Wednesday, December 28, 2011

Hurry Up and Wait

    Yesterday was my first day back at work after a long Christmas weekend, and it started off with the usual post-holiday bang. In outpatient surgery, we had twenty-five cases among six operating rooms, evenly divided between gynecology, ENT, and orthopaedics. By one-thirty, I had already placed four femoral, three sciatic, and two brachial plexus nerve blocks, and finished interviewing my last case. Although it was hectic, we had good momentum, and I felt cautiously optimistic. If the winds of fortune are blowing in your favor, even if you're the late doc running a busy schedule like yesterday's, it is still possible to have an early day where you get all your work done in ten hours, instead of fourteen. You may actually get to go home while it's still light outside. My cases had all started on time and were moving forward at a reasonable pace, and one of the surgeons was running slightly ahead of schedule. It definitely looked promising. Somewhere around two-thirty, though, the progress came to a roaring halt. We'd suddenly entered a time warp, and time wasn't just standing still, it was taunting and ridiculing us, like a playground bully. Whereas we'd previously been getting cases back to the operating room with Michael Jackson-style choreographed precision, we were now a troupe of unrehearsed dancers, floundering in a slow motion ballet. Instantly, I knew we'd veered off course into that much-dreaded parallel universe known as "Hurry Up and Wait." This is an operating room phenomenon, a dead zone which typically coincides with shift change. Between two-thirty and five o'clock, operating room personnel begin to disperse, reducing the number of available staff to assist with cases.  This loss of personnel translates into fewer rooms that can be run concurrently. A surgeon who had been operating efficiently in two rooms to improve turnover time, will be down-sized to one room in the Hurry Up and Wait zone, and any remaining cases will now be done in series, instead of in staggered parallel.
     Like the Archangel Gabriel heralding the Apocalypse, Hurry Up and Wait is also an unwelcome harbinger of doom, auspiciously warning you of bad fortune that is heading your way. You're almost certainly going to have an unanticipated difficult airway, and you'll probably break a tooth during the intubation. If you're really unlucky, you'll inherit at least one urgent case involving a patient who's had sphincter-altering surgery, with only four hours of NPO time following his lunch of a Big Mac, shake and fries. Your illustrious duties might include starting a central line because no one else can get an IV on your patient, or draining a rapidly expanding neck hematoma on that fresh cervical fusion, the one whose face is bulging and turning blue as he struggles to rip off his hard collar. Don't even dare to think you'll get by without at least one patient who has unremitting post-op nausea. In the world of outpatient surgery, the badness associated with Hurry Up and Wait always seems to be concentrated into the last one or two patients of the day; without exception, the last patient out of the operating room is going to have some kind of unforeseen, frustrating problem. If you're the unfortunate designated late doc on a day like this, you count your blessings if you make it home before eight o'clock.
     There is an old saying that anesthesia is 90% boredom and 10% terror, but Hurry Up and Wait easily encompasses both categories. Characterized by a confounding, circular pattern of microscopic bursts of intense activity, followed by interminably long periods of complete inertia, it sneaks up on you, taking you by surprise. Once you realize you've entered the "zone", it's already too late; you're pretty much toast. The 90% boredom component of Hurry Up and Wait is obvious. For example, at five o'clock yesterday, I was still supervising three anesthetists in three operating rooms. From the way things were slogging along, I knew it would be a very late evening. I didn't leave work until eight o'clock, just after our last patient of the day, who had gotten out of the operating room at six o'clock, was finally discharged from the recovery room. Naturally, she was battling significant post-op nausea, and the nurses and I spent close to two hours rescuing her with IV fluids, Zofran, and Reglan. Boredom is not necessarily a bad thing in and of itself. If you plan ahead and bring along a book or some anesthesia journals to catch up on, you can be productive while you are waiting for your cases to finish. But, boredom makes you sleepy and hungry and mentally dull, making it easy to be caught off guard. You start thinking about all the things you'd rather be doing, like working out or eating dinner with your husband. You watch the clock, and every minute that passes becomes a milestone, a countdown which culminates in your return home, only you do not pass "go" or collect two hundred dollars; you simply collapse into bed. The 10% terror?  That's a little less straightforward. Imagine, if you will, Adam and Eve, at the moment they partook of the fruit from the tree of knowledge. They became sentient, aware, no longer blissful in their ignorance. Surviving just one Hurry Up and Wait day equates to a bite of that forbidden fruit; you only have to experience it once. You are then rendered permanently scarred by the painful awareness that, at some point in the future, you will be revisited by Hurry Up and Wait, and no matter how diligently you prepare to avoid catastrophe, you'll be burned again, terrorized by post-op nausea, sky-high blood sugars in the diabetic who inadvertently received four millligrams of Decadron, or the hyper-anxious Xanax-taking patient who has a room air oxygen saturation of 99%, yet "can't take a deep breath."
     I got home a little after eight last night, my outlook somewhat improved after learning that I'd have today off. Brad had just returned from his job in Dunwoody, and despite enduring the gnarly two hour, against-traffic drive back to Rome, had stopped at Mellow Mushroom to pick up a Greek salad for us to share. We ate the salad, watched a little TV, and went to bed. Tomorrow, I'll once again be the late doc in outpatient surgery. Maybe by then, I'll have snagged my overdue stroke of good fortune, where the Force is with me, and Hurry Up and Wait is nimbly vanquished by Come On, Let's Go.

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