"I am thoroughly enjoying the 'Hopkins 24/7' show, as I am a nurse here at Johns Hopkins ... but my one concern is, where are the nurses? Teamwork is what has made Hopkins the number one hospital in the country ... not just the doctors ..."
"What's the big deal with this nurse issue? Let's get something straight. Hopkins established its reputation because of its doctors, not nurses ..."
- Comments by Internet chat-room visitors, reacting to the ABC series "Hopkins 24/7"
The Johns Hopkins Hospital operating room floor is a scruffy place: old tile floors, block walls, cold steel doors that swing open with a continual parade of men and women in green scrubs. Once inside, they dig into boxes of shower-cap paper hats and lean into the wall as they cover shoes in blue paper slippers.
Pushing paper masks up against their noses, they tie them behind their heads in two places and scrunch up the bridge for better ventilation before they take up a post inside one of the 23 operating rooms lining the seventh floor.
These are the nurses unseen by the TV cameras.
Some wear rubber-soled clogs, with holes to let air circulate. Janet McIntyre, 46, the coordinating nurse for pediatrics surgery, prefers sneakers as she moves in and out of the operating rooms, checking for safety issues, relieving people for lunch, running down three flights of stairs to a supply room of boxes stamped with enough codes to confuse the Pentagon.
Once, 20 years ago, she wore hard white shoes, a white uniform and cap. Now, in her scrubs - a safety pin securing her rings inside her shirt pocket during surgery - she is indistinguishable from the doctors.
Nursing is her passion; she is the right hand to the surgeon, mentor to residents and interns, and special assistant to anesthesiologists, all things that serve a nurse's central role of patient advocate. She also gives out her phone number to patients. Hopkins is a big place, and she volunteers to be their guide.
"I know the system," she says, "I can direct them."
Nurses wait in line to work in McIntyre's pediatrics OR.
The close-knit team of 12 nurses and eight medical techs offers a back story to the real-life dramas being aired by ABC about the doctors who work the floor: Ben Carson, who cut out part of the brain of toddler Alex Moody to stop her seizures; Paul Colombani, the chief pediatric surgeon, who tried to save a young girl from cervical cancer; and Michael Ain, the pediatric orthopedic surgeon who overcame his condition as a dwarf to succeed in medical school and specialize in correcting skeletal deformities in children.
McIntyre has taped episodes of "Hopkins 24/7" to show her daughter, a pre-med major at College of the Holy Cross. It doesn't bother her that she does not appear in them; she's content to know that in the operating room, her opinion is valued.
As the coordinating nurse, she's in charge of the schedule and safety; several times on this day she will weigh in on safety - remind an intern to wear protective goggles or a doctor to wear a special mask. She wants to make sure the whole room is "in sync."
"It's my Catholic upbringing," she confides.
In the hallway, she signals Sarah Byun to take off her earrings before going into the OR.
At 23, Byun is the newest nurse on the floor. She took part in the toddler's seven-hour brain hemispherectomy and held the door open for ABC camera operators as often as she handed Dr. Carson supplies during the operation.
But her work in the huge operating room was outside the field of operation - and the camera's view. As circulating nurse, she sits over to the side, climbing on and off her stool, recording details, reaching for supplies, leaving hourly to reassure the waiting parents.
On this day, she's playing the same role in a gastrointestinal case involving a 1-year-old with reflux. She runs Dr. Colombani's operating room while he inserts a feeding tube into the child's stomach. As soon as she sits down, she is up again, off to a hallway cart to find the right sized dilator, a rubber tube that allows the surgeon to see better.
Next the scrub nurse - the nurse or tech who hands equipment to the surgeon at the table - needs sponges. Then the tech asks for suture, the silken thread used to stitch shut a wound. Byun pulls individually wrapped packages from shelves of marked boxes behind her and walks them over.
In the report on her desk, she describes all that happens here today - the lines of fluid the child has been hooked up to, his medical history, the location of his family during the operation, and her efforts to keep the child warm.
As the surgeon finishes, she moves to help the scrub nurse account for the supplies she'd listed on the chalkboard before the operation. One, two, three ... they count, until they locate 12 needles. Six, seven, only eight gauze pads. Donning purple plastic gloves, she reaches into the garbage for a clump of bloody gauze pads. Nine, 10. She drops them back into the garbage, stripping off her soiled gloves and dumping them atop the heap.
By phone, she orders a bed so the child can be transferred and alerts pediatric intensive care nurses. She turns to the sleeping child, touches him softly and puts on his diaper. Then with her next patient in the anteroom, Byun hands the toddler to another nurse and moves out.
The relief nurse, Courtney Campbell, a nine-year veteran of the OR, walks in as the resident finishes a dressing on the toddler. She is walking back and forth, checking supplies, when suddenly she stops and turns to the operating table. Something is missing from the dressing around the baby's new feeding tube.
"You forgot to put the red nipple on," she calls out to the doctor.
He looks up in disbelief.
"Why didn't you tell me that before?" he yells.
In the 'background'
In another operating room, circulating nurse Judy Manning, 29, prepares for an 11-year-old girl who has juvenile rheumatoid arthritis. Nurses can spend an hour outfitting a room, refilling a cart of supplies - rounding up trays of dozens of sizes of scissors, sometimes three trays of tools, and in orthopedic cases, three trays of artificial body parts. Recently they had only 24 hours to find the right size telescoping rod - a $1,000 piece of equipment they don't stock - before a child with brittle bone disease and a bad fracture flew in from Kansas. Luckily, a manufacturer's representative had one.
Usually Manning works with Dr. Ain. Today she's assisting Paul Sponseller, who will inject dye into the girl's hips and take pictures to try to determine how soon a hip replacement might be needed. Manning, 29, first came to Hopkins as a child with her family, when her sister was treated for Crohn's disease, a chronic intestinal condition.
"You have to have a big heart to work in peds," she says. "People say, 'How can you do that?' I say that about working with adults."
The child and her mother chat until the girl's head drops to the operating table, her lovely long auburn curls swirling around her; the nurses know this regular patient and her mom, and Manning walks out with her hand on the older woman's shoulder.
When she returns, she checks the patient consent box while an operating room technician checks the anesthesiologist's equipment.
"We are the background to everything," Manning says.
For the moment, though, she is baffled: the X-ray machine is dead and nothing seems amiss. She makes a call, then walks over to the monitor and turns it on. Voila!
She moves the machine into place as the resident puts a needle into the child's hip.
The nurse glances at the tray of surgical tools and two cups of clear liquids she has measured out and set down. One is saline, which is mixed with dye, and the other a steroid, used to reduce pain from the procedure. The doctor calls for the steroid but the scrub nurse picks up the saline. Manning halts him, double checking, before handing the doctor the right one.
The child is asleep when she arranges the covers over her chest. From her stool, she works the chart, but never takes her eyes off the anesthesiologist; in an emergency, she is the one who would have to call for help.
For an orthopedic procedure, it is short - just 45 minutes. As Manning calls pediatric recovery to remind them of the allergies she has listed on the girl's report, Dr. Sponseller peels off his gloves and heads for the door, leaving his resident to finish up.
He has no illusions about the work of nurses.
"They basically run the show," the doctor says. "The unique thing about Hopkins is that nurses are part of the continuum. There are so many residents and medical students [coming though] that they have to do a lot of the teaching that goes on - they probably have a greater role here than at other hospitals."
All about love
In the pediatric OR, they are involved in the front end and back end of surgery. They keep a book on every doctor. The nurses know what each doctor likes and doesn't like, how they stitch up wounds, what equipment they prefer. They share this information with residents and medical students who do the grunt work and whose success depends on keeping the bosses happy.
Introducing new doctors and students to universal precautions - how to put on gloves, how to open up a sterile 4x4 pad, how to protect their eyes with goggles - is McIntyre's special concern. "We teach them how to gown and glove," she says. She is particularly watchful over them in emergencies, when new doctors are most likely to forget these precautions.
She is someone who always wants "to take something to the next level." In 12 years in OR, learning constantly about medical specialties and diseases, she's never been bored. Her specialty is pediatric otolaryngology - ear, nose, and throat medicine.
Near day's end, McIntyre relieves the circulating nurse in the case of a 6-year-old girl born with airway papilloma virus. The child has been here 52 times for the same operation. Every six weeks, she comes in to have growths caused by the virus cleared from her trachea so she can breathe more easily. The nurse has gotten to know the family, and the child. "She's very spirited," McIntyre says.
Nurses, the anesthesiologist and the child's grandmother skip with her down the hall, making a game of guessing which room will be hers. Oops, too far, they say. She turns around and skips into the room and jumps up onto the table.
McIntyre has been in the room already, to check the red sighting on the laser so it lines up with the "fire" the surgeon will aim into the girl's throat. She knows it sounds mundane, but ensuring instruments are prepared properly and knowing the sequence of events to use them makes her part of the effort to unblock this child's airway.
She and the grandmother move close the child, holding her, while the anesthesiologist hands the girl a mask and lets her judge which whiff of grape smells stronger. As soon as the little girl's eyes close, McIntyre walks the grandmother down the hall to the waiting room. "And how are you doing?" she asks.
When she returns, McIntyre rolls up a pillow and places it under the child's back, propping up her throat so the doctor can see better. Before he starts, she drapes wet towels over the girl to prevent a chance burn to the skin. In one last look around, she verifies that everyone is wearing goggles and masks. All but the anesthesiologist are wearing a special filtered mask, an extra precaution against the virus. She motions him outside to change his mask.
A few minutes after the doctor begins he complains of being hot and asks her to lower the temperature. "It's 70 degrees in here," she replies, checking the thermostat. "It's fine."
One of the basic jobs of pediatric nurses is to keep the patient warm - the warmer the better for recovery. Vanity is another big issue with McIntyre. She makes sure kids' bodies are covered.
"I remember as a child, 5 years old, having my tonsils out, with that gown on and my butt flapping in the breeze," she says.
Twenty minutes pass. The virus inside the little girl's throat has grown thick in five weeks. "We need to watch her overnight," the surgeon says. "Will you arrange for a bed?"
As they finish, McIntyre prepares to unwind. There are no cameras around to record it, but before she goes home she will check supplies and make a mental note of the patients who will get letters and e-mail from her. If she stays in this job as long as she expects, McIntyre may see the child before her outgrow her disease. For now, she looks forward to her return.
"I love people," she says, "and nursing helps you love them a little bit more."
In the final installment of the six-part documentary series "Hopkins 24/7" a third-year resident quits her job after seven years in training, and an emergency room physician loses two patients on the same night. The show airs tonight from 10 p.m. to 11 p.m. on ABC (WMAR, Channel 2).