Cascade Hospital Entrance | ER | ICU/Ward | Trauma |
Cardiology | Forensics | Genetics | Infectious Disease | Neurology | Obstetrics | Oncology | Orthopaedics | Pharmacy | Psychiatry | Surgery | Toxicology | Miscellaneous | Hospital Emergencies

Last updated October 22, 1999

The Cascade Hospital is a resource website designed specifically to help FANFIC and other FICTION WRITERS who want to make their stories more medically authentic. It is NOT for people seeking answers to personal medical questions -- that is a job for your private physician.

Department of Surgical Services

~ the operating room and surgery ~

Please read the Sentinel and Medical Disclaimers. This is intended as a general guide to the OR for fanfic writers. This is by no means a substitute for medical advice which, of course, should be obtained by your primary physician.

This page was written by Linda, a Sentinel fan who is a cardiovascular RN first assistant (translation: she assists the surgeons directly during an operation!). She has worked in the operating room for many years and volunteered to write this section. (Robyn made some very minor edits.) Thank you, Linda, for being our Cascade Hospital Director of Surgical Services!

Laparotomy
Laparoscopy
Thoracotomy
Thoracoscopy
Exploration of (name that body part); removal of foreign object
Craniotomy
Burr holes
Open Reduction, Internal Fixation (ORIF) of (Name That Bone)
Arthroscopy
Vascular Surgery

After hours
If things don't turn out well

Introduction

Surgical Services includes the Ambulatory or Day Surgery unit, the Operating Room proper, the recovery room or PACU (post anesthesia care unit), and perhaps Endoscopy (where invasive diagnostic procedures such as colonoscopy, bronchoscopy etc are performed under sedation). The entire department will have a director (an administrative-level RN) and each individual unit will have a charge nurse.

The layout of a well-designed department will have a large reception area/waiting room with post-op interview rooms off to the side. The ambulatory surgery department will usually be directly behind the reception area and will be restricted to patients and immediate family. Family members go to the waiting room once the patient is wheeled back to the OR.

The inpatient holding area (if any) will be beside the ambulatory surgery center. Elevators, preferably service elevators should be nearby to eliminate long trips down corridors. Both the holding area and day surgery units connect to the OR itself through automatic doors. Access through these doors is restricted to department personnel only, and after a designated point only those in scrub attire are permitted. Any unfamiliar people are stopped and challenged, and escorted out of the department if necessary. The OR will have several individual operating rooms, usually specialized by service (i.e. orthopedic, cardiovascular, general surgery, etc.) Somewhere will be a sterile supply and/or instrument room.

There is always some kind of control center for the OR -- it may be called the nurses' station, control desk, schedule desk, whatever. This is where the charge nurse and unit clerk coordinate the schedule. There is usually a big board or computer schedule to inform everyone of the day's progress. Communication to the individual rooms is via intercom or telephone. Nothing happens in the rooms without "the desk" knowing about it.

Immediately adjacent to the OR is the recovery room, or PACU. This is a large room with several bays. There is a monitor in each bay (ECG, blood pressure oxygen saturation), an oxygen outlet and a suction outlet. There are curtains that may be drawn if necessary, but most of the time they are kept open so that the nurses can better keep an eye on everything.

Read this carefully: Family members are almost NEVER allowed back into the recovery area. First, it violates the patient's privacy, as well as the privacy of the other patients. Second, family members get in the way. Third, family members are usually not emotionally prepared to see their loved ones wired for sound, asleep, or (usually) in extreme pain.

There is always a "crash cart" in PACU, plus at least one more in the OR.

The recovery room is usually connected to Day Surgery via a limited-access hallway, and there is also easy access to the service elevators for patient transfer to a regular hospital room. There should also be quick and easy access to ICU for direct transfers to and from OR.

The department is locked and secured after hours. On-call crews have keys or access codes for electronic locks. There's a lot of expensive stuff in there, and it needs to be kept secure.

You can't cut the power to the OR, either. Federal code requires that all hospitals have generators that come on after no more than 10 seconds - and every piece of equipment plugged into a red outlet is connected to the generator. Now if the water's cut off, the OR will cease to function. No water means no scrub sinks, and no water also means no steam for the boilers, which in turn means no autoclaves (instrument sterilizers)

This isn't just an OR thing, but I just thought of it - cell phones are not permitted in hospitals - there is a potential for interference with monitors and other sensitive medical electronics.

Ambulatory or Day Surgery

A recent trend in ambulatory surgery has been the "stand-alone" surgery center, where patients can undergo relatively simple procedures not requiring an overnight stay. Examples of these procedures would be cataract removal, tonsillectomies, tubal ligations, arthroscopies, removal of skin lesions, simple hernia repairs, etc. The patients remain in the facility until they are fully awake and stable and leave with a family member. The current standard of care for nursing is to follow up with the patient by telephone within 48 hours.

Admission

An ambulatory surgery center in a hospital follows the same basic guidelines; the surgeon's office will schedule the case and will have the patient go in a couple of days in advance to have blood drawn for lab work. The usual battery of tests is a CBC (complete blood count), a Chem-8 (basic metabolic panel), urinalysis, chest X-ray, maybe a bleeding time or PT/PTT/INR (blood clotting studies) depending on the procedure. If there is a possibility that the patient may need a transfusion related to the procedure a "type and cross-screen" is also drawn. These lab values will be checked by both the surgeon and the anesthesiologist upon admission.

For a scheduled surgery, the patient is instructed to not eat or drink anything after midnight, and is given a check-in time. He or she is shown into a small room, asked to change into a gown and remove all jewelry, glasses, contacts, dentures, hairpins, etc. Depending on the type of procedure the patient may be allowed to keep his/her underwear and/or socks. An ID bracelet is placed on the patient's wrist on admission. This does NOT come off. Period. If there is jewelry that will not come off (i.e., a tight wedding band and swollen, arthritic knuckles) and is in the area of the procedure, or if the procedure will involve considerable post-op swelling (such as coronary bypass), the ring may have to be cut off. If the patient refuses, a release must be signed. Religious medallions may be removed from the neck, but wrapped in gauze and taped to the patient's hand.

The adult patient is going to require IV access. Some facilities have very well trained RN's that make up the "IV start team", or, more commonly, the anesthesia provider starts it. It's now common practice to numb the area with some local before the Big Needle Stick. Commonly used fluids are lactated Ringer's solution, normal saline (especially for diabetics) or D5 1/2NS (5% dextrose with 0.45% saline) Pre-op medications, sedation, antibiotics etc, are given via this route. Children and young adolescents are usually not subjected to IV's while in day surgery due to the high anxiety factor (for both patient and family member). They receive an IV after they are asleep in the OR (the anesthesia provider will usually use an inhalation agent to get them off to sleep). (See "Anesthesia")

If the anesthesia provider needs to do any special procedures, such as starting central or arterial lines, placing regional nerve blocks or epidural catheters, this is done at this time.

Informed Consent

Somewhere around this time, if this hasn't already been taken care of in the physician's office, the consents need to be reviewed and signed. There are two sets: one for the surgeon, one for the anesthesiologist. Needless to say these need to be signed BEFORE any sedation is given. The content of the consent forms must outline the procedure and risks versus benefits, and may vary from state to state. I'm from Louisiana and we have to have separate "material risks" forms for each component part of the procedure - for open hearts I not only must have a permit for the bypass surgery, but a permit for the use of the heart-lung machine.) If blood transfusion is a possibility, a separate blood permit must be obtained. The patient and the physician sign, and depending on the state, a licensed person (RN or LPN) may need to witness the signature. A person under 18 may not sign his or her own permit unless he or she has been declared "emancipated" by the state. An incapacitated person may also not sign - next of kin is asked to do this (or whoever holds the medical power of attorney). A patient who has received any kind of sedation or narcotic is considered incapacitated. In the absence of family members, telephone consent may be obtained, and two licensed people must hear this verbal consent and document it on the medical record. In an emergency situation and in the absence of family or written provisions, consents are handled later.

In the meantime, the RN assigned to the patient in Day Surgery reviews the chart for the required information and confirms it with the patient. If the patient has any allergies, these are documented and an allergy band (usually red) is placed next to the name band. These allergies are also posted on the front of the chart. If the procedure involves one extremity or one side, the patient is asked which side the procedure will be operated on. The surgeon is also required to "identify" the surgical site and may even write on it with a marker (his initials, the words "THIS ONE", etc.) There's a reason for this. Everyone's heard the horror stories about wrong legs being amputated, knee replacements done on the wrong side, healthy breasts removed.... When the chart review is complete the patient is ready for the OR - the circulating nurse will take the patient to the surgical suite when everything there is ready.

Inpatient Surgery

Inpatients in general do not go to Day Surgery, but to a separate "inpatient holding area" in the department. The chart review and consent procedures are identical. ICU patients needing surgery or patients with infectious diseases such as TB usually go directly back to the OR. ***Fanfic Warning!!! I know that it's really, really tempting to write a "he was taken to the OR and almost had X, Y, and Z done and thank GOD he was rescued in the nick of time" type story...(and for this reason I have really, really big problems with Finkelman's Folly). In real life this just would not happen. Orderlies just don't waltz into a room and pick up a patient. They MUST ask the patient their name, their surgeon's name and the procedure. Then they MUST check the patient's armband and make sure it matches with the name of the patient they're supposed to pick up. Then they have to get the chart, which must also match the name of the patient, from the nurse taking care of the patient (who will know if his or her patient is about to go to surgery, because he or she will have been told by the scheduling desk to prep the patient.) If the patient is unresponsive or on a ventilator, an RN and perhaps anesthesia will come to pick the patient up. In this case, the OR nurse will receive a short! "report" or summary of the patient's condition prior to transferring responsibility. A brief chart review will clue the nurse in as to what's going on - if someone's in with, say, a head injury and an orderly or nurse shows up to take the patient back for bilateral below-the-knee amputations, SOMEONE IS GOING TO CATCH THIS, EARLY, unless the entire hospital staff is in on the scheme. Plus, unless he's the bad guy, the surgeon can usually recognize his own patient!

By the way, there are usually no orderlies on duty in the OR at night or on weekends, unless the OR department is large and busy enough to be staffed 24/7. Assuming that Cascade has a population of around 500,000 people and probably has more than one hospital, this may or may not be the case. After hours the "on call" crew will handle everything, so this means that an RN will come for the patient.

Behind the Double Doors: The Operating Room

Cast of Characters:

Surgeon

Assistant (can be another surgeon, a resident, a PA (physician assistant) or RNFA (RN first assistant)

Anesthesiologist (MD)

Anesthesia resident (MD) or CRNA (Certified Registered Nurse Anesthetist)

Circulating Nurse (RN)

Scrub (may be an RN, LPN, or unlicensed tech) -- sets up the sterile supplies, hands the instruments

Perfusionist (operates the heart-lung machine on open-heart cases)

Medical student(s) if a teaching hospital -- observes, holds retractors, sometimes gets to help with suturing or other things depending on the surgeon in charge

A big case may require two circulators, or more than one scrub to hold retractors, etc.

OK, we've made it this far. The patient has been admitted and checked into either Day Surgery or the inpatient holding area. The circulating nurse checks the chart and ensures that the appropriate consents have been signed, and checks the patient's armband. She makes sure that the anesthesia team and the scrub are ready before giving the patient a warm blanket and wheeling the stretcher to the OR.

Most OR's are kept at about 65 degrees. Most have stereos. (Mine has a 6-disc CD changer; sure wish I had DMX as well...)

Masks, hats or caps and shoe covers are required in the individual rooms.

The patient is helped onto the OR bed itself, which is almost always hard and cold. A safety strap is fastened above the knees. Another warm blanket is applied while the patient is connected to the ECG monitor. A blood pressure cuff is applied to one arm and a pulse oximeter probe attached to a finger. The bright overhead lights are not turned on until after the patient is asleep.

I'll cover the actual induction, maintenance and reversal of anesthesia in the "Anesthesia" section.

When the anesthesia provider gives the go-ahead, the circulating nurse does whatever she needs to do to get the patient ready for the procedure; placing a Foley, shaving, positioning, etc. A gel grounding pad is placed, usually on the patient's thigh or back, to protect the patient from burns from the electrocautery unit, which will almost always be used. A disposable warming blanket is placed and hooked up to a warm air blower.

By now the surgeon and assistant should be outside the room at the scrub sink, washing their hands.

The surgical site is now prepped according to the surgeon's preferences. Betadine is still probably the most popular prep used, but it can irritate the skin and is washed off afterwards. There are some wipe-on type preps such as "Duraprep" that are also widely used; this stays on the patients' skin for a long time and leaves a yellowish film.

Once the prep is dry the scrub helps the surgeon drape the patient with sterile drapes, leaving only the surgical site exposed.

During the case the circulator does the necessary paperwork (perioperative patient care record), makes sure the scrub has everything he or she needs, generally runs the case. He or she will also call out to the family if possible to give brief updates.

I'll list the most common surgical procedures in "Operations".

After the operation is completed and while the surgeon is closing the wound, the circulator and scrub count all the sponges, needles and instruments used on the case. They have already counted once, before the case began, and the numbers had better match. I'm sure you've heard horror stories about surgeons leaving things in the wound - this is how we avoid problems like that.

And yes, some surgeons really do have "closing music."

After the case has ended the circulator will place tape over the sterile dressing and help the scrub wash the remaining prep or blood away. The patient will be covered with more warm blankets and the circulator will remain at the patients side until he or she is awake enough to be extubated, (if that's possible). The patient is carefully transferred back to a stretcher or PACU bed and wheeled into the recovery room, accompanied by the anesthesia provider. The surgeon has probably already left the OR and gone ahead to PACU to dictate his operative note for the medical record. Once the patient reaches PACU, the circulator "reports off" to the recovery room nurse, completes her paperwork and returns to the room to help clean up.

If the patient is unable to be extubated, (too sick, too cold, etc.) then he or she will usually go to the ICU directly from the OR, once the circulator has called the ICU nurse, given a brief report and made sure that a ventilator and respiratory therapist are available.

The surgeon will then talk with the family in the waiting room or post-op consult room.

Recovery Room (PACU)

This unit is staffed with registered nurses and is under the direction of the anesthesiologists.

Once the patient is wheeled in he or she is immediately connected to the monitors and a baseline set of vitals is taken. Temperature is very important, as the patient is usually quite cold when he or she arrives. A "good" temperature is considered to be in excess of 96 degrees. If the patient is cold, a forced air warming blanket is applied. Oxygen is started by mask and maintained until the patient is fully awake and responding. Post-op X-rays may be taken and lab work drawn here.

In the event of an emergency, there is always a "crash cart" and a "difficult airway cart" in the recovery room. All PACU nurses are considered critical care nurses and are ACLS (Advanced Cardiac Life Support) certified. (That's super-advanced CPR).

The surgeon will have written orders for pain management; if the patient is complaining of pain he or she will receive pain meds via the IV (usually morphine or Demerol). If the patient has an epidural catheter in place they're usually relatively comfortable. If the patient received a spinal, they will be numb from the spinal site all the way down - this must wear off completely before the patient can be released from PACU.

Epidural catheters can usually stay in for 72 hours, connected to a small pump that delivers a predetermined dose of pain medication. The anesthesiologist will pull it out at the appropriate time. Another effective method of post-op pain control is the PCA pump (Patient Controlled Analgesia), which gives the patient the option of pushing a button and releasing a small amount of medication (usually morphine or Demerol) into the IV. There is a lockout mechanism that prevents the patient from giving him or herself too much.

Again, family/friends/significant others are NOT allowed in PACU.

Vital signs are recorded frequently, every 5 minutes. Usually the minimum stay in PACU is 30 minutes. The RN will continually assess the patients' responses, level of consciousness, etc and monitor the "score". Once a predetermined post-op score has been met, the patient can be discharged to the floor or Day Surgery after the anesthesiologist has signed the release. A room assignment will have been made by now, and "report" will be called up to the floor. The recovery room RN will accompany the patient to his/her new room and will personally report off to the receiving RN.

Anesthesia

There is always an anesthesiologist assigned to every case, although he or she may not be in the room with the patient the whole time. That job falls to either the anesthesia resident or the CRNA (certified registered nurse anesthetist).

Types of anesthesia

• General - the patient is "asleep" and usually intubated.
• Spinal - the patient receives a dose of medicine (Lidocaine or Marcaine) directly into the back, numbing the patient from that point down. Patient receives some sedation along with this. Spinals are usually done in the OR due to the potential for low blood pressure. Can last 6 to 8 hours depending on the medicine used.
• Epidural - a small caliber, soft plastic catheter is introduced into the epidural space in the back, and medicine is delivered in small doses. Patient may have some sensation but no pain. Used frequently in management of labor. Catheter may be left in for 3 days for post-op pain control.
• Regional - a specific part of the body is numbed for cases usually involving arms or legs. Example - an axillary block, where medicine is injected into the nerves at the armpit, numbing the arm. Lasts several hours.
• Local - an injection of numbing medicine into the tissues around the operative site. Lasts from 20-30 minutes up to 2 hours, depending on the medicine used.

When the patient first rolls in the anesthesia provider's job is to connect him or her to the monitors and obtain a baseline set of vitals. Vitals are taken and recorded every five minutes. Essential vitals are ECG, blood pressure and oxygen saturation.

The patient has probably already received a little sedation in Day Surgery or inpatient holding. An oxygen mask will be placed over the patient's face (this smells strongly of plastic as the mask and air circuit are replaced every case) and more sedation (Versed or fentanyl) will be injected into the IV. Some medications (Diprivan, Valium) burn on injection, so sometimes some local (Lidocaine) is injected first to numb the vein. The circulating nurse will stand at the patient's right side and provide reassurance to the patient and any assistance to the anesthesia provider. The patient may feel dizzy, weak, and sometimes the sounds in the room seem to become louder. Itchy noses are somewhat common, especially with fentanyl. The patient is officially "asleep" when the lid reflex is lost - this is tested by gently stroking the eyelashes. If the patient doesn't blink reflexively, he's asleep. At this time a muscle relaxant such as succinylcholine or a curare agent is injected, paralyzing the patient so that the endotracheal tube can be placed. As detailed elsewhere, a laryngoscope is used to visualize the epiglottis and vocal cords before the tube is placed. The patient is "bagged" for a few breaths until tube placement is verified, then the tube is taped in place and the ventilator portion of the anesthesia machine turned on. Oxygen, air, nitrous oxide and a variety of anesthetic gases can be delivered via this machine. IV fluids are maintained, and blood can be given if necessary. In every room is a medication cart with plenty of drug, including several that would be needed in n emergency. Needless to say in trauma and open heart rooms are carts containing the "code drugs" that would be needed in the event of cardiopulmonary arrest.

At the end of the procedure, the gases or "agents" are turned off and the patient is allowed to awaken. Long acting muscle relaxants are reversed with the appropriate medicines and as soon as the patient is able to breathe for him/herself the tube is untaped and pulled. Oxygen is delivered by mask until the anesthesia provider is satisfied that the patient is OK (sometimes the throat goes into spasm after the tube is pulled), and then the patient can be transferred onto the stretcher. If the patient is very cold or for other reasons cannot maintain an airway or oxygen saturation, the tube will be left in and the patient will be bagged all the way to the ICU, where a ventilator should be waiting.

For short procedures that require general anesthesia but not intubation, the patient may be "masked", i.e. with the anesthesia provider holding the mask over the nose and mouth while the patient breathes an anesthetic gas.

Children are usually induced by holding the mask over their face and having them breathe an agent, usually Halothane. Although everyone involved tries very hard to reassure the child, the experience is very scary and claustrophobic for them, and they struggle and fight all the way down. Once they're asleep a small IV is started.

The anesthesiologist is responsible for determining the patients "score" in the recovery room and must sign off on his or her release to the floor.

The Operations You'll Probably Want To Write About

An incision into the abdomen. Bowel cases, gunshot wounds, internal bleeding following trauma. Can last from 30 minutes to several hours. Long midline incision. The surgeon pokes around and tries to find internal injuries and repair them if possible, then sews the person up. Sometimes drains are left in (they look like plastic grenades with a tube going into the abdominal cavity). A LOT of post-op pain.

Using a laparoscope (small instruments guided by a small TV camera) to do the surgery. Uses three or four small incisions that are covered with a Band-Aid afterwards. The camera is on the end of a stiff metal rod which is placed into the abdominal cavity through one of the incisions. The surgeon performs the operation by watching a TV screen. Very small tools are inserted through other incisions for cutting, cauterizing, sewing, irrigating, etc. Common laparoscopic procedures: tubal ligations, appendectomties, hernia repairs, cholecystectomies (gallbladder removal) etc. Can last 30 minutes to 2 hours, depending on what's being done. May need to be converted to an "open" case. Can be quite painful afterwards; hiccups common also due to some retained carbon dioxide gas (used to distend the abdomen during the case)

Incision into the lateral aspect, or side of the chest, for lung cases or other thoracic or vascular trauma. Requires the patient be positioned on his or her side. Very painful incision. Unless an entire lung is being removed, the patient will have a chest tube for a few days afterwards. If the chest is opened from the front (a midline incision), as in heart surgery, the incision is a sternotomy. The sternum (breastbone) is actually wired together at the end and the skin closed on top of that).

Yes, we can do "minimally invasive" lung surgery, usually to obtain biopsies or to correct a collapsed lung by stapling off a weakened segment. Less painful than a thoracotomy; still requires a chest tube aftewards.

This is where a foreign object (read "bullet") is removed and the wound explored, cleaned, irrigated, repaired and closed. We're not allowed to call a bullet a bullet for legal reasons. Defense attorneys have a field day with those who do. The doc who removes it must make a mark on it (so he can identify it in court) and it must be handed directly to the police, who must sign for it. Nobody is EVER permitted to keep his or her "foreign object". (Or removed body parts, for that matter.)

Sorta like a crani, but on a smaller scale. This is where subdural or epidural hematomas are evacuated. Essentially the neurosurgeon takes a big 'ole drill bit to the head over the clot so it can drain. Takes 30 minutes to an hour. Useful in the management of severe head injuries.

Unless it's a very simple fracture, most adult fractures require surgery so the bone can be properly realigned to heal properly. An incision is made over the fracture, the bones are re-aligned ("reducing the fracture") and they are "fixated" with pins, plates, and screws, whatever hardware is required. X-rays are taken during the case to ensure that the correct alignment is obtained. A drain may be inserted to remove blood or other fluid that accumulates. These cases look like wood shop. On a multiple trauma, more than one fracture may need to be fixed. A cast is usually not required, just a soft bulky dressing and a large Ace wrap. Time required really depends on the bone(s) involved and the severity of the fracture. A really, really badly shattered bone may require external fixation - the end product looks like scaffolding is holding the limb together while the bone heals. These are painful injuries, and require a lot of painful physical therapy.

All compound fractures require surgery. Period. They are also considered a "dirty wound" and require lots of irrigation and antibiotic treatment.

Back to the scopes...this is where a joint is examined with a very small scope. Torn cartilage can be removed, and some minor ligament work can be done. Most common targets are knees and shoulders. Used frequently with sports injuries for diagnosis. Can take 30 minutes to an hour - mildly painful. Patient may need some PT.

A broad subject - this can range from a controlled, elective procedure like a carotid endarterectomy to clean out a clogged artery, to an emergency lap for a ruptured abdominal aortic aneurysm. (Those are NOT fun. Trust me.) In the context of the Cascade Hospital, we would probably need the services of a good vascular surgeon for some kind of trauma, such as an MVA (motor vehicle accident) or a gunshot wound. The goal is simple in vascular surgery: find the bleeder, clamp it, see if there's anything else bleeding, assess the damage, repair it, make sure that whatever organ or body part that vessel supplies has enough blood flow, get the heck out. If there's time, an arteriogram can be very useful. This is a special X-ray where dye is injected into the bloodstream, giving us a very accurate picture of the circulation and any vascular injuries. Repair of injured vessels can be as straightforward as closing the hole with suture or as complicated as replacing all or part of a vessel with a vascular graft. The location of the injury is very important, too. Trauma to the great vessels in the chest is very, very bad news. Frequently the patient dies on the scene or in the ER - this is where you see chests opened up in the ER (Princess Diana) as a last ditch effort. It's no picnic when the subclavian vessels get damaged, either, (so watch all those "minor" shoulder wounds!) Anything involving any part of the aorta is very serious, including where it splits in two at the groins. It doesn't take long for someone to bleed out from a lacerated femoral artery.

Need details on more procedures? Let me know and I'll be happy to fill you in. Email Linda.

After Hours

Unless the OR is staffed 24/7, once a surgeon posts an emergency case the house supervisor will call out the "on-call" crew as well as anesthesia. Some hospitals require their crews to stay in-house in special "call rooms" which are little more than closets with beds. The call crew should be in the OR within 30 minutes, but the supplies for the case need to be pulled and set up, so it may really be a good hour or so before everything's ready. Unless the circulator's called for additional help, it's going to be a bare-bones crew and everyone's going to be cranky if their beepers went off at 2 a.m.

If Things Don't Turn Out Well

Every now and then it has to happen; a patient expires. If there's enough warning, a smart circulator will have informed the desk that things are not going well. The charge nurse can then give the family this information, usually with a hospital chaplain right there. If the patient is Catholic and hasn't received the Sacrament of the Sick sometimes a priest will dress out in scrubs and come into the room (they do at my hospital) to anoint the patient. If the patient expires, the surgeon talks to the family (by now a chaplain will certainly be there) while the OR team cleans the patient up. Usually the medical examiner is called at this point and the determination is made as to whether or not an autopsy is required. If so, all the tubes, IV's and catheters must remain in place until the autopsy. The family is always given the option of viewing the body, which is wheeled into a small, private area away from other patients. I allow the family as much time as they need. When they're done, the body's either wrapped and taken to the morgue or (if no autopsy is needed) the funeral home comes to take the body.

Most states now require that the families be asked about organ donation; at my hospital the chaplains do this. (At Robyn's hospital, a special team of trained nurses does this.) If the response is "yes" then the appropriate tissue bank is contacted.

This Sentinel page created by Robyn