic Arch Aneurysm of 4.7cm / Marfan syndrome Procedure: Total Aortic Arch Repair Team: Attending: Chief of Cardiothoracic Surgery First Assist: Attending Cardiothoracic Surgeon (Aortic Program Co-Director) Second Assist: Attending Cardiothoracic Surgeon Anethesia: 2 Attending + CRNA Nursing: 2 Scrubs / 2 Circulating (1 family liaison) CCP: 2 Position: Supine Aortic Clamp Time Target: 120 min Total CPB Target: 280 min DHCA Target: 18 degree C (cerebral) / 24 degree C (systemic) - ~55 - 65 min Selective Antegrade Perfusion: Yes - 35 degree C (bladder) - ~30 - 35 min Surgical Hx: AVR - September-2016 (post-op tamponade) Total Operative Time Target (incision-to-close) (min): ~660 - 720
  2. Has anybody been in a trauma case where the patient had two significant injuries that required establishing two separate surgical fields (sequentially)? I was called in at 2AM for an adolescent MVA - she was evaluated in trauma and scans indicated the need for a decompressive craniectomy. She was placed in the 'sitting position'. I was second assist and about 90 min into the craniectomy, her IAP began to spike (~20 mmHg). Could actively see her belly swelling. Decision was made to cover the craniectomy and had another team immediately scrub-in for a 'crash laparotomy' - I began the prep as others repositioned her to supine. By the time the trauma attending did the midline, her belly was severely distended to the point she looked pregnant. Never seen so much blood pour out of an abdomen (even a ruptured AAA) upon opening and we lost pressure as the team struggled to find the source. They cracked her, but was futile. Has anybody had this happen? It was probably the most intense case I've scrubbed in a long time just because we ditched one critical field for another. Would appreciate others' perspectives and experiences...
  3. ctsurgeryscrubrn

    OR nurse pursing NP

    @scrubulator Hi there - I got my FNP two years ago and it did take a bit of 'refresher studying' to re-acquaint myself with bedside nursing. I've only been in OR Nursing (specifically CT & Trauma) since I obtained my BSN. In some ways, I was able to add unique perspective to our lectures and clinicals given that most of my classmates were either purely med/surg or ICU - they were very interested in my experiences in the O.R. I was accepted to a p/t DNP program and will be starting next fall.
  4. ctsurgeryscrubrn

    Bedside / ICU Surgery (Decompressive Laparotomies)

    Thank you! The ex-lap we had to do bedside was on a 10 yo who had been in a bad MVA and had a major liver laceration that was done via emergent laparotomy two days before. It was a bloodbath going back in, especially in a non-operative environment.
  5. ctsurgeryscrubrn

    Bedside / ICU Surgery (Decompressive Laparotomies)

    Thank you, Rose. Always such great advice. Had an emergent laparotomy in the PICU this evening for ACS. Was a total blood bath - had to get wiped down several times by the circulator. Parents were right outside - was awful as they could hear us struggling to gain control of the bleeding and then the start of the resuscitation.
  6. Hello - In addition to my Cardiothoracic scrub position, I was nominated to join our new ‘ICU / PICU / SICU rapid response team’ that will be responsible for assisting in bedside rescue surgeries (mainly decompressive laparotomies for ACS and thoracotomies for cardiac tamponade). Does anyone have any experience with this, and any tips / suggestions? Here are the key responsibilities of the ICU Rapid Response Team “RRT” Scrub Nurse: Setup of sterile field, including gloving-and-gowning of primary and support practitioners; Initiate life-saving measures prior to arrival of primary practitioner including measures as recommended by ACLS (e.g., closed chest compressions); Identification and direction of ICU nursing personnel to obtain requisite instrumentation including, but not limited to: thoracotomy tray, laparotomy setup (bookwalter retraction, etc.); Working with RRT Circulator to establish sterile perimeter in room; and, Primary operative assistance in the sterile field (including first assisting if resident / fellow is not available).
  7. ctsurgeryscrubrn

    Rejected from OR nurse residency

    @Reaz I went through Northwestern’s Perioperative Nurse Residency program and can certainly give you some perspective on my class and the types of nurses I went through the program with...if that helps.
  8. ctsurgeryscrubrn

    Most “exciting” surgical specialty

    I scrub Cardiothoracic and also take call on our Level-1 Trauma service. They are both ‘exciting’, but I think Level-1 Trauma is probably where you get the most amount of adrenaline. Nothing gets my blood rushing like hearing over the intercom that we have an L1 “Direct-to-OR” (we call them DTOs) with active CPR going on with an ETA of 5 min out.
  9. ctsurgeryscrubrn

    RNFA

    Hey there - I am a CRNFA and get to practice in that capacity in Cardiothoracic Surgery. It is definitely an institution-specific thing. I have heard of people going through an RNFA certificate program and never getting to function in that capacity. I am at a teaching institution, so we have residents and fellows, but when you build credibility with the top CT surgeons, they help ‘sponsor’ your experience and enable you to practice at the highest-end of your credentialing. So in summary, I think it depends on your ability AND the willingness of the surgeons you work with to give you the ‘reps’ you need to become a dependable, proficient and technically-skilled first-assist in the sterile field.
  10. ctsurgeryscrubrn

    How do I get an OR job?

    Hi Theresa! Is there a particular specialty you are shooting for, or are you applying to a general float OR Nurse position? More than happy to add my perspective.
  11. ctsurgeryscrubrn

    Is it impossible to get in OR or what?

    Yes - I would agree that the best way into the O.R. at a top institution is through a formal residency program offered by the hospital.
  12. ctsurgeryscrubrn

    Pre-Op Surgical Team Walk-Through's

    I scrub on a high-risk CT team (mainly high-risk and complex aortic procedures with pathology (Marfan, etc.) and re-do cases). Recently, our team started doing 20 - 30 min pre-op walk-through's whereas the entire team will get together and the surgeon or fellow will walk the entire team (PAs, RNs, CCPs, Anesthesia & CSTs) through the upcoming case. These cases usually are 8, 10, 12+ hours. As a scrub nurse, it's very helpful and really brings a sense of purpose and cohesion to all. I know it's unreasonable for this type of thing to be done on all services or before all cases, but was wondering if any of the O.R. nurses out there have ever participated on such pre-op sessions (?)
  13. ctsurgeryscrubrn

    Floor to the OR?

    @FurBabyMom What do you like most about the O.R.? If I wasn't in a dedicated scrub role on the CT team, I'm not sure that I could stay in the O.R. long-term.
  14. ctsurgeryscrubrn

    Death on the Table

    @FurBabyMom - I so much appreciate your advice and your willingness to share your personal experiences. I think it’s important to remember that as far as medicine has come, surgery (at its core) continues to be extremely brutal for both patients and their providers. The growth of ‘minimally-invasive’ and ‘robotic’ techniques (which I think are wonderful when used appropriately) does not mean that often times, the best and safest way to the root of the problem remains a massive open procedure requiring saws, chisels, and large retractors. It’s not easy to explain to patients or their families. And when things go wrong in hearts (as I would imagine in neuro), they go wrong fast. Everybody on the team gives so much to try to restore life against many factors, time being the most critical. I never want to grow ‘numb’ to a death-on-the-table, but when you scrub on the high-risk aortic team, I am constantly reminded how we are often faced with uphill battles (the 2AM aortic dissection; the Open TAAA repair in a morbidly obese smoker; the Marfan’s patient who is for a re-do of a re-do of a re-do, etc.). But, they need us and in-turn...we need each other.
  15. ctsurgeryscrubrn

    Choosing an Operating Room Specialty

    Hi Julez! Belated welcome to the ORNurses ‘Fra-rority’. I am a second generation O.R. Nurse - my mom was a scrub nurse in hearts at Cleveland Clinic for nearly 20 years. I had a natural inclination to hearts after hearing so many interesting, dramatic, and exciting stories from her time at The Clinic - albeit, many did not have fairy tale endings. Entering nursing school, I certainly noticed that perioperative nursing was not encouraged and floor experience (either med/surg or ICU) was seen as the default ‘immerse yourself in the basics’ specialty. I had to basically fight for a perioperative rotation. I was able to gain great experience that enabled me to obtain a post-graduate perioperative nursing residency out of school. The residency was a 6-month program where we got to scrub and circulate nearly all of the specialties (Hearts, Trauma, Neuro, General, ENT, Vascular, and Outpatient). Hearts just felt right to me. Although I know many don’t like the repetition of cases, teams, etc., it suited me perfectly. I liked working with the same core team (surgeons, anesthesia, etc.) AND I loved the opportunity to scrub high-acuity marathon cases (our institution doesn’t have CSTs scrub hearts). It’s certainly not all ‘fun and games’ and there is more than a fair share of heartbreak, but it feels so right to me - I always say “I didn’t choose hearts; hearts chose me.” I think that’s cliche, but something we should all be on the lookout for - a specialty or niche where we feel completely in ‘our element’ even when put in high-stress, uncomfortable situations. Feel free to PM me, and I wish you all the luck and fulfillment in your perioperative career.
  16. ctsurgeryscrubrn

    Death on the Table

    We've had a couple younger patients expire on the table in the past couple weeks during high-risk aortic procedures (both were re-do's and we operated for 15 and 16 hrs, respectively, prior to expiration). It's been very difficult for me - scrubbing on the high-risk CVOR team comes with these types of outcomes and I know what I signed up for, but it is still heartbreaking. They always say that high-risk CT surgery is where you, as a practitioner, need to maintain emotional distance from your patients. However, I've never subscribed to that idea and believe that in order to be the ultimate advocate, you have to build relationships with your patients no matter what they'll be on your table for. Has anybody worked on a high-risk team where there have been more frequent D.O.T's than other surgical specialties? Any tips for coping and not facing emotional burn-out?
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