In most cases, they're the last people patients see before being put to sleep by the anesthesiologist and the first ones they see when they wake up.
They are the operating-room nurses: the registered nurses who provide patient care before, during and after surgery.
It's a high-stress job that requires emotional and physical stamina, the ability to operate complicated equipment and a knowledge of literally hundreds of operative procedures as well as surgical instruments and supplies.
On a typical eight-hour shift, an operating-room nurse may be involved in up to four cases, ranging from patients undergoing gall bladder surgery to victims of auto accidents.
Work Closely With Others
Sometimes they work an entire shift with little or no break. With or without a break, they must be able to work closely with other surgical-team members who are under stress. As one 35-year veteran of the operating room said, "In other areas of nursing you have a chance to walk away from it for a few minutes. Here, you can't."
For operating-room nurses, a sense of humor is considered a necessity for emotional survival.
Today is the seventh annual Operating Room Nurse Day, a little-known national observance honoring the unsung heroes of nursing services.
At UCI Medical Center in Orange--a level-one trauma center offering all services 24 hours a day, seven days a week--the operating-room staff consists of 30 registered nurses.
This is a story about a day in the life of one of them--Suzy Cummings, who, at 28, has eight years' experience in the operating room.
"Our staff has been involved in cases since early morning," operating-room nurse Jo Demos said. "We've done patients from age 87 down to 8 months this morning."
Demos, clinical resource consultant for operating-room services, was escorting a visitor on a tour down the T-shaped, white-walled hallway, which passes by eight operating rooms.
It was 1:15 on a recent Friday afternoon, a half hour before Cummings and three other operating-room nurses on the evening shift come on duty. A part-timer since returning to work from maternity leave in September, Cummings would be working a 10-hour shift that would not end until 12:15 a.m.
At the moment, Demos said, six operations were under way: multiple skin grafts on a man who lost his arm in an accident, brain tumor surgery, a breast biopsy, gall bladder surgery, an abdominal hysterectomy for cancer and an infertility procedure to determine whether a patient is able to have a baby.
So far, no trauma cases. But, Demos said, Fridays usually were fairly busy with trauma cases.
And, she observed, the weather was nice, and the traffic was picking up.
It's referred to simply as "the board."
It's a wall-sized, white-grease-pencil board at one end of the operating-room hallway. It lists the names of patients, operating procedures they will be undergoing, the operating-room numbers, and the names of the doctors and nurses assigned to each case.
The board, as Demos explained, "is our bible, our guide for the day."
And it's where Suzy Cummings and the other operating-room nurses on the evening shift reported after changing out of their street clothes and into their blue uniforms: a cotton scrub suit and disposable shoe covers and caps.
Tall and thin with her medium-length blond hair tucked inside her surgical cap, Cummings stood in front of the board with Demos and two other evening-shift nurses.
'Need Some Help'
As they read the assignments, Demos noticed a bed being wheeled around the corner from the emergency room.
"We need some help here," she announced to the nurses.
Cummings went over to the bed and examined the patient's medical chart. Then she wheeled the bed down the hall, stopping outside Operating Room 4.
"Are you warm enough?" she asked the patient, an elderly man who had broken his hip in a car accident two days earlier.
"I'm pretty comfortable--considering," the man replied in a raspy voice through an oxygen mask.
Cummings said the surgeons would be putting a Richard's screw--a large stainless-steel screw--into the man's hip in order to stabilize the fracture.
Meantime, Cummings and the patient would wait in the hall until a nurse, a technician and a housekeeper finished cleaning and preparing the operating room for the next patient.
In operating-room parlance, it's called "turning over" a room, a task that takes 15 minutes or less.
Sitting in an empty operating-room office for a brief interview, Cummings said that she grew up on a farm outside the small Nebraska town of Murdock.
She decided to become a nurse in high school after taking a biology course from a teacher who was, she said, "an anatomy and physiology enthusiast. I really enjoyed it, so that kind of led me into nursing."
Cummings, who earned a nursing diploma at Bryan Memorial Hospital School of Nursing in Lincoln, Neb., in 1978 and later received a bachelor's degree in nursing from the University of Kansas, worked a year in the operating room at the University of Kansas Medical Center in Kansas City before going to work in the operating room at Suburban Medical Center in Overland Park, Kan.
That's where she met her husband, Dennis, who is a nurse anesthetist.
Husband Joined Navy
The couple moved to Huntington Beach three years ago after Dennis joined the Navy. He is stationed at Long Beach Naval Hospital, where he works the 7 a.m.-to-4 p.m. shift.
"When I was working full time we didn't see each other much," Cummings said. "We saw each other about 16 waking hours a week before I went to 10-hour days."
But being married to someone in the same profession has its benefits, she said.
"It's an advantage because it's easy to talk shop," she said. "The other person has a full understanding of what goes on back here. It's easy to understand when (the other person) has to put in overtime because you know the situation."
Cummings, whose daughter, Kelly, was born in May, returned to work part time two months ago. She splits a full-time position with another nurse and works two 10-hour shifts a week.
"In a way I really miss working full time," she said. "However, I really enjoy being with the baby."
After placing a box of medication in a supply-room refrigerator, Cummings checked the board again.
"You look to see how many cases are going on, where they are in progression and go from there," she said. "There are always a thousand things to do. You just kind of do whatever needs to be done. If you don't have an assignment, you help turn over a room or put away supplies.
"On our shift it can be tremendously busy or very, very quiet. We tend, I think, more toward being busy than quiet."
With no specific task assigned to her, Cummings put on her surgical mask and entered Operating Room 6, where a female patient was undergoing minor abdominal surgery to determine fertility.
Patient Was Awakening
"Suzy, how're you doing, babe?" one of the doctors said.
"OK," she said. "You got everything you need here?"
"Yeah, I think so," he said.
The patient was beginning to wake up from the anesthesia, and Cummings went outside to get a metal transport frame. Returning, she picked up the wall phone and dialed the recovery room.
"Hi," she said, "this is Suzy in 6. We'll be out with our case in a moment."
She wheeled the patient down the hall to the recovery room, where she gave the recovery-room nurses a report on how well the patient tolerated the procedure, how much blood she lost, whether she has any allergies and anything else out of the ordinary.
Cummings returned to the board, then reported to Operating Room 6 to set up for a microsurgical procedure: Surgeons would be removing strands of tissue around the patient's Fallopian tubes that are preventing her from becoming pregnant.
In the hallway outside Operating Room 6, Demos peered through the small window in the door at Cummings standing next to the patient on the operating table.
"Notice the look on the face--the eyes," Demos said. "It's an expression that is firm, supportive, helpful: It says, 'I'm here, I'm caring, What do you need?' That patient knows she's there. She (Cummings) responds to that patient."
Demos said nurses in other specialties sometimes criticize operating-room nurses for being "technically oriented" rather than patient-care oriented. She heartily disagrees.
"If you watch their hands and faces, they're demonstrating care," she said. "The nurse literally joins the patient: They do get emotionally tuned into their patient.
More Than Just Technical
"Yes, our patients are asleep, but they're not asleep before or after the operation. We get comments after surgery from patients who say, 'Gee, I was glad you were there. Someone took the time to talk to me. Thank you.'
"That's not technical orientation."
Inside the operating room, the anesthesiologist informed the patient that she will be given some oxygen before being put to sleep.
"Now think about something really nice and pleasant for a while," said Cummings, holding the woman's hand. "You're doing just fine. We'll take good care of you while you're asleep."
The microsurgery was under way.
Standing next to the rear wall of the operating room, Demos described Cummings' duties as circulating nurse.
She must constantly monitor blood and fluid loss and watch for breaks in sterile technique that cannot be seen by the surgeons or scrub nurse because they are so close to the surgical field.
She'll keep her eyes on the patient to assure the patient's safety while she is under general anesthesia--watching for any unusual pressure on the patient from the equipment, for example.
She will watch the surgeons to anticipate their needs so the surgery can be performed as quickly as possible. "You have to be able to literally read the mind of the surgeon in order to anticipate their needs and keep the care going as quickly and efficiently as possible," Demos said.
She will check with the anesthesiologist to determine what anesthetic agents are being used in order to get a better understanding of the patient's recovery period.
She'll take all the discarded sponges and weigh them or lay them out so they can be visualized for blood loss and counted accurately. And she'll complete the operating-room record, which lists everything that occurs from the time the patient enters the operating room until the time the patient leaves.
"You have to have an ability to put your hands and minds together," Demos observed. "If you have two left feet you just can't make it in an operating room."
Cummings, Demos noted, may or may not get a dinner break.
The hospital cafeteria is open from 5 to 6:30 p.m. but, as Cummings said, "everybody brings their own. You just eat when you can."
The operation was over.
"Thank you, everyone," the attending physician said.
Cummings took down the surgical drapes, taped the patient's dressing in place and brought warmed blankets to place on the patient, who was just waking up from the anesthesia.
"Surgery is over," Cummings told her. "You did real well. We're going to be going to the recovery room soon."
After taking the patient to recovery, Cummings entered Operating Room 4, where the elderly man was still undergoing hip surgery.
Cummings will be relieving the circulating nurse, who had been scheduled to go home at 3.
A team of three doctors had just inserted the Richard's screw into the patient's hip and the operation, which started at about 2:30, was almost over.
Dozens of orthopedic surgical instruments, including power drills, were strewn over two tables. Standing near the patient was a fluoroscopy unit, a large C-shaped machine that provides X-ray visualization of the hip on a TV monitor.
"Suzy, can I have your shoulder for a minute?" the scrub nurse said to Cummings.
The scrub nurse leaned over and rubbed her forehead on Cummings' shoulder.
"Itch," Cummings said with a grin. "The first time you're scrubbed and can't touch your face, it itches. But it'll go away after a while."
With a laugh, she added: "Hazard of the job."
While the orthopedic surgeons worked on closing the patient's wound, Cummings removed some of the instruments and washed them. She finished the sponge and needle counts, gave the scrub nurse the dressings and estimated the blood loss. She asked the patient, who had been awake during the procedure, how he was doing.
After the surgeons closed the wound, Cummings taped the dressing, helped the doctors lift the patient off the table to his bed and wheeled him to recovery.
"OK, we're ready for lunch," Cummings announced, walking down the hallway to the operating-room lounge. The lounge is furnished with two couches, a dining table and chairs, a refrigerator, a coffee maker, a microwave oven and a black-and-white TV that, at the moment, was tuned to the news.
"Oh, what's happening in here? Somebody had a baby?" Cummings said, opening the door and seeing the dining table decked out with a paper tablecloth, paper plates and a cake.
One of the nurses at the table explained that they had just had a baby shower for a co-worker.
Cummings took her frozen dinner out of the refrigerator and placed it in the microwave. The meal was macaroni and cheese.
'Fairly Typical' Evening
"We have Oreo cookies, so that makes up for it," she said with a grin as she sat down on the couch with two cartons of milk.
She was asked how the evening was going.
"It's fairly typical," she said, adding, "We're happy to eat."
Was she tired?
"No, just thirsty," she said, opening one of the cartons of milk.
Cummings said she enjoys working on orthopedic cases.
"I like orthopedic procedures because they are interesting, and the doctors are fun to work with," she said.
She glanced at the TV.
"Gosh, we could be watching 'MASH,' she said, getting up to change channels. Responding to the obvious question, she said: "Oh, we love it."
As the familiar "MASH" theme song played, Cummings was asked if one particularly busy day stands out from all the rest.
Enjoys Doing Trauma
"They don't stand out anymore," she said. "It's just kind of matter-of-fact. Actually, I like it when it's busier than slower.
"I enjoy doing trauma, working with the patients. They present a big challenge because they're often multiple traumas. They may have several teams of surgeons working at once, and it takes a lot of preparation and work to do all these things simultaneously or in rapid succession.
"I went into it (nursing) because I enjoy anatomy and physiology, and you certainly get a marvelous opportunity to see anatomy firsthand down here."
Cummings acknowledged that it's not unusual to become emotionally involved in some cases.
Involved With Children
"Children are a prime example," she said. "Last night we did a little tiny baby who had been born at 3 in the afternoon. The entrance to her stomach was too narrow, so she couldn't eat. The surgeons created a new passage."
While working in Kansas City, Cummings recalled, she was involved with numerous open-heart surgeries on children.
"It was very hard for me when they were really sick, and they didn't make it. On the other hand, it was very gratifying when they did. The results are immediate: Often, the child who had a very bluish tint to his skin coming into the surgery will leave with a healthy pink color."
What particular emotionally wrenching cases stand out in her mind?
"The ones I don't forget are really sad," she said.
Would she describe one?
"I'd really just as soon not," she quietly replied.
Her dinner break over, Cummings walked briskly down the hall to Operating Room 4, where she began preparing the room for an auto accident victim. It was the first trauma case of the evening.
The patient, who at the moment was in the emergency room, had hit a large truck. When the patient arrived from emergency, a technician informed Cummings that the man had had his ear and the side of his face sewn up and had been given a pain shot an hour ago.
Cummings would be serving as scrub nurse for this operation, in which orthopedic surgeons would wash outthe patient's leg and toe wounds and reset the broken bones.
As scrub nurse, Cummings said, she would provide the appropriate instrumentation, maintain the sterile field and assist the doctors as indicated.
The patient, who had been given a general anesthetic, was now asleep.
"We could have music again," the nurse anesthetist said. "Oh good," one of the surgeons said. He stood on a stool and turned on a tape player on top of a metal cabinet.
The sound of Wham!'s "Wake Me Up Before You Go-Go" filled the operating room.
"So how's your little girl?" the other surgeon asked Cummings as he and the circulating nurse began applying a brownish antibacterial solution to the patient's leg and toe.
"Just marvelous," Cummings said. "Do you know she's got two teeth already? . . ."
The surgeons were waiting for X-rays to be developed so they could finish putting a cast on the patient's leg.
The tape player, which the anesthetist had kept going throughout the procedure, had stopped and the rock 'n' roll surgeon had popped in another cassette.
"I'll finish up with 'Born in the U.S.A.,' " he said as Bruce Springsteen's music filled the room.
Cummings wheeled the patient to recovery and returned to the operating room to do more cleanup.
"It's been quiet for a Friday night as far as trauma goes," she observed out in the hall. Then she smiled: "Now I think it's time for a break."
After a 20-minute Oreo-cookie-and-diet-Coke break in the lounge, Cummings and Karen Wallace, who served as circulating nurse on the last operation, headed back down the hall.
There were no more scheduled patients, but their work wasn't over.
"Well, the place is a mess," Cummings explained. "There's lots of stuff to put away, rooms to stock. . . ."
Their work done, Cummings and Wallace stood against the wall in the hallway, talking.
"The nice thing about being in OR (the operating room) is you get to have a one-to-one relationship with the patient," Cummings said, adding that she likes that "because I feel it gives me an opportunity to give my best efforts toward that one patient. I think they get a higher quality of care."
She noted that she approaches each patient differently.
"Some people react very well to humor; with other people it's better to just be calm and quiet; others are full of questions. So you do it on an individual basis.
And, she added with a smile, "a sense of humor is good to have down here. It would be real boring otherwise. Right, Karen?"
"It's time to go home," Wallace observed.
"Is it?" Cummings said.
"It's the midnight hour," Wallace joked as she and Cummings walked slowly down the hall to the locker room.
The evening shift was over.