Thursday, June 15, 2017

Whatever Happened to Sluice Rooms?

It's a conditioned response. Whenever I observe a Whippersnappern wearing gloves for routine patient care or  worse, comingling sheets soiled with scatatolgical resideue and run-of-the-mill dirty linen my anxiety mounts to intolerable levels. Someone is going to be raked over the coals for these misdeeds. Hospitals of yesteryear had unique protocols for these unpleasant circumstances.

Any sheet soiled with solid matter-what a euphemism-required a sluicing in the dirty utility room. A lovely, white 6 foot porcelain slab lined one of the walls of the dirty utility room. It was not for napping. At the elevated end of the sluice there was a massive faucet capable of unleashing a Niagra Falls torrent of water flow. The depressed end of the slab terminated at a slop sink which had a massive drain. This drain could accommodate a bolus biomass of stool the size of a bowling ball. Don't ask how I came to know that  little factoid. Someone had the foresight to install a trap on this sink which seemed to me comparable to the diameter of a subway tunnel. At least once the fetid fecal foosball facsimiles were beyond the trap they were gone for good and you could breath again.

To properly sluice a sheet place the origin of the offending substance at the lowest point of the sluice nearest the slop sink. If you enjoy inhaling aerosolized particulate matter simply reverse this procedure. Now for the fun part; turn that mighty faucet to full blast and watch that mass of olfactory offensive material sliding away on it's merry way to the waiting slop sink. Some types of residue affectionately referred to as smears, mucilaginous masses messes,  or pasty blobs require some encouragement from the intrepid sluicer and for this unsavory task a squeegee borrowed from housekeeping acted s a pusher. I always found it strange that the housekeeping personnel never asked for nursing to return their squeeges.

Suddenly, like a bolt out of the blue in the very early 1970s a memo from the nursing director came out stating that sluicing was no longer required due to improvements in the hospital laundry system and we could simply toss soiled sheets into the hamper. Sluicing like the lobotomy was gone for good and nurses were ecstatic.

This really piqued my curiosity and called for a personal visit to one of my favorite places which was our on site laundry operation. The Hispanic staff working the laundry were among the most content of all hospital staff despite working in a place that reminded me of Dante's inferno. This place was hotter than a brick oven, louder than a Pittsburgh steel mill and to top it off, smelled funny and that's putting it nicely. These folks made $2.20 an hour and were overjoyed with their pay (minimum wage was $1.65 an hour.) They were some of the nicest people in the hospital and even helped me with my lackluster Spanish skills.

When I asked about the new sluice free linen policy they happily showed me their brand new washers that had a built in sluice cycle. The washers had huge outlets that opened before the start of the wash cycle that permitted a huge flow of water through the batch of linen before the wash was initiated.

I was invited to observe a mechanical sluice cycle and it was very impressive. The mighty roar of the water being injected through the linen sounded like a 747 on take off roll in the midst of a rain storm. These giant sluice/washing machines had to be one of the greatest engineering accomplishments in healthcare history-and you thought anesthesia was an impressive invention. An open drip ether drip mask is nothing compared to these sluicing behemoths.

A few years ago nurses from my alma matter were invited to a homecoming. Changes made in the use of space at the hospital were depressing. The old OR suite, home to much drama and lifesaving (I hate that "L" word with a passion.) had been remuddled remodeled to fancy administrative offices. The beautiful terrazzo floors had been covered with Karastan carpet and pretty pictures hung on the walls. The sluice room on one ward had been converted to a data processing room filled with computer doo dads with blinking LED lights.

Crude rooms that were vital and offered maximum utility for patients  were converted to an office sitters paradise and an electronic wasteland. A depressing commentary on contemporary healthcare.

Wednesday, June 7, 2017

Operating Room Superstitions

 Old time operating rooms were fertile ground for the proliferation of  superstitions. Surgeries performed with equal technical excellence can have profoundly divergent outcomes causing thoughts of supernatural powers. Unexpected complications can occur without reason or explanation. Practices and behaviors that accompany good outcomes can be elevated to cause and effect status even when there is no supporting science. A Cartesian circle of the highest order develops. (I tossed that Cartesian word in there to try and sound smart..I'll be darned if I know what it really means.)

Superstitions have one thing  in common with science, they gain real traction with repetition. Thoughts like "Hey..the patient always does well when I use that scrub sink near the door." Pretty soon another nurse notices the same phenomenon and a "lucky" scrub sink is born. If a superstition does boost confidence it becomes much like a positive affirmation. Thinking positively was not one of my strong qualities and some superstitious actions do serve to boost confidence in nervous Nellies like me. If there is no danger to the patient and superstitions boost staff confidence a positive aspect of such non - science backed behavior becomes apparent. Without further ado, I present the magic superstitions I have encountered over the years and there is not a single full moon or "Q" word among them. No nurse would dare tempt fate by uttering the "Q" word especially when the moon is full.

Intracranial aneurysm surgery is a high stakes and nerve wracking procedure. Dr. Oddo, my favorite neurosurgeon had a couple of unusual habits for aneurysm clippings. Rule #1, No talking during the surgery and now comes the mystical  photon diminution exsanguination challenge. After the offending aneurysm is clipped, the overhead and ceiling lights in the OR are turned OFF for one full timed minute. The bone flap cannot be wired into position until the lights out test is completed and assurances of a dry field confirmed. I asked Dr. Oddo if the rationale for this test was the fact that it would be dark in a closed skull and he admonished me for overthinking the matter. "I do it because it's effective," he muttered.

Surgeons love to brag about their "bucket time." This refers to the interval from incision to when the diseased organ is ceremoniously tossed into the kick bucket. Every circulating nurse worth their salt  knows the sooner that pathology infested gall bladder or ripe appendix is bagged up and out of the room the better. If a resident wants to fool around with the specimen looking for stones or what not-do it in a scrub sink outside the room. Get that thing outta here-It's bad JuJu of the highest order! Skin approximation at closing time is so much easier when that specimen is gone and the anesthetist will thank you too when it's emergence time. Everything is just...better.

This lucky maneuver was brought to my attention by a very bright Filipino surgeon. In his native country, the surgeons would place a huge leaf from a tropical plant under their  scrub caps as an aid for cooling. Serendipitously, it was discovered that surgical outcomes improved with the tropical leaf  undercap maneuver. We don't have tropical forests in Chicago unless you count that flower shop on Belmont St. in July, but we have cabbage leaves readily available in the hospital kitchen. This green vegetable worked just fine and there was usually a head (of cabbage) in the OR refrigerator. Just look under all those blood bags-yep we comingled food, blood, and (get em outta here) specimens in the same refrigerator. Our overseers were safely hidden away in their offices and dared not even approach the double doors to the OR.

Here is an oldie but goodie that every old nurse has probably practiced. The idea of transferring this maneuver from the bedside to the OR was a stroke of sheer genius. When a patient is declining rapidly old school nurses would tie a knot in a corner of the bottom sheet usually at the foot of the bed. It's best not to question superstition practitioners, but the explanation had something to do with binding the soul to the body. If a problem developed during surgery some circulators would duck under the table under the guise of adjusting a Bovie pedal and knot the sheet covering the OR table.

If sheet knotting is such a great thing I thought maybe we should just knot the sheet before each case prior to draping. An old nurse was quick to admonish me, "It doesn't work that way Fool. The knot has to be secured after the patient begins that downward slide. You should have learned that in nursing school."  I stand corrected.

Thanks for indulging in my foolishness. My blog always experiences a marked decline in readership after the traditional school year ends. Somehow, I did not think foolishness and academics mixed, but I must have been wrong.

Thursday, June 1, 2017

Let's Stop Using These BS Terms

Calling a doctor's office an INSITUTE such as Two rivers Orthopedic Institute. When a doctor hangs out his shingle he can't be the founding father of an institute. The term "institute" refers to an entity that combines clinical practice, research, and academic endeavors under one umbrella (another BS term if I've ever heard one.)  I better be more careful.

Clever spellings of terms like orthopAedics, just to sound like a bigshot. It's orthopedics unless you happen to live in England. I interviewed  asked an orthopedic man the rationale for this nonsense and he said it was being used a  nod to the history of the specialty. That's piling BS on top of BS if you ask me.

Calling patients "consumers."  This was tried in the past by calling patients "clients." It did not work back then and won't work now because it depersonalizes sick people seeking help. History is on the side of calling sick people patients, so let's not mess with it.

Let's stop calling dense urban centers with lot's of health issues "medically underserved."  There are lots of medical folks in your nearby hospital. The problem is horrendous, intractable social problems not a lack of medicine or medical personnel.

Doctors who refer to the number patients cared for as a "patient panel." I'm not sure where this one came from, but suspect it has something to do with remuneration. How do you determine the size of your "panel?"  Maybe the number of patients you see per day times  the number of days you see patients. Patients have highly variable levels of acuity. Maybe it would be easier to categorize by acuity before assembling a panel or just say how many people can give you a phone call and be seen by a provider. Yikes, provider sounds like another BS term and that's stacking BS on top of BS. I'm getting into some really bad habits here.

Free pharmaceutical samples from your local, friendly Doc that are not free or samples. UPMC the dominant domineering health system here in Pittsburgh hands out bottles of cheap generic drugs plastered with advertisements for their brand of health insurance. It's enough to make me sick!

Physicians that promote themselves by proclaiming they are a Harvard educated medical specialist. From my experience an Ivy league education does not promise a good outcome. That sounds like a misguided superiority complex to me.

 Two BS terms for the price of one - "experience" and "journey."  Your weight loss journey begins with a surgical experience with our Harvard educated (oops) bariatric surgeon.  Weight loss is not a journey and having your gut rearranged is not an experience.

Here is a real gem. "Work needed to undergrid  healthcare  reform involves a new paradigm in perception." That "paradigm" word has been around forever. Dr. Slambow, my favorite person to scrub with, said that whenever you here that paradigm word it's someone attempting to sound smart when they don't know what they are talking about. Maybe I need to come up with a new paradigm with this foolish blog.

Friday, May 26, 2017

What is This Newfangeled Juxta Business?

Medical terminology is in a constant state of flux and I'm all for change if more concise or precise - hey it rhymes- information is provided by the new term. But what's this new fangled juxta prefix  applied to anything and everything all about?

We have juxtaglomerular, juxtacortical (brain or kidney?), juxtapyloric,  juxtavertebral, juxtachondral, and who knows what juxta  else. In the good old days we had prefixes like peri-,circum-, or in plain speak,  thereabouts. These old school terms worked very well but,perhaps lacked some of the cache of the newfangled juxta speak. However, I think the lingo from yesteryear was more straightforward and served it's purpose well.

Youngsters seem to have a preoccupation with inventing new  terms to replace old school terms that have withstood the test of time. On a recent visit to the Carnegie Museum it was a shock to find all the dinosaur names unrecognizable. A taxonomic smart aleck had pulled a switheroo with all the classic dinosaur nomenclature. The venerable T. Rex (I can't spell the full name) was renamed Tarbosaurus. I think that sounds like the name of a docile creature like some delicate avian species. It certainly does not jibe with a apex predator like the T rex.

All this terminology and taxonomy malarkey calls for some harsh correction from the Oldfoolrn  Institute for the Advancement of Medical Terminology. It's always nice to know the prognosis when various medical terminology terms ejaculate from the tongues of sophisticated medical  banterers. It's a simple matter to tack on a suffix to the medical term to indicate prognostications.

If a good outcome is anticipated the suffix is  -goodjuju which can be abbreviated GJJ. If  a  storm is brewing on the medical  horizon and the patient is juxtaing the drain-oops I mean circling the drain, the appropriate suffix is badjuju or simply BJJ. Here is a sample: Aortic dissection BJJ or erythematous skin lesion GJJ. My system is straight forward and fun. Feel free to use the next time you are typing in a diagnosis on the EMR. Maybe if enough folks use this system it will gain traction, just like that silly Juxta prefix.

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Sunday, May 21, 2017

A Tale of Two Brain Lesions

It was near the end of a long shift and  after plodding along for 10 hours or so we would run the printer on each monitor to obtain a strip for the medical record. I always believed random and routine collections of patient data had limited usefulness, but that's what the bosses wanted so I happily complied.  Suddenly, something strange happened, as I looked up to the waveform on the monitor, it looked like there were 2 or even 3 waveforms plastered right on top of another where I knew only a single waveform could  be  present.  This caught me completely off guard and I began to attribute the multi-waveform  apparition to my end of shift fatigue or some sort of whacky monitor artefact-not likely- but it seemed like an easy explanation. That little voice in the back of my head spoke up and said, "Nothing serious..probably just a brain tumor..he..he."

 As I went about my care, I noticed the monitored patient was lying there  intently listening to a CBS news report and anchorman Dan Rather was in a somber mood relating the story of  Lee Atwater, the head of the Republican National Party. He collapsed  at a public appearance and was subsequently diagnosed with a brain tumor. He was receiving radiation implants and all the latest modern medicine had to offer for such an ailment at  the prestigious Montefiore Hospital in NYC. I made a mental observation to myself that rich people always get state of the art care. I  never used much in the way of healthcare services but doubted I would have access to Lee Atwater quality of care if I was sick. Some people have all the luck.

Lee Atwater was ahead of his time with various political spin jobs  and even fake news. After elucidating the fact that one of his opponents had mental health issues a story was spun that eletro shock therapy diminished his mental capacity. During his illness Atwater found God and joined the Catholic Church. He made frequent biblical references and later it was discovered his Bible was sealed in a presentation box and never opened. Atwater kept  making his pitches and spinning right through an illness that would likely  be a terminal event. Some habits are tough to break.

As time went on more strange things began happening to me. One day I found the back passenger floor of my Subaru littered with 7 or 8 cans of NEHI non carbonated lemonade. I was a Diet Coke person and it was a complete mystery how these empty lemonade cans got there. Maybe someone broke into my car and left their Lemonade cans behind. I didn't even like the stuff.

 Then late one night on the way home from work I had an epiphany while feeding quarters into a vending machine at an out of the way K-Mart in a not so nice part of town. It was me with the Nehi Lemonade consumption. I suddenly developed a craving for NEHI Lemonade, but had no memory of purchasing this  mythical beverage. At least  I discovered how those empty beverage cans found their way to the floor of my Subaru. Oh well..chalk it up to rotating shifts and too much stress. Life sure can be strange.

A couple of weeks later things got really crazy. I began having very vivid visual perceptual distortions. When I looked upward, it looked like I was in a blinding  snowstorm. A really bad blizzard like distorted vision that occurred primarily while driving. I gave myself a mental pat on the back and remember thinking; that's one good reason for leaving the snow tires on all year. This was taking place at the end of June in Pittsburgh. I knew I was in deep trouble because it does not snow in Pittsburgh in June. That thought about snow tires failed as a rationalization for my newly acquired blizzard vision.

Another symptom began driving me nuts (or nuttier than my foolish baseline) and that was itching like I had never experienced. I tried self medicating with Benadryl without much luck. Soon I was totally disoriented and had no idea where I was at.

I don't know how I wound up in the ER of a big academic trauma center. There was  no obvious trauma although there certainly could have been with me driving around in such a befuddled state. I owe a huge debt of gratitude to whoever delivered me to the hospital. I related my complaints about having blizzard vision to the youthful ER doc and soon I was having blood drawn for toxicology studies and promptly admitted to the inpatient psychiatric ward-they had a lot of beds in psych and probably needed the business. I remembered Dr. Slambow, my favorite surgeon always saying that I was a bit different from others, but that's what made me such a good scrub nurse. I guess he had a valid argument and I was coming home to roost.

The psych ward was very nice. I had a private room and the nurses were all pleasantly chatty with chipper attitudes-so different from my sourpuss co-workers in the OR. Just when it seemed like everything was going to be OK a profound sense of tiredness came over me. The cheerful  nurses quickly shed their perky demeanor and quickly  called one of the psych residents who  had an explanation, "The toxicology reports came back and he had a trace of Benadryl in his blood." No fooling! I was itching like someone in the middle of a poison ivy patch and admitted to taking Benadryl. It was more than 25mg. of Benadryl clouding my sensorium.

As my consciousness was  quickly sliding off to LaLa land I noticed an agitated figure standing at the foot of my bed. It was a neurology attending physician and he was not too pleased that I had been admitted to the psych ward.  He ordered a STAT CT scan to be followed by an MRI if the CT was negative. Back in the early days of MRI they called them NMRIs (the N standing for nuclear.) The  neurologist was now apparently in charge of my care. Just when I was beginning to appreciate the perks of a therapeutic milieu on the psych ward, I was slapped unto a Gurney and transferred to the not so pleasant  nuero/neurosurgery floor complete with overworked nurses and overly serious physicians. I liked the psych floor so much better.

The CT scan was normal, but a spinal tap showed traces of what was thought to be an old bleed. The neurologist wanted my head inside that NMRI machine pronto. My next recollection was being stuffed into that long skinny sewer pipe of an NMRI machine. This is certainly cozy I thought as my shoulders scraped the bore of the tube. If I happened to be any wider they would have needed some melted butter to slide me in. The various booming and banging noises reminded me of a motorcycle ride and the tight quarters were just like some of the caves I squeezed myself into as a youngster. The NMRI was turning into a fun little journey down memory lane.

The fun was turning out to be short lived as I was aware of a rush of people into the room. When people started rushing into the OR to see something, it was not a good sign. I figured the same principle applied to NMRI rooms. Here we go again, I thought. Trouble  on the horizon.

Sure enough I had an "impressive"  NMRI according to the down in the dumps neuroradiologist. I remember thinking, maybe you are impressed, but I'm depressed."  What seems to be the problem I inquired and he blurted out, "You have multiple areas of T2 signal intensity in the periventricular area of your right occipital lobe. It looks like a stroke or tumor." That little voice in the back of my head was getting real chatty. "I'm dead meat."  it kept repeating.

I was beginning to regain some of my cognitive abilities and started getting cold feet at this hospital. When they began talking about an open brain biopsy, I asked them if they had heard of stereotactic head frames. They indeed were up to speed but only had CT compatible head frames and my lesion would not image on CT. I pulled my ace in the hole out and informed them I was transferring my care to the internationally known father of Pittsburgh neurosurgery, Dr. Robert G. Selker.

I had worked with Dr. Selker and knew him personally. I did not care for his ultra conservative politics but he was the best in the business. Dr. Selker reviewed my care and just shook his head. "They had you on the psych ward?" he asked incredulously. "That's just plain stupid."

Attempts at a stereotactic biopsy were never successful and Dr. Selker thought the risk of hemorrhage was greater than any benefit. I remember telling him to go ahead and give the biopsy  a whirl because I had 9 lives just like a cat. He thought about it for some time and said, "If that's true what's that pile of dead cats doing under your bed?" The biopsy was off and Dr. Selker said he was certain the lesion was a low grade glioma. "If I were to biopsy the lesion, it's going to come back a low grade glioma and I would not know what to do with it."

I was to have an annual MRI to follow the progress of the mass. The first few years there were small changes. When I had 2 MRIs that showed no change about 7 years after the onset of symptoms, I decided to stop seeing Dr. Selker.

Lee Atwater died in 1990 and Dr. Selker died in 2010. I managed to outlive them both. I guess I was the lucky one and neuro gods really do look after fools like me.  Sometimes good fortune trumps medical intervention.

Wednesday, May 17, 2017

It's Payday



So many of you have been perusing my post, "Nursing Joins the Money World" that I thought you might be interested in an oldie but goodie post about nurse compensation. It takes a reckless fool to post paystubs online, but here they are. For the shocking details click on the link below.  I calculate that for a 3 hour trauma case in 1972  I took home the princely sum of 10 bucks. Doing just about anything solely for money takes all the fun out of it. Although my paycheck failed to show it, I felt very rich while at work in the OR  and paradoxically when the going got rough, I was most fulfilled and grateful.

http://oldfoolrn.blogspot.com/2015/02/fools-gold-its-payday_25.html