Monique Ramsey (00:01):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. So today we're talking about something that's very interesting. We're going to kind of go behind the scenes and we're going to have Nurse Ruth lead us because when you're thinking about a cosmetic procedure, you might be curious about where your surgery is going to be, who's going to be there, what's it look like? So having Nurse Ruth, who's been with the center, I think over 20 years now, she's worked in the clinic, a lot of you may have met her before, but she now is working in the operating room, and so she's going to give us a glimpse into what's that like when we're making dreams become real every day. Welcome, Ruth.

Ruth (00:45):
Hi. Thank you.

Monique Ramsey (00:47):
Yeah. So, surgeries can be pretty early in the morning. How early do you start your day?

Ruth (00:55):
Do you really want to know this Monique?

Monique Ramsey (00:57):
I Do. I do because I'm asleep no matter what you tell me, for sure.

Ruth (01:00):
Okay. So I wake up at four in the morning because I like to work out before I go to work. So I usually work out from four to five, and then I take a shower and I yell at my 13-year-old to get ready. And then I leave my house by 5:30 and we're here by six.

Monique Ramsey (01:14):
Okay. And so that first case, do you have your patients come in at six in the morning?

Ruth (01:18):
No, we have them come in at 6:30. And so myself and the other, whatever, another nurse is working with me, we arrive at six. We have to clean everything before you come in, which makes perfect sense. We mop the floors, wipe down all the lights with all the antibacterial bleach stuff, and we count all the medications. We set up the rooms, so we're setting everything up at six 30. We have you come in and that's when we meet you and whoever's taking care of you, and we take you to your respective rooms to start the marking process and the consents and everything.

Monique Ramsey (01:47):
So for everybody, if you haven't been to our clinic before, we have our own ambulatory surgery center in our own suite. You just don't see it when you come in to visit us normally because it's busy. But we have two operating rooms and a recovery room and a marking room. It has its own entrance and its own exit. And so Ruth, it kind of explain just what that ambulatory surgery center is and the accreditation, I know you probably know a lot about it.

Ruth (02:18):
I do.

Monique Ramsey (02:19):
I'll kind of tell people what it's like because I think people don't dunno what to expect. Is it just a back room where I'm having surgery or is it like a hospital?

Ruth (02:28):
So, when you have an operating room, there's a lot hundreds and hundreds of pages of guidelines that you need to follow to get an accreditation. The best accreditation organization is called Quad A. They're the elite and they're the ones who accredited the hospital, like the XiMED Center that's next to our office would be accredited the same as we are. And so in order to maintain accreditation, you have to go through a tremendous number of things to make sure that you're up to par. And this is basic things like the medications you supply, the equipment that you use, the cleanliness standards, vents, ducts, the temperature of the room, the humidity, the calibration of the machines, the backups. I mean, it's extremely extensive.

Monique Ramsey (03:17):
And probably all the documentation.

Ruth (03:19):
Documentation.

Monique Ramsey (03:21):
Like, if something goes wrong here, if this machine fails or if the power goes out, all the things that could happen, right? I'm assuming there's like hundreds of pages.

Ruth (03:31):
There's literally hundreds of pages. But just as an example of power going out, because something somebody would worry about is in each operating room we have to have a backup battery that lasts a minimum of three hours to power everything in the operating room, should there be a sudden loss of power. And then we have to have, that has to be tested at least once a month. And then we have to have a log of the test that we're performing. There's a log and a test for everything in the operating room, our crash cart, obviously everything has to be maintained. We have a weekly test log, we have a checklist of every medication needs to be in there, our pads, everything is checked frequently and logged and everything has a place and everything has a log for it. Same thing with the credentialing the providers. So all of the surgeons and nurses that you work with, we have extensive personnel files, all their continuing education, their licenses, their curriculum vitae, the procedures they're allowed to perform, what they've been trained in. That is all something that is part of our surgical center, and that's available at all times.

Monique Ramsey (04:27):
That's really cool because I think when I started in 1991 that at that time there were no rules, no laws. I believe it about having, you could have surgery in a closet. Really, and I'm not joking, nobody should, but there was doctors like going rogue. And so in 1996, it was the same year we moved into where we are now in XiMed, that's when it came to be like law that you had to be accredited by one of these,

Ruth (04:59):
A body.

Monique Ramsey (04:59):
Right. Yeah. A body of, you know, an organization. And prior to that, when we were down on Prospect in La Jolla, we were Medicare certified and state licensed, which was sort of,

Ruth (05:11):
That's a whole other.

Monique Ramsey (05:13):
That's a whole other thing. And it was sort of,

Ruth (05:14):
But it's not that far off from Quad A.

Monique Ramsey (05:16):
Yeah. And one of the things when we were looking at it was they had certain things about how many sinks and certain things. It was just odd. But anyway, it was sort of above and beyond and we weren't doing insurance reimbursement, so we didn't have to do that again, but at least the consumer was protected from 1996 on. So I think patient safety is something that obviously we care a lot about. And educating you as you're thinking about a surgery, so segueing that to that morning of surgery, how do you make patients feel sort of safe and comfortable during getting ready for surgery and then afterwards?

Ruth (05:53):
So the number one, we have a lot of mothers that have surgery, right? I'm a mom too, and I've worked here for now over 21 years. And when they're really nervous, the first thing I tell them is I'm a nurse here and I've worked here for 21 years. That means I've also seen every possible complication, right? There is nothing I've ever seen that's kept me off the table or any other staff member. Both my parents have had surgery here, same time, same day. I've sent tons of friends here, all of our doctors operate on their spouses. We are operating, I remember in your Dr. Oleson, may he rest in peace said, we operate on others as we like to be operated on ourselves. And that is true. And so when you tell patients that, they're like, oh, you've done all these things here too? And I'm like, yeah. So I watch you on the table and then I get on as soon as I can. I just wait for my next procedure, my next approval.

Monique Ramsey (06:47):
All of us, exactly.

Ruth (06:49):
My patient said that today. I said, yeah, we both said that while you were asleep that we both wanted what you were having done. So that's the number one thing I tell patients. And then also, I reiterate obviously the skill of our surgeons and our anesthesiologists and how I would happily put my life in their hands anytime. And I refer people to them. I would never refer people to our office if I saw bad things happening. And I certainly wouldn't put myself at risk. So we do things the way they should be done. There's a reason we have a great reputation.

Monique Ramsey (07:20):
And that it's legit. And we actually, it's legit because people don't know. And back in the day when we had two doctors, not six for a little while, I think when we first moved in, it was a lot quieter. We could say, if nobody's back there, if we had a consultation,

Ruth (07:41):
Oh, we did. We'd walk people back there, I remember.

Monique Ramsey (07:44):
And they wanted to see the OR we're like, Hey, we can walk you back and we can show you. And then they were like, oh, okay, I feel better. But we've got six busy doctors, two busy operating rooms, recovery. There's no way to do that anymore. So we did put, and it was filmed a couple of years ago, but we do have a 360 degree tour of the OR suite on the website. And so I think if you go under, well, I don't know, but I'll find it and we'll put it in the show notes. But it does let you do one of those walkarounds, and I'm sure it's probably out of date now because that was maybe three or four years ago. But at least we have something and we should do it again to update it, because it does help to know where you're going to be and if you can picture yourself. So they come in and you bring them in to that marking room?

Ruth (08:29):
Correct.

Monique Ramsey (08:29):
They get changed. And then what happens next?

Ruth (08:32):
So we bring them in, we tell them to get, that's the first thing exactly, we tell 'em to get changed. And then we of course introduce ourselves. I always try to find something out, and I love connecting with people, so I always try to find something out about the person, see how nervous they are. Obviously you're going to go over your consent, what you're having done today, we're going to get your vital signs. If you're of age, everyone gets a pregnancy test. We have you signed final consents that day, any medications that you've taken. Then after the nurse has done her part, then we have the surgeon will come in and mark you. And so they'll go over this again. Okay, we've discussed this. They'll do the markings. We do take photos of the markings. The anesthesiologist will come in, they'll go over your chart, your health history, any previous concerns you have about your anesthesia or issues you've had in the past, say nausea or vomiting.

(09:16):
They'll go over that with you. And then once everything is done, that is when we walk to the operating room. And I understand that that is unusual for some patients because when they've had surgery at the hospital, they've gone from a gurney, they've been wheeled in. And so walking in was an unusual step for them. And I think that's when people are the most afraid is when you're walking them from the marking room to the operating room. The operating room is different, a lot of equipment, big lights. To us, this is another day at the office, right? For you, this is a foreign land and it seems cold, it's always very cold in there, it's clinical. There's equipment everywhere. We do have a warm bed with a blanket, and so you have people lay down on that. We always talk to you while we're hooking you up, make you feel as comfortable as possible. And once they start the IV, they do give you a medication that makes you relax and you can tell almost immediately, because whatever the expression was, immediately reverts to a smile.

Monique Ramsey (10:10):
Oh, really?

Ruth (10:11):
Okay. Yeah. They start feeling relaxed. They start talking to you. But usually just talking to people about their lives is a good way to make them feel comfortable.

Monique Ramsey (10:18):
Okay. That makes sense. Yeah. So then you go to sleep, right? You're probably mid-sentence and you're out.

Ruth (10:28):
Often, yes.

Monique Ramsey (10:29):
And then boom, you're being woken up saying, Hey, you did great. And there's like zero time has passed in your own brain, right?

Ruth (10:38):
Yep.

Monique Ramsey (10:39):
So are they still in the OR when they're waking up or are they in recovery by that time?

Ruth (10:44):
So they've been transferred to recovery. So you not have, most people don't have any recollection of either falling asleep or waking up. They'll even have conversations with you about something, their cat or whatever. I mean, and then if you say something to them in recovery about it, they'll say, I don't even remember that telling you that.

Monique Ramsey (11:02):
Oh, really?

Ruth (11:03):
Yeah. And so that's very typical. So even though they'll talk to us, they might not remember what they said. So during the process of waking up, the medications for anesthesia act very quickly. And obviously our anesthesiologists are extremely experienced. So they know when the surgeon is complete, they know exactly when they're going to change the medications so that you're waking up upon the finishing of the surgery. So we put all the dressings and everything while you're still asleep, so we're not jostling you around and bothering you. And then once there's no tubes that are in your mouth and you're breathing fine, then we transfer you to the bed and then we bring you to recovery. But you won't have any cognition prior to that. No, when you finally wake up in recovery, you've probably been there for 10 or 15 minutes.

Monique Ramsey (11:48):
Oh, really?

Ruth (11:49):
Before you remember being there. Absolutely.

Monique Ramsey (11:51):
Oh, interesting. So you may be awake, but you're not really awake.

Ruth (11:55):
But you're not going to remember it. And oftentimes what's funny is often your surgeon will come in and they'll want to talk to you in recovery and they'll tell you something and you go, yeah. And then they never remember that they actually met the surgeon, but the surgeon was there and they wanted to talk to you because they might have gone into their next surgery, but they like to come over and say hello, but they often don't remember. But that's okay.

Monique Ramsey (12:12):
So how many surgeries take place in the OR each day on average, would you say?

Ruth (12:17):
That's so variable, Monique? I mean, today there were only three. Tomorrow there's four. And then on Friday I think there's seven or eight. I'd say

Monique Ramsey (12:27):
Between the two rooms.

Ruth (12:28):
Between the two. So I'd say eight or nine or maximum. Those are some pretty wild days. But it also depends on what you're doing. And breast augmentation takes an hour and a half, but if you're doing a face and facelift and neck lift and eyes and some derm abrasion that can take five or six hours, or you're doing a full mommy makeover, it can take five or six hours. And that doesn't make a surgery dangerous. I remember a lot of patients expressing anxiety, oh my six hours, that seems like a long time. Well, a for you, it's going to be like nothing. But no, we do that all the time. Dr. Saltz did a tummy tuck on me a long time ago, and she did it by herself and it took her like six and a half hours. I was awake in 45 minutes out the door. Now that's not necessarily normal. I'm just kind of a spazz.

Monique Ramsey (13:08):
Now. Let's talk about that behind the scenes, the OR prep. How do you prep the OR for a patient? What goes into that?

Ruth (13:19):
Okay, so prior to a patient coming in, obviously everything has to be sterilized. Procedures are done sterilely. So before the start of the day, obviously the rooms are cleaned between every patient before the start of the day. Everything has to be wiped down with a antimicrobial antiviral solution, all the floors have to be mopped, and everything in an operating room is disposable equipment wise. So you make the bed with a disposable kit, the anesthesia circuits that we use to breathe that is all disposable, IV tubing, all of that. So you're going to set up an iIV you're going to set up an anesthesia circuit. Obviously the medications are all one use vials per patient. So everything is done ahead of time. When we do say breast implants and you have something called sizers. So a patient says, I really like the size of a, this might not mean anything to most people, 350 cc implant. The doctor isn't going to just pull an implant off the shelf and stick it in the patient. We're always going to try first to make sure it looks symmetrical. We sit them up. So you're going to make sure all of those are sterile and those are ready per patient. So you're just going to make sure that everything is clean, sterilized, and fresh for every patient coming into the room.

Monique Ramsey (14:31):
Even if the night before, after the last case they clean the room, you do it again, but you're cleaning it again.

Ruth (14:37):
You always clean it again in the morning prior to starting. And then of course, in between every single case and we're talking, every surface gets wiped down. And then when patients, obviously instruments are sterilized. So prior to a patient coming into a room and everything's been wiped down and cleaned, then you have all new that's going to be laid out. That has been completely sterilized gone through. And that's another process that through our quad A that you have to have specially calibrated sterilizers with indicators stating the sterilization. It's a big process but necessary for proper technique.

Monique Ramsey (15:08):
So if we imagine you back in the OR suite, let's talk about what your job is and then who else is with them during that? As the patient, who else is with me? Who am I going to meet or who am I going to see?

Ruth (15:25):
Of course. So the person you're going to interact with the most is probably the circulating nurse, which is myself. Or we have Michelle or Jolynn, we have Jason, Rachel, those are all of us, all the people that are generally back there. And we bring you in there. So we're going to meet you that morning or that day at any time, get you checked in. And then we are the ones who will walk you to the operating room, put on all the monitors before you go to sleep. We will be there, we're there to ensure that the surgical team has everything that they need during your procedure. So our job is to make sure that you're positioned correctly. So when you go to sleep on an OR table, your heels are padded, your arms are padded, there's a pillow under your knees. It's not just laying a patient on a table and then sticking a bunch of monitors on there, and there's a whole process that's involved.

(16:16):
But we're going to take care of all those things. Make sure your comfort's attended to. Also everything that's necessary during the procedure, we're giving the operating room technician who they're there to assist the surgeon. So the surgeon's there, of course, there's an anesthesiologist. You have the nurse like myself, and you have the surgical technician who's handing the surgeon all the instrumentation during the procedure. So they're assisting the surgeon directly during the procedure. And then anesthesia is, obviously making sure you're asleep, monitoring your blood pressure, all your vital signs, and then you have the nurse. So there's four people total that are there with you.

Monique Ramsey (16:49):
And I think that's a really good point that the circulating nurse, okay, first of all, they're a nurse. You have to be an RN.

Ruth (16:59):
Oh, yes, you have to be a registered nurse, RN.

Monique Ramsey (17:00):
Okay. So it's not a tech or not the tech is the OR tech, but not like an MA or something.

Ruth (17:07):
You have to be, no, in an operating room, you have to be a registered nurse. You also be a registered nurse to do recovery room.

Monique Ramsey (17:12):
And that's not the same person either.

Ruth (17:14):
It is not. All of us, most of us do both jobs. But no, it is a completely different position. And actually you need to have a completely different knowledge set to do that as well.

Monique Ramsey (17:23):
And because I remember hearing, and I don't know if this is standard anymore, but back in the day, some places didn't have a dedicated circulating nurse for that room. That circulating nurse might have run around to a different room or to recovery. And that's maybe not a thing anymore. But I think knowing who's in the room with you, and maybe as you're doing your homework, asking who's going to be in the room with me is a good question.

Ruth (17:49):
Yeah. I don't know how you could do a good job without being in the room the whole time. Yeah, I mean, especially too with some of these surgeries too, Dr. Swistun, who does a lot of our breast implant illness cases, he's taking photographs the whole case, You have to be in there with them if they're doing liposuction or skin excision, you have to be measuring, weighing tissues, writing everything down. I mean, you're responsible for all the documentation and there's constant needs during surgery for equipment and changes. So you have to be there the whole time. And that's just essential.

Monique Ramsey (18:18):
Now, what are the team dynamics? Let's get on the, again, behind the scenes, what are between the OR nurse and the surgeon or the techs and the anesthesiologist? Is it talkative? Is it quiet? Is there music? I know we're not dancing in the ORs.

Ruth (18:35):
Only if the music's really good. No, it's very variable.

Monique Ramsey (18:38):
Not like on TikTok.

Ruth (18:40):
Oh no, I've never seen that, but I'm sure there's been some obnoxious things.

Monique Ramsey (18:43):
It's not good.

Ruth (18:43):
No, we don't do that.

Monique Ramsey (18:45):
But give us a flavor of the behind the scenes.

Ruth (18:48):
So generally, we do have a really good time. It depends on the surgeon and the type of case it is. It's on facial, on face cases and nose cases, honestly, there tends to be a lot less talking. The surgeon wants to concentrate on what they're doing, and they're going more slowly, more carefully. So there's not going to be a lot of chitchat. And one of your jobs in being a good operating room nurse and technician is to understand what the surgeon wants and how to act accordingly. And you have to read, just like any other job, you have to read the temperature of the room. Certain procedures like liposuction, there can be a lot more talking because you're not dealing with these big blood vessels. It's just a less stressful procedure, honestly, for the surgeon. So it just depends. Dr. Brahme really likes music.

(19:41):
Dr. Salazar doesn't like any music. He wants to concentrate. He wants a quiet room until he's at the end where he's closing the incision, where that's just sort of routine stuff, then you can do the music and he'll do more chitchatting. But I understand that I like quiet when I study. So for me, if I want to concentrate, I can't have noise either. So that makes perfect sense. But yeah, it is variable person to person. But for the most part, it's a very jovial, positive environment. We all really enjoy our jobs, and I think it's obvious. Of course, they don't get to appreciate that since they're asleep, but that's okay.

Monique Ramsey (20:13):
All the time you spend with your doctor, you're having a nice little nap.

Ruth (20:19):
Exactly. And if you can imagine too, and I didn't really understand that until I worked back there for the patients. The patients are asleep. So the crew back there is a very tight group because we are literally spending all day every day together. So the dynamics of the team are extremely important, and we feel we have a very cohesive team that's honestly like a family.

Monique Ramsey (20:42):
And it's always fun because when we see you guys back there, you've got your bonnets and your booties and masks. We don't, and you can barely see who's under all of it.

Ruth (20:52):
You really can't.

Monique Ramsey (20:52):
And when we all do a dinner or something together and it's like, oh, okay, I know who you are. It's so fun.

Ruth (20:59):
Oh, you have hair?

Monique Ramsey (21:02):
That's right. So what would you say Ruth is the favorite part of your job?

Ruth (21:06):
That's kind of hard. I really like my job. I mean, I'd say just for an example today I had a patient who, Dr. Brahme took his daughter to the airport this morning, so he was running a little late. So I like to communicate with the patient. So one thing I learn is people do a lot better when they know what to expect. So if somebody's going to be waiting and you tell them ahead of time, this is what's going on, they're going to be a lot happier than if you told them nothing. So I just let this patient know, oh, can you be here a little later? Because he's late and she had her surgery. She went home, and on her way home, she texted me and said, you made me feel so comfortable today. Thank you so much for making me feel good. That's the best part of my job.

Monique Ramsey (21:46):
That's so cool.

Ruth (21:46):
So anytime you can take somebody that feels really uncomfortable or nervous and turn it into a positive for them where they remember you in a good way and they remember the experience in a good way, best part of the job.

Monique Ramsey (21:57):
And I think that's so true that if you just tell people what's happening or what's going to happen, it's make them part of the process. Because certainly if you're sitting there for 45 minutes going, why am I still here? And what is going on? And then your mind goes crazy with all the possible things that could be happening.

Ruth (22:16):
And I'm certainly no genius, but I've learned from, we all learn from mistakes. And in the past, I know that when patients weren't communicated with in the operating room when I was working with Dr. Saltz, they were upset. And I've always found that when I start letting them know early on, this is what's going on and he's running behind, and this patient, this surgery took longer than expect whatever it is, there's so much less upset when you communicate.

Monique Ramsey (22:42):
Yeah. Now, are there any surgeries that, or I guess surgery, really more procedures that you find are the most exciting to help with? Because I know you and I are kind of the same in that we like to geek out over the details, all the things. So are there certain kinds of cases that you enjoy more than others or,

Ruth (23:02):
I mean, I like learning. Dr. Salazar really likes to teach while he's operating. So I like details like you said. So I want to know. I don't want to just stand there and watch the surgery. I mean, I do, but I also want to know. It's nice to understand the body and see what they're doing. I think watching Dr. Riedler do a nose is really interesting because prior to her coming to our office, I'd never really had a lot of experience watching rhinoplasties, and watching her do a nose was a completely different experience for me because of the way she completely rebuilt a nose. And the first time I saw it, I said, wait, you just completely rebuilt that nose. Not everyone does that, right? She said, no, not everyone does that. That's the way I do it. And so even just seeing the differences between the different surgeons and all their different techniques, because every surgeon has a different technique to end up at their preferred place.

(23:51):
And one of the surgeons, so I know I'm totally digressing, cuz I don't know which surgery I would say was my favorite to watch, but I asked Dr. Swistun, I said, why did you become a plastic surgeon over other type of surgeon? He said, well, if you do somebody's gallbladder, you have to do it the exact same way every single time. And if you don't and you digress because you think your way is better, you're probably going to get in trouble. He's like, there's this step, this step, this step, this step, there's absolutely no room for anything else. He said, as a plastic surgeon, there's a lot of interpretation and you find your own way to do things as you see best, and you're constantly learning and refining and honing your techniques, but you're the one who ultimately has the ability to choose how you want to do the procedure.

(24:43):
And that was sort of mind blowing to me. I thought, oh, this makes sense. Okay, I'm not a creative person, so I didn't really understand why, what was it? And I've asked a lot of them, what made them choose plastic surgery too? And I remember Dr. Smoot, I believe, said that when he started working with breast cancer patients and he saw how wonderful they were and how amazing of a transformation and the difference he could make in their lives. And so that sort of got 'em really interesting to see how they ended up on that track.

Monique Ramsey (25:15):
Right. I guess they try a lot of different things when they go through residency and they

Ruth (25:20):
They have to do general surgery first, right? They have to do all of that.

Monique Ramsey (25:24):
So yeah, gallbladders don't sound very fun. So how does your role change if you're helping different doctors? Does it change at all, or is it kind of like the circulating nurse does the same thing?

Ruth (25:37):
You have the same responsibilities. All the doctors, we have six surgeons and six different ways to do things. There are certain things that always can be the same with sterile preparation, but positioning is different for every doctor. The medications they like to use are different. The way they put in implants is different. The types of implants they like to use are different. The way something like a facelift where they place the incisions, the way they do the hair, the way they prep the face, the medications they use to prep, everything's different for every surgeon. So that's actually one of the more challenging things about learning operating room. We said there were, there's six and that, and that's for every procedure, right? So for every procedure,

Monique Ramsey (26:13):
Right, the matrix gets really big.

Ruth (26:16):
So every doctor does all these different things. They also want very different things per procedure. But you obviously, that's part of how you learn.

Monique Ramsey (26:25):
Right. Right. Yeah. I would think just learning each one and their personality and the way they like to do things.

Ruth (26:32):
The way they mark is all different. different pens, different equipment, different.

Monique Ramsey (26:38):
Well, even Dr. Swistun on the podcast last week, we were talking about life after 360 lipo and a glimpse into behind the scenes of that procedure. And he was talking about how he preps them standing up or with the Betadine wash, and normally you'd be asleep maybe when they're doing that.

Ruth (27:01):
So we did, we did those on Friday, and the gal has to stand on with their arms out on a big mat, and I had hot betadine and I was painting her with it. And then they get on the bed and they're all sterile and they have their arms out. And it's tricky. We take sterility seriously. We re-prep the patient multiple times every time we're moving them. And the 360 liposuctions is probably the most complex as far as the way that the, I mean, and there's obviously reasons for everything, but the way the patient's being positioned and the way he does it. So that's the most complex as far as how to get the patient in the proper to have it perfect. But he's always involved, which makes it much easier. He'll say, oh no, move the leg a little bit this way. I want this hip this way, which is helpful, but yeah.

Monique Ramsey (27:46):
Well, and you guys have to be kind of strong if you're flipping a patient over, right?

Ruth (27:50):
Yeah.

Monique Ramsey (27:51):
I mean, because dead weight, they can't help you by saying, oh, let me help you roll over.

Ruth (27:58):
The operating room is a very physical job, which is probably one of the reasons I like it. I don't like sitting or sitting at a desk is very hard for me. So no, you are standing, bending, moving the entire day. And when I first started doing it, I actually was pretty tired at the end of the day. Now I can work 12 hours all day, no problem, and I'm not tired. But yeah, it's very physical

Monique Ramsey (28:19):
Now, do you ever face any challenges as an OR nurse, or would you say that is the biggest challenge is learning all the different ins and outs of every procedure and every doctor?

Ruth (28:30):
It is. And if things don't go as planned, how you're going to handle things. If you have a patient in recovery that's having pain that's not responding to the pain medications or their blood pressure wants to stay persistently low and you've tried this, that, and the other thing, I mean, we are a medical facility and you still, whatever goes on, we have to be prepared to deal with it and deal with it correctly and safely.

Monique Ramsey (28:54):
And probably quickly too sometimes.

Ruth (28:57):
Absolutely.

Monique Ramsey (28:58):
You're making a judgment call on something and like, oh, okay, this is now we need to do this. And I love the fact that with our anesthesiologists, there's one for each room. And if one room finishes early and somebody goes away, but they can both be there or you've got the one, it's really nice. And I can't remember when I was back there filming one time where it was sort of like, oh, well we've got this extra person and we're going to make sure everybody's in a good spot. And it was kind of a cool watching everybody work as a team, but you've always got that whole group of people. It's not like a surgeon. They might go out of the room and they're going to go to the next patient, but

Ruth (29:43):
You don't walk into an emergency room and there's one nurse standing there. It's all about having multiple people that have multiple different roles. We had a patient that this was not known to the patient, but she had a very difficult, what we call an airway. So when you're somebody's under anesthesia, you're protecting their breathing tube and you're making sure that they're ventilated properly because they're not doing it themselves with the anesthetic. And this patient had a very difficult entry point to get the tube in. And so the fact that there were two anesthesiologists there were crucial because they both said afterwards, if only one had been there, they probably would've had to stop the surgery. The patient didn't have health issues. It was a mechanical thing, but still having two there made it so everything went smoothly. And then they were able to give the patient a note so that if she ever had to have surgery again, the future physicians would be aware that that could be an issue. So she was very grateful.

Monique Ramsey (30:36):
So was it like an anatomy thing with her?

Ruth (30:37):
In her case, it was an anatomy thing.

Monique Ramsey (30:39):
Oh, interesting.

Ruth (30:40):
And she hadn't had an anesthetic before, I don't think, where she had to have an intubation, which they do for things like facelifts and noses because you don't want to be swallowing blood. So nobody knew. And so if they find something like that, but then, yeah, obviously it's important for us to know and for her future physicians to know.

Monique Ramsey (31:00):
Yeah. So how do you help prevent complications, like infections or other things that can happen I guess with a surgery?

Ruth (31:09):
Well, you're always keeping tabs on what's going on. So basic things obviously are proper sterilization of your instrumentation, prepping the patient with the antimicrobial. We also start prior to surgery, so we actually have patients use antimicrobial scrubs before surgery, and that's been shown to reduce infection rate. When patients have drains in, they take antibiotics afterwards. So day of surgery, obviously the patient's open, that's the biggest risk. So sterilization within a certain number of minutes of incision, usually within a minute is an antibiotic infusion. So patients get a pretty hefty dose of antibiotic intraoperatively during surgery because shown to be the crucial moment. And then if it goes over a certain number of hours, that dose is repeated. So this is all based on data and what's recommended. And then obviously after closure, when we do procedures with drains, antibiotic solutions actually infused through the drain. So that for with a breast surgery, it sits in a bath of antibiotic inside the drain that we clamp in the beginning, and then eventually we'll turn to suction because you want the extra fluid out of the body. But antibiotic washes are done throughout the body when there's any breast surgery. And like I said, antibiotics are kept on board while patients have drains in, drains can be a risk of infection. And if there are infections, we track everything as well.

Monique Ramsey (32:32):
One of the other things I was thinking about when you were talking about prepping that room and your different instrument packs, and this came up on my calendar within the last week, is national timeout day and taking a timeout, so tell everybody

Ruth (32:49):
What a timeout is?

Monique Ramsey (32:50):
What a timeout is, and what is done to make sure they might be asleep when you're doing this, right?

Ruth (32:55):
Oh, they are asleep. So that's prior to the incision. So after you get the patient in the room, patient's asleep before the whole team has to be at the present, we do something, call the timeout. So the timeout is everyone stops and is listening. We say the patient's name, what's on the consent, the procedure being done, and if there's any allergies. And then everyone concurs and then the procedure commences. But timeout day is a standard part of an operating room so that there aren't mistakes made with, I think they probably originally started with things like, oh, we amputated the wrong leg.

Monique Ramsey (33:28):
Oh God, can you imagine?

Ruth (33:29):
Or I mean, I think unfortunately most of those things come from something like that. But no, that's absolutely what we do prior to a procedure so that everyone's on the same page before anything is done. That's what a timeout is.

Monique Ramsey (33:42):
And then I know we're not having instruments left in people. You hear those weird social media stories like, oh, a clamp was left in the lady's belly. I'm assuming there's counting all the time too.

Ruth (33:54):
There's always counting. So at the beginning of the surgery as well, that's separate from a timeout, but the number of sponges and the number of sutures are always going to be counted. So say that we start this surgery with 11 sutures and 10 we call laparotomy sponges. So every time, and you almost always are adding to that count during surgery, depending upon various needs. If I add seven more sutures that we know at the end of the case that we have, I think I said 12, so 19 sutures, we're going to count to make sure that there's 19 sutures so that there's a needle. And if you can't find one, you look on the floor or it is sponge, so you find it, but you have to make sure that you're not leaving things in the patient. That's just sort of a 101 thing, but absolutely.

Monique Ramsey (34:37):
Yeah, exactly. But it's a 101 thing, but at the same time as that,

Ruth (34:40):
Patients need to know what happens.

Monique Ramsey (34:41):
We as consumers, you hear these random stories and you're like, oh, is that a thing? And should I be worried? So just last into some of the questions are about you and really the OR team. So what education and training does there need to be, other than learning your doctor and learning, there are ways, but just sort of is, besides being an RN, is there certain certifications you have to have?

Ruth (35:10):
I mean, ideally you have something called a C-N-O-R, which Rachel actually does have where there's certified OR nurse. Most of our people have come from the operating or not the operating, the emergency room and ICU honestly, backgrounds. Obviously I had a lot of plastics experience. So for me it was sort of a natural foray into this or post-anesthesia care units. So most of the people that are attracted or end up doing that have done higher acuity care and then they sort of transition into that. But you obviously have to have your certification. I do all my continuing education in operating room, so we have to have continuing education to keep our licenses. So we all do it for the operating room because obviously that's what we're specializing in. But as far as being an operating room nurse, it's honestly just like at the hospital, it's on the job training. But most all of our nurses actually have extensive backgrounds. Jolynn is one of our or nurses, and she has 25 years of operating room experience.

Monique Ramsey (36:03):
Wow. Wow. So she's probably seen it all too.

Ruth (36:07):
Same thing with Liz actually. Liz also has at least 20 years of operating room experience.

Monique Ramsey (36:14):
Something we are always doing at La Jolla Cosmetic is staying on the cutting edge. So how do you stay on the cutting edge or the team on the latest tools or tricks or technologies to make the job safer, better, easier for the patient?

Ruth (36:31):
Well, we always, we're constantly learning new things and obviously every time we bring in a new technology, there's something called an in-service. So all of us have to learn it. We have something, I dunno, I'm sure you guys have discussed Ellacor as an example, or the new nano fat that we're doing. So every time a new technology gets brought on, we're educated by the people that are bringing it to us to say that the nano fat, which of course I desperately want stuck in my face. So they're taking the fat, they're processing it, they're putting it in, they're explaining to us how it regenerate cells and the benefits and how it helps soften scars with the micro fat. And then we also obviously have to learn how the equipment physically works. But we attend all those trainings and then we read the literature as well.

(37:15):
And what fun is it if you're not learning, every time there's a meeting, big national meeting, I used to go with Dr. Saltz and she would have me sit there with all the doctors to learn what's going on. Because if you can make it better and there's something new that you can do, let's try it. So I think that all of us are embrace new technology and we obviously as a center are always looking for improved technology. So we're going to implement it in the operating room, then we're going to learn about it and often volunteer ourselves for the trainings.

Monique Ramsey (37:48):
Exactly. I'll be a Guinea pig.

Ruth (37:50):
Yeah, so anytime there's a training, I'm the first in line to offer my services.

Monique Ramsey (37:54):
Yeah. So everybody, thank you for listening. Thanks Ruth. This was so interesting. Is there anything like that we missed that we didn't?

Ruth (38:03):
No, I hope I didn't digress too much because I do talk a lot.

Monique Ramsey (38:05):
No you didn't. No that was so, I think it's super interesting and we will put the links in the show notes we can put to the 360 degree little virtual tour.

Ruth (38:14):
Yeah, that'd be nice.

Monique Ramsey (38:16):
We'll do that. And then I'll figure out a time you guys are so busy, it's like how do we have time for a guy to come in and do a new video? But because I think it is helpful just to feel like, oh, this is where I need be.

Ruth (38:28):
People are nervous about the day of surgery, that's when they're the most intimidated for sure. We do give a lot of patients something called gabapentin before they come in, not everybody, and that definitely helps take the edge off. But still for most people, they're pretty nervous. Once the surgery's over, they're fine. It's like all the anticipation, just like everything in life. But yeah, we are all professionals. We all have the same procedures you do and we're back there to make your experiences as good as it possibly can be.

Monique Ramsey (38:54):
And that the recovery room, I think there's three beds, right, in recovery?

Ruth (38:59):
We have two beds and then a chair.

Monique Ramsey (39:00):
Oh, that's right. Okay. And then there's a little nice back door, which is the best because you have your procedure, you don't want to see anybody, not like you'd care at that point, but you know.

Ruth (39:13):
Yeah, people don't want to go back through the lobby.

Monique Ramsey (39:13):
They don't want to go through the lobby or down the elevator or something like that. So we have the best spot in the whole building. We have the back door, we can wheel you right to your waiting car. So, alright, well this was fun. Thanks, Ruth.

Ruth (39:26):
You're welcome. Anytime.

Monique Ramsey (39:28):
Yeah, so I know you've already worked a really long day, so I appreciate you coming in at the end and coming in to share the dish on the back behind the scenes in the OR. So thanks everybody for listening. We'll put those things in the show notes and we'll see you on the next one. Bye-bye.

Ruth (39:44):
Okay. Take it easy. Bye bye.

Announcer (39:46):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla cosmetic is located just off the I-5 San Diego Freeway in the XiMed building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram @ ljcsc. The La Jolla Cosmetic Podcast is a production of The Axis, T-H-E-A-X-I-S.io.