Wednesday, July 11, 2007

Nowhere Warm

Not so many few years ago, back when I was still a practitioner in the Operating Room, I’ve gotten the precious opportunity to assist in my first major OR case. Prior to any surgical case, the scrub nurse should:

(1) Eat inasmuch as many foods as you can, as very simple procedures could last a lifetime;

(2) Be prepared for catapulting instruments and projectile objects either from infuriated, impatient surgeons, or from the patients themselves (blood, pus, skin staples, ligatures);

[There was one time when an intolerant surgeon mishandled a scalpel and pierced my gloved hand (and my hand as well).
Though she profusely apologized, I was infuriated by her behaviour that I almost send an Incident Report and a Letter of Complaint to the Medical Director. It didn’t happen though as her pleading touch the good-natured-ness in me.]


(3) Be familiar with, and prepare the OR suite, including the OR table, the instruments, glove sizes of surgeons, their preferred kinds of sutures, etc. etc. and;

(4) Be intellectually prepared (as congruent as possible to the surgeon’s line of thinking) as some first-time surgical interns or medical clerks have the (alarmingly frequent) propensity to mental block during surgeries and one thing a surgeon loathe in an OR suite is an unreciprocated question, or a dumb question to an easy query.


Usual co-nurses of mine would be very proud and pompous in bragging about their first cases—some of them have assisted in craniotomies, thoraco-cardiovascular surgeries, abdominal surgeries and the likes, while, I, myself, am mourning that on my first OR suite, the first case of the day, I got to assist in an AKA, not “also known as,” but an above the knee amputation.


Most scrub nurses do not personally know the patient when they are wheeled and transferred to the OR table.
That was one thing that delineates the practice of Medicine and Surgery. In Surgery, one is not required to personally know the patient. All that matters are the patient profile, the knowledge of his diagnosis, the plan of management, and the operative details. It is not unusual for surgeon to feel detached from their patients. The less their emotional involvement over a particular patient, the more objective their practice becomes. While in Medicine, a strong sense of interpersonal relations is always imperative.

When this particular patient was wheeled to the suite, I browsed over his records and found the following pertinent history:

The following may be too graphic for certain readers. Continue if you feel completely secure of what you're about to see.







Source: (No promotions implied).

Chief complaint: Non-healing (ulcer) wound, dorsum of left foot.

Medical History: (+) Diabetes Mellitus, 5 yrs, poorly-controlled, (+) Hypertension, app. 12 yrs, poorly controlled, mean BP=140-170/90-110

Pertinent Social History:
smoker, 30-pack-years; alcoholic beverage drinker, 100-ounce-a-day.

Clinical Impression:
Buerger’s Disease


Buerger’s disease is an inflammatory condition of the small arteries and veins of the distal extremities with subsequent clotting and terminal occlusions.
It results in ischemia (decreased blood flow) to the distal limb, progressing to gangrene (cell death), ulcerations and necrosis. The etiology of this disease is unknown but is almost always associated with constant tobacco use. There is no definitive medical treatment, and surgical amputation is almost warranted in late, intractable stages.

More information about Buerger’s disease here, (for laypersons) and here (for paramedical professionals).


The surgery went uncomplicated.
I have repressed the images of opening the skin, slicing the subcutaneous layer, cautering the muscles and fascia, and slicing the bone using the furious giggly saw back in my unconscious memory. It was like watching Texas Chainsaw Massacre only cleaner, and in this scene, the surgeon and yours truly, are the one slicing the leg off. (Though I was tempted to take the amputated leg home, I guess I’m still too sane to do that).

When the surgery was over, I visited him in the ward for the completion of some requirements.
The initial meet-up was excruciating. When he asked me what job he should try now that one of his legs got amputated, I was dumbfounded. It was then that I knew that he used to be a jeepney driver.

"Surgery is the only specialty where we don't waste time getting to know the patients. They're slabs of meat, we're butchers” said a character in a surgical show.
Perhaps there is truth to this saying. Separating the dictates of the heart from the expertise of the hands is probably what keeps most surgeons sane, particularly this surgeon who makes her own living cutting limbs and installing metallic rods on bones.


Suchman and Wolinsky, in their Theory on Stages of Illness Behavior, believes that one of the principles involved in the aspect of sick role is that one is not responsible for his illness condition—that the person did not cause his illness.

When I first learn about this theory, I thought that people who take their health for granted had indeed found a good excuse in Suchman. Though this theory will still be subjected to endless biomedical debacle, and though I still believe that people do not really intend to get sick, the multidimensionality of health, and its personal nature dictates a personal responsibility to it. Ultimately, the course of our health is dependent not on other external factors, but on how we manage to preserve it despite insurmountable odds.

Perhaps that patient is still alive by now.
Maybe he had found another way of making a living, to support his family and to provide for their needs. Perhaps he had stopped drinking and smoking… or perhaps not. God forbids that when I enter another OR suite, all I will see is a familiar face, whose other leg needs to be cut. And when that time comes, I’ll be more than willing to assist in one.



he posted images are copyrights of their respective owners and the author does not, in any way, claims the ownership of the aforementioned images. The original links are posted respectively for reference.


Anonymous said...

Ewww. Gross. Hihihi.

Sure ex links tayo.

ruff nurse-du-jour said...

That foot was nothing compared to the one we amputated from the poor man. (Channeling blood spurting out of the diseased leg).

I guess he ultimately did learn his lessons. Diabetes, High Blood Pressure, Buerger's Disease, non-compliance and smoking may not be the perfect combination after all.

Added you up. See you soon. =)

Myk said...

Ack! I just hate the OR complex! Hahaha... Pero kawawa naman si manong...

I was giggling at the scrub nurse's to do list. Very true ha. Lalo na 'yung flying instruments with matching foul words pa madalas. That's why I hate the OR. Displacement is always present...from the surgeon to the scrub nurse...sometimes from the head nurse or nurse supervisor to the nurses din...

ruff said...
This comment has been removed by the author.
ruff nurse-du-jour said...

Well I have to agree with you. Poor manong, and poor scrub nurses. I guess they're the most unappreciated member of the surgical team. They usually get all of the blame, and they never get to receive the appreciation and respect they deserve.

There was this one time when the medical intern turns into a stone (a la Ibong Adarna) everytime the surgeon asks her a question. She couldn't answer even simple questions like "what is this muscle? or this vein? nerve? etc." so I got to answer everything, and thankfully I did well. It was in the end of the surgery that the surgeon finally knew that I'm a student nurse and not an intern. It was that moment that made me feel that nurses, indeed, can be appreciated for the work that they do.

AND... I think a surgery will never be complete without a glance of a flying instrument or a rupturing suture. I think that's just the way things are. Hehehe.

chase said...

i was once a tenant of the OR suite when i had my appendectomy surgery 2 months ago.
entering the threshold between life and death is so scary.

but i think working there is way much scarier than being under the table.

i don't have the guts, and the stomach to see all that in reality..


ruff nurse-du-jour said...

thanks for the visit atty chase. =)

aaaw, your appendectomy and your appendectomy scar? how could i forget...

surgery is a really scary thing. i know, people come under the knife day in and day out, some emergent while some are elective, and by now people must have thought that im used to the stresses of it but i beg to differ. people die on the table, some people walk into the OR suite and leaves at it comatose or unconscious, while some ends up uncomplicated. you'll never know. it is not intrinsically evil, though, but there are risks involved. and it is upto us (and our surgeons) to determine if the benefits really do outweigh such risks.

by the way, i used to have a collection of pictures of diseased organs, amputated limbs, etc. i took while i was at the OR. im trying to find where they are. =)


netherchild said...

sure we link exchange. :d ill add you up right away.

you got nice stuffs in here. ^^ nurses are cool. we are cool.

ruff nurse-du-jour said...

thanks for the tag, ive added you up too. thanks so mucho.

i luuurve harry potter. hopefully my blind date will show up on saturday, er, i mean, hopefully i will show up on saturday to meet my date. its kinda complicated, though im hoping that the weather will be fine by then. =)

go go go nurses! hehehe.. see you soon. =)

Franx Budi said...

As a nurse you are very brave to do operation. I can not imagine if I were you...augh. It's a good experience for you Ruff

ruff nurse-du-jour said...

Thanks for the visit franx, and thanks too for the comments. =)

I guess if that is what it entails to become a nurse, I'd be more than happy to do my part. After all, every thing has a reason, and it had indeed taught me some really valuable lessons.

It is my pleasure to add you in my friends list. =)

chase said...

you're allowed to take photos in the OR?!!!!

that should be banned!!!

i just hope no pictures where taken during my visit to the OR..


Eeeeek! Those pictures are the reasons why I can't be a doctor.

kit said...

quite an impressive and informative article...whew.. now I'm having second thoughts on smoking! tnx! :)

ruff nurse-du-jour said...

@chase. yup, EVERYONE, and by everyone, i mean, everyone is allowed to take photos in the OR (its unethical but that stuffs usually happen). they're mostly taken by medical students/interns for their case presentations. i used to have a similar collection before. i seem to have lost them when i reset my laptop. =)

wanna see some of mine's? =)

ruff nurse-du-jour said...

@misterhubs. don't you like my pictures? i posted them specially for your liking and enjoyment..

just kidding!!!

sure, sure mr hubs, no more gross pictures in the future. hehehe

ruff nurse-du-jour said...

@kit. i never even knew that smoking could lower the sperm count, affect the composition (even the taste) of your seminal fluid, and it can even cause impotence. *wink

aside from lung cancer, etc. etc., you know the drill. =) i dont know why i keep on associating stuffs with the "unmentionables." =)