Dirty

Open Letter to Mike Rowe of Dirty Jobs,

WARNING WARNING WARNING

(For you who enjoy my gross work stories only.)

I do not exactly have a "dirty" job, in fact, mostly, quite the opposite. I cannot see any way that a film crew could safely, or legally, come into surgery, and let you do what you do. Safely, for the patients. Legally, for the hospital, even with consents. The reality Life in the ER type shows even have to largely do "recreations." Our patients are in the most vulnerable positions of their lives, everything we do is to ameliorate the risk. Having an extra two or three people in this place increases the risk of infection, as well as error.

But.

If you could, and we could manage all the risks, and it was a "good" day, oh, what I could show you, get your (double-gloved-sterile) hand into, expose your (now) expert nose to. Indulge me a Fantasy Dirty Jobs episode.

I'd get you in about 0630, train you to scrub your hands, gown and glove. The trauma page would bleep, followed by the thrice repeated overhead announcement, "Code Trauma alert one, code trauma alert one code trauma alert one." In that flat, calm delivery of the PBX. We'll head down to the ER, and a bloody patient with broken bones sticking out, in a C-collar rolls in on a gurney with the airborn EMTs in attendance. Miraculously, the trauma surgeon and ortho guy are both there, and tell us this patient will be coming up right away. We call up, then go up to get everything ready.

We help open supplies, as the entourage bursts through the doors behind us. Along with about a dozen others, nurses, techs, orderlies, ER staff, Arterial line techs, we move the road rashed, broken, bloody person on a slide board onto the OR table. Code Brown. Meaning, well I have the RN, so I get a towel half wet, and wipe bottom of excrement, drying with the dry half. Towels to catch blood.

I may get to prep the surgical site(s). I'll recount the semi vs train traumatic amputation of both legs of a large woman that I had to prep, or the metal signpost through both legs in a car rollover - needing two orderlies to hold up metal and leg while something like clean, if not sterile, meant awkward sloshing of prep solution, or when both ankles hung on by tissue threads, or crushes so bad it was difficult to tell where to start, or femurs so broken that a new joint appears mid thigh, and a tall, strong leg holder needs to pull up, and out, as I scrub soap over the wobbly skin.

Once surgery is started, there is little dirty. You can scrub in and hold retractors, to closely watch the scrub passing instruments and lap sponges as fast as I (as the second circulator) can open them, count them, while holding retraction, as well as passing ties, suture, to stop those messy streams of red beads over arms, hands, if unlucky, faces. I will be there to wipe potential drips off of glasses or foreheads.

But this settles down into a fairly tidy process of stopping bleeding, rodding the leg, or putting on an external fixator (a frame with bolts through the leg bones, a quick fix on contaminated fractures - those that came out through the skin, or on a patient too unstable for longer surgery, or who need that liver laceration fixed first) instead of the old traction method. So, I take you to a nice burn room in progress.

It's 100F here, the smell is pervasive, and we wear plastic aprons to protect ourselves from the fluids. Some produced by this mercifully unconscious ICU patient, much added as dressings, and healing solutions. Nothing sterile about any of this. We remove encrusted staples holding skin grafts onto raw wounds. The residents pick away dead tissue. Nothing about our patient looks human, or unhurt, so I have to imagine, and feel a moment of "Poor dear" to keep myself human. Sweat pouring through our scrubs, I will pull you out to get fluids, and another case for the experience.

This one is a patient I have worked on before. We stand beside the anesthesiologist during induction, and find the dentures - which the patient denied having in. These teeth-in-need-of-cleaning get laid on the chest, as I hold the cricoid cartilage to facilitate intubation, and hold the underlying esophagus to the stomach closed off. Suctioning of thick yellow mucous may leave you wanting to dry heave slightly, but your mask will catch morst of it. Then, I take the dentures to clean, and get into a cup, with ID attached. Pancreatitis does nasty work on the abdomen. This one is a horror show of yellow, rotting gut. The surgeon carefully staples the ends, and removes part of the large intestine that has blown up to dramatic proportions, obstructed by a tumor. The mess of gurgling fecal matter goes into a pan, the pathologist is there, handed a scalpel and pick-up by the scrub, and shares the aroma with the room, exposing the mass. I assist the RN in the room, getting out the wintergreen, dabbing a tissue, and wiping the oil on the masks of those scrubbed in. Some refuse, as they too strongly associate the mint smell with dead bowel for it to stop the nausea.

At the end, I am back beside the anesthesiologist, and even though the sterile supplies are away, and everyone else in the room has their mask off, I still have mine on. The patient rouses, coughs as the doc extubates, and a wad of phlegm hits my arm and mask. I stand there, holding flailing arms, to keep the patient on the bed, and the IV in the arm. Yup.

We will return to the first room, just emptied, to wipe every drop, every smear, of blood from every surface in the room. The smell of blood, moistened by vesphene, has a pungent, metallic tang that stays in one's nose. We'll follow the orderlies as they pour bloody irrigation buckets into the hopper, gather overburdened laundry and garbage bags - often leaking, to the dirty instrument room. We''ll take the elevator down to decontam, following the instruments. Good folks in gowns and gloves, face shields, take the many instruments, and remove the bioburden, bone from the total joint rooms, mucous from the sinus surgeries, blood from everything, with toothbrushes, round cleaners, pressurized streams of water, enzymatic detergents, before the sets go through the high pressure cleaning machines, later, after sorting, they will be sterilized.

Finally, the real horror. It's 1900. We'll clean up the lounge, where everyone has been leaving their left-behind beverages, forgotten food containers, catalogues, newspapers, the boxes of bagels from the morning meeting - only crumbs and one half-bagel inside, the remains of a birthday cake. Blankets are strewn over the couches, a cola has been spilled over one table. I'll save you the disgust of the fridge and microwave.

So, you see, it could work, but I rarely have a day with this much. It happens in a day, some days. But some days, it's all tidy laparoscopic and well orchestrated joint replacements, tiny hand cases, tonsils, well irrigated bladders. Surgery ideally, has almost no blood loss, and is tightly controlled, calm, planned. The rooms are cool, immaculately clean, much joking among staff, a little music in the background.

So, you see, a dirty, sterile, job. Not as smelly as sewer cleaner, nor as dangerous as coal miner, but not a soft, cushy office gig either.

Z