Nurses versus Surgeons

Seven a.m. in the surgical hallway of Fort Anonymous U.S. Army Hospital on a dark December morning. Nurses in clean surgical scrub attire hurry between Central Supply and operating rooms with bundles of instruments and sterile drapes. Others wheel patients on stretchers, each to an assigned operating room. Anesthetists check their gas machines and syringes as the surgical teams gather at the scrub sinks, cleaning hands and forearms the required five minutes with antiseptic soap.

“I can’t find my scrubs!” a surgeon complains to the chief operating room nurse as she walks by, her eyes checking her nurse lieutenants as they go about their assigned tasks.

The chief nurse stops to look at the surgeon, then at the nearly empty rack where surgical scrub suits for the operating rooms are stored. “Why do you suppose that is?” she asks him.

“It’s not my job to know why that is,” he fumes. “My job is to be in the Operating Room fifteen minutes from now, ready to operate. Where are my scrubs!”

“Well, let’s think a minute,” she says. “How many scrub suits are hidden behind your desk in your office? How many stayed on the floor in the intern’s lounge when you changed back into street clothes last week? If you don’t put them in the laundry hamper, Major, they don’t get picked up. I can’t give you what I don’t have.”

“I don’t care about that,” the major snaps, “what we need in this OR is one of those scrub-dispensing machines!” He stamps off down to the laundry department to harass the workers who unload the laundry delivery truck each day. But they really couldn’t do anything about scrub suits the truck hasn’t picked up, and therefore can't deliver again.

“Dispensing machines don’t solve the problem,” the chief nurse remarks to her assistant. “The hospital in San Antonio had them when I worked there as an instructor. You have a card to insert, you punch in your size, and out comes a scrub suit. But the surgeons can’t be bothered to dump them back into the machine’s bin at the end of the day and get their card credited. If they don’t return them two days in a row, the machine voids their card and they come screaming to the nurses again.”

She turns her attention to another surgeon who is demanding a certain surgical instrument NOW. ”Dr. B is using it in Room 3,” she said. “We can have it resterillized in about 20 minutes.”

“My patient is on the table now. I need it now."

“It’s already in use. You didn’t think of that when you changed your scheduled time for this case, did you,” she says patiently.

“Look, I’m a surgeon. Surgeons operate. Nurses get instruments ready. If that one’s in use, get me another one from the supply house.”

“The supply house that sells that instrument is in Omaha,” she says sweetly. “I can ask them to send it urgent express, and we can have it for you on Wednesday. Otherwise we have to wait till Dr. B’s case is finished in a few minutes and we resterillize the one we’ve got.”

“I’m going to bring this up in staff meeting.” He strides angrily off down the hall.

“Do that,” she calls after him. “I’ll give you the serial number and cost figures. It’s expensive.”


Five hundred people attend the all-hospital Christmas dinner a few days later. Part of the entertainment after the meal is Christmas carols. Each group of tables is assigned one verse of “Twelve Days of Christmas.” The operating room crew’s tables are assigned to sing “seven swans a-swimming” with each successive verse.

“Colonel, Ma’am?” A nurse lieutenant leans across the table. “Seven swans a-swimming sounds kind of dull,” she says. “How about ‘Seven surgeons screaming’?”

“No,” says another nurse, “They don’t actually scream. What else could we say?”

The chief OR nurse lets them work it out. They finally agree on “Seven surgeons whining.” The chief nods. This isn’t her idea, but it expresses the thought.

“The Colonel says it’s okay,” is whispered from nurse to nurse down the row of tables.When the sixth verse of the song finishes, their verse is next.

“On the seventh day of Christmas my true-love gave to me-" The surgical nurses rise as one and sing out, “seven surgeons whining–"

There's a pause in the large hall. “I don’t think those are the right words,” the song leader says from the head table. “Let’s try again. On the seventh day of Christmas my true-love gave to me–"

The surgical techs rise again, “Seven surgeons whining-"

In the following silence, two or three voices from the surgeons’ tables are heard, “Hey, now, what is this?”

“See?” a nurse exclaims triumphantly, “there you go again!”

Later, as the party breaks up and people are saying their goodbyes, the chief surgeon and the hospital commander come over to the chief surgical nurse. “Colonel, what are you doing to those nurses?”

“Wasn’t my idea,” she says. “But, ya know, sometimes they need a little morale-building. See y’all Monday morning!”

Heart on the Cutting Edge

October 31, 2000: The conference room was jammed with people, some picking up a sandwich and a bottled drink, others already seated at the long T-shaped table or around the edges of the room. A secretary brought in more chairs. At the far end of the room a couple of technician types hover over a foot-long object resting on two wheels at one end and a leg at the other. It looks like a toy farm tractor.

I choose a sandwich, look around for a seat, find none, and balance my paper plate with one hand while standing to see over the heads of those seated closer to the demonstration.

“Because a few molecules of air gradually seep through the plastic,” one tech was saying, “the pump occasionally must be vented by pressing this button, to restore full air volume in the pumping chamber. The heart will stop for six seconds during this and then the pump will automatically start again at sixty beats per minute and gradually come up to its original speed.” He demonstrated. The tractor-like toy on the table went Thug. Thug… thug…thug, thug, thug, and a heart monitor began to beep.

A stack of printed brochures is being passed around. I hold my plate with one hand, put my sandwich between my teeth, take a brochure and hold it under my armpit for the moment. The second tech uses an overhead projector to shine a diagram up on a screen. I glance around the room, see that the audience is mostly nurses, ambulance EMTs and a few doctors.

The speaker continues, “You’ve all been invited to this orientation because, up till now, patients with heart-assist pumps have been confined to large hospital centers while they await their heart transplant. But as you know, there are now around three thousand candidates for a heart transplant each year, and far fewer heart donors than that. This model you see on the table is an entirely new concept, allowing the patient whose heart no longer has the strength to maintain life to live in your community and function almost normally for years.”

He flashes another diagram on the screen. “Sacred Heart Medical Center’s Heart Transplant program now has successfully implanted the Pneumatic HeartMate Assist device in more than a dozen patients. At present, we in Spokane are the only center in America licensed by the FDA to do this experimental procedure. All of our subjects are still alive; some have gone on to receive a new heart transplant, others have been discharged to live in their home communities, including one here in your area. We want you to be familiar with the device and with what to do, and what not to do, if the patient should ever need medical assistance.”

I look at the gadget with renewed interest. The brochure shows a man carrying it on a strap over his shoulder, with a large plastic tube going into his mid-section somewhere. Another picture shows an elderly man with a backpack, fishing by a stream; in another, a blonde young woman is playing with her child. None of them seem concerned with the tube in their abdomen. I turn my attention back to the screen.

“As you can see, the internal pump is a simple design, attaching the bottom of the heart’s left ventricle to the aorta, with two valves to ensure one-way flow. The pumping chamber is implanted inside the abdomen. A flexible diaphragm separates the blood circuit from the external pneumatic pumping circuit which is powered by the control panel you see here on the table. Each time the blood-circuit chamber is 90% filled with blood from the heart, the control panel causes air to press against the chamber diaphragm, emptying the chamber into the aorta and onward to the arteries of the body. The air-pump locks on to the tube emerging from the patient’s abdomen. Each patient is sent home with two complete pumps, plus a hand operated pump for extra back-up, and several sets of rechargeable batteries, each set capable of six hours operation before recharging It can also run from an a.c.wall outlet, with the batteries taking over in case of power failure”

He went on to explain the meaning of each of several alarms; one directing the attendant to vent the pump, another to indicate the battery is getting low. “And this one,” he pressed something causing the control panel to flash a red light and emit shrieks, “tells you to change to the back-up pump immediately.”

He passed around a second brochure. “This one is for you doctors. There’s not really much that’s new. When the yellow light goes on, vent the pump. And remember, the patient can be in any kind of heart rhythm and the pump will still move the blood. The ventricle may even be fibrillating but the patient can still remain conscious. If he drops below a flow of two liters a minute, give large amounts of IV fluid and correct the heart rhythm. If the pump fails, switch to the backup pump and call us, to get him back to Spokane. You ambulance people, remember to vent the pump once for every 1,000 feet change in altitude, but you shouldn’t need to, going over the pass to Spokane. This pump system does not require blood thinners; one aspirin a day is usually enough. Most medicines are given in the same manner you would give them to anyone else. Any questions?”

I had one. “I got here a little late; maybe you already explained why this one set of instructions you handed out is written in Japanese.”

“Oops.” He looked flustered, reached into a box under the table, handed out English copies. “We invite patients from all over the world. I don’t know how that got in there. Other questions?”

“How long do these pumps keep working?” someone asked.

“The longest laboratory test is still running after eight years. Four of our patients so far have each logged over 200 days and counting. Obviously, pumps eventually wear out. We haven’t yet found out when. That’s one reason the project is still classed experimental. But the device is no longer just a bridge to keep the patient going until heart transplant. With the shortage of donor hearts, we anticipate many people will live with this device for years.”

“Does the HeartMate eliminate the need for CPR if a patient’s heart stops?”

“Play it the same way as you do with any other patient. If there is no pulse, that means no significant flow, and you need to give chest compressions. We’d just as soon that didn’t happen in the first three months after surgery; the connections inside the patient are sturdy titanium, but could be dislodged before scar tissue seals them in. Ordinarily all patients are kept in Spokane those first three months. After that, we want to see them every six months, but we are available 24/7 to answer your problems, and our phone numbers are in the handout."

“Cost?”

“We require either proof the insurance carrier will cover costs (which most don’t as long as a procedure is experimental) or three hundred thousand dollars on deposit, to cover all costs and on-going follow-up. We have no grant for this, but we do refund any unused amount. It’s not cheap, but compared with heart-transplant costs and on-going treatment, we think it will prove cost-effective and will eventually be accepted by insurance carriers.”

I consider another sandwich; then decide I had better not increase the program’s costs any more than necessary.

But as I carried my (English language) instruction book home I thought, it’s going to be scary, the first time the ambulance arrives with one of these people, but we’ve got the directions and the equipment, and the back-up folks in Spokane. Kind of awesome—Kellogg, Idaho on the cutting edge of a new technology, one of the first towns world-wide to participate.