As the circulating nurse in our busy OR that Friday, I went to pre-op our last case: "Katie," a 14-year-old who'd been diagnosed with multiple osteochondromas. These tumors are typically composed of bony fibers and cartilage. They're usually benign but can cause pain. On several occasions Katie had come to the ED with pain so severe she'd vomited. She needed OxyContin to sleep at night and had stopped going to school. The lesion on the underside of her left arm was so painful she couldn't even brush her hair. A larger lesion on the inner aspect of her scapula caused searing chest pain when she took a deep breath. She'd seen a neurologist, psychologists, the pain service, and finally our orthopedist, who would remove the lesions and give her back her life.
We were preparing the OR when the pre-op nurse called to say Katie had locked herself in the bathroom and was crying uncontrollably. Her mother was trying to talk to her through the door. The problem was that Katie didn't want to remove her bra-didn't want any men to see her naked. Her mother wanted us to lie and say that the bra would stay on.
As a rule, an OR nurse's job is very technical; we interact with patients and their families only briefly. Before the operation we quickly assess the patient and ensure that she or he is prepared for surgery. We introduce ourselves, then check and double-check documents and lab results. Patients don't often remember the nurses who hold their hands as they go under anesthesia, nor do they realize that those nurses pride themselves on being the patients' advocate while they're asleep.
In the case of a pediatric patient, a parent or guardian signs the consent forms. But if a child voices strong opposition to surgery, it's the OR nurse's ethical responsibility to investigate the concern. And so I assured Katie's mother that we'd take excellent care of her daughter, but that I'd want to be honest in speaking to Katie.
I had to introduce myself to Katie through the bathroom door. Once she let me in, I gave her a tissue and asked her to sit down and take a deep breath. I told her I'd explain everything that was going to happen from the time we left the pre-op area, and that it was my job to keep her safe through her surgery. I said I'd answer her questions. I said I wanted her to feel comfortable with the plan before we went ahead.
Katie responded that she wouldn't take off her bra and didn't want anyone to see her naked. As I crouched in front of her, I thought how much easier it would be to do as her mother had asked and just lie. But I knew this would violate Katie's modesty, and the trust she'd just put in me. I didn't want to fuel a distrust of those who'd care for her in the future. And I remembered how difficult it was to be 14, with raging emotions and a changing body.
So I told Katie the truth: eventually, the bra had to come off.
At first, she seemed even more upset. But then I told her I'd be the one to take the bra off after she was asleep-the one keeping her covered, making sure only those who needed to be there were there. I promised to treat her like I'd want to be treated myself. And that all this would be worth it to not have the horrible pain.
Katie was still crying when I said the surgeon would be coming to see her in a few minutes. I told her I'd watch the bathroom door from the outside if she kept it unlocked. I told her to think about what I'd said. Then I went to inform the attending surgeon about the mother's concerns and Katie's wishes.
At last, Katie emerged from the bathroom, her eyes swollen, nose dripping. She said she'd do it if it would happen as I told her it would.
We proceeded. After several hours, two osteochondromas the size of golf balls had been removed. Before Katie woke up, I redressed her-socks and all-and wheeled her to the postanesthesia area. I went to visit her that following Monday. She told me she was embarrassed that she'd cried but was glad I'd told her the truth.
In the perioperative area it's easy to forget the value of simple actions like preserving the modesty of our patients. But on this day, communicating honestly with my patient paved the way for a successful surgery.