Friday, August 18, 2017

Side Rail Peference Separates the Bedside Nurses from the Office Sitters

Any bedside nurse can attest to the fact that the only safe side rail on a hospital bed is one that runs the full length of the mattress from head to foot in a single section. All old school hand cranked beds had full siderails that were raised and lowered guillotine style or hinged to swing out and below the bed when giving care. My favorite was the straight up and down style release because the swinging rail bed had to be moved out from the wall to drop a rail. When dealing with a patient determined to exit stage right it is sometimes helpful to butt the bed against a wall as a containment aid.

Old full length side rails engaged with a reassuring clunk that meant business -  similar to the feeling of a cycling shoe engaging with a clipless pedal - the patient is safe and I'm going to ride forever! At times it can be difficult to disengage from a bike pedal which always results in a fall for me, but I cannot recall any patient falls from an engaged full length side rail bed. Those old school side rails prized function over form which is the exact opposite of new fangled split side rails that are ubiquitous in today's hospital world..
The split rail special shown above is the office sitters dream bed and one big nightmare for the bedside practitioner. Sure it looks less intimidating and has better aesthetics than a full rail bed, but note the egress points between the foot of the bed and the bottom side rail. There is also an potential exit between the two rails that usually results in an extremity entrapment which is never pleasant. I've witnessed harried nurses lube up a patient's leg with Lubafax in a desperate attempt to slide it back to bed from under or between a siderail. Without the Lubafax those side rails are like Chinese handcuffs and the harder you yank on that leg, the more difficult it is to free.

Another fairly common exit strategy with this type of bed is often called the "flying buttress" for lack of a more technical name. The patient does a 45 degree rotation while prone and uses the bottom side rail to leverage his hips up and over the bed. It's prudent for a nurse to intervene while the buttress, so to speak, is still flying because the landing can be a real doozey when the patient impacts the floor. Thankfully most patients emit a verbal warning in the form of a shriek when they get stuck over the siderail and suspended in an uncomfortable, to say the least, position. At least the Surgilube or Lubafax is unnecessary with a flying buttress.

Today office sitting busy bodies are claiming that siderails are restraint devices which is pure balderdash to old nurses who like to think of them as freedom from falling incident devices. All an old nurse needs to keep just about any patient safe in bed is an extra sheet, a washcloth, and a roll of 3 inch gauze. The sheet is applied lengthwise across the patients chest and under the arms. The ends of the sheet are tied under the bed with the full length side rail up.

Mitts are applied by asking the patient to squeeze a rolled up wash cloth. The roll gauze is applied to the clenched fist from the wrist to fingertips creating a boxing gloved appearing hand. This also has the advantage of ceasing IV pulling or self adjustment of Foley catheters by the patient. I have seen motivated patients discontinue their NG tubes by clamping the tube between the mitts and yanking. This only happened once though because seasoned, old time nurses would bridle their NG tube by. OOPS never mind bridling - that's fodder for another post. Bridling of NG tubes is cruel and unusual punishment in my opinion and should never be done.

Egress minded patients are best kept far apart from each other. Semi private rooms become the devil's workshop if a couple of these bed bail out kings become buddies. Many times I have seen one patient perfect an exit strategy and then proceed to free his neighbor from bed. Once freed from the surly bonds of the hospital beds these folks just love to yank on Foleys, discontinue IVs and get into unimaginable mischief.

Full length side rails were highly functional and cost effective. Old hospital beds cost hundreds of dollars, not thousands like the beds of today. It's hard for me to fathom how something so highly functional could go by the wayside.

Thursday, August 17, 2017

If President Trump Tweeted About Disease

Cancer is bad, really bad, but so are oncologists. That chemo is equally bad as the disease they are curing. They are both equally to blame for the disease.

Wednesday, August 9, 2017

Montefiore Hospital Pittsburgh - A Unique Design

Architecture is not my area of expertise ( at my age about the only expertise left is shooting off my mouth) but I know a really special hospital building when I see it.  Pittsburgh's Montefiore Hospital was built into a hillside, ala, Pennsylvania bank barn style. The main entrance was located at the top of the hill which meant that a substantial portion of the hospital was below you as you entered. A subterranean wonderland of caring catacombs.
Montefiore Hospital, Pittsburgh, like a tree, it's supporting
roots were underground

The apex of the hill entrance floor was aptly named MAIN. There were three floors below main identified by letters."C" level on the very bottom  contained the operating rooms and recovery rooms, "B" level housed critical care units and "A" level contained the morgue and  cafeteria which served the best homemade bagels I have ever tasted. This was the only hospital I worked at that had the morgue so close to the cafeteria. This hospital made exclusive use of those double decker gurneys to transport bodies and morgue supplies were delivered in a cart that looked exactly like patient tray carriers so the general public was unaware of any morgue related activity near the dining area. Pretty clever.

Locating the OR on the very bottom of the hospital was a real switheroo for an older hospital as the most common locus was the very top floor. Explosive anesthetics were never used at Montefiore because a basement explosive mishap would have been catastrophic. There was little foot traffic on "C" level and this was a very quiet OR.

Montefiore's ER was underground on "B" level and accessed by ambulances entering a tunnel like opening from a side street. When recovering trauma patients related stories about near death experiences involving journeys through a tunnel, nurses set them straight by explaining that their near death experience was not all that ethereal. They were just entering the ER.

Having worked at Catholic, Protestant, and Jewish Montefiore, my nursing journey (I hate that journey business) has been an ecumenical experience. Of the three permutations, Montefiore was special. Some hospitals are focused on research, education, or making money but Montefiore was patient care oriented to the highest degree. Patient needs were the highest priority here.

There was never any of that "We will have to see if you are covered" or "That  treatment is unavailable because it's against church teaching."  Patients migrated to Montefiore like salmon swimming upstream knowing that once in the hospital, kindness and concern reigned even if their journey was one way. Dying patients never received a hospital bill.

The director of nursing even made rounds to the nursing units and never harangued or harassed a soul. She frequently inquired if we needed anything. If it was for a patient, we got it pronto.
Montefiore had its own 3 year nursing diploma school that was open from 1902-1974 and floors were staffed almost exclusively with RNs

In 1990 Montefiore was bought out by a giant healthcare corporate entity, UPMC. The first thing to go were the homemade bagels - they fired the baker. Next on the corporate agenda was renaming all the hospital floors; "C" became "1" and so forth. They even installed kitschy computer screens in subterranean rooms and connected them to an outside camera.

Maybe the renamed floor numbers made sense, but you cannot replace caring with virtual window  kitsch. Today a patient is lucky to find a pleasant nurse that is not umbilicated  to one of those computer on wheels monstrosities. It breaks my heart to return to Montefiore today. What is gone will never be replicated

Thanks for taking the time to peruse my foolishness. I have no idea how that stray line crept in at the conclusion, but I cannot seem to get rid of it!

could be wheeled from an ambulance to the ER without even having to open a door. si sized o

Friday, August 4, 2017

Emerging Nurse Leaders - What in Blue Blazes?

It doesn't take all that much to rankle my hackles these days. From nurse office sitters that don't know the basics of setting up a Mayo stand or how to cut a series of ligatures all the exact same length with just 2 snips of your Straight  Mayos. These are the same folks who dictate aseptic procedures while sneezing without a Kleenex. Regulatory and office sitting busy bodies regularly let loose with more crap than a chimp on laxatives and it's high time they stopped circling the bowl.

What the heck is an EMERGING nurse leader. It's high time they got off the pot and did something for a patient. Find someone to suction, milk a chest tube, load a Raney clip and by the way that Foley bag needs emptied. Emerge already and do something. Back away from that desk, arise out of that comfortable chair and for gosh sakes do something. While you were preoccupied with emerging other nurses were out there actually doing things for patients. Enough is enough!

Friday, July 28, 2017

The Souttar Craniotome

Every surgical specialty has a memorable instrument from the past that inspires trepidation in modern folks; urology had the Kollman dilator, OB had the cephalotribe,  and neurosurgery had a host of ghastly  tools to fashion approaches to the brain.

The dicey part about accessing the brain is that it's covered in a very durable, hard, boney box-like structure, the skull. The dura which covers the brain lies directly beneath the skull. The trick is to get through the bone without harming the underlying dura. Just like fashioning a small round opening in a boiled egg without touching the white.

Modern pneumatic craniotomes  in use since the mid 1960's do a great job of this. There is a blunt foot on the end of that whirling dervish of a  cutiing blade that leaves the dura unscathed. It was invented  by John Nash who ironically became one of the first customers to utilize his invention. He required a craniotomy for a brain abscess shortly after marketing his device.

My favorite neurosurgeon, Dr. Oddo, just loved antique neurosurgical  instruments and had them proudly displayed in his office. I was fascinated by an unusual device for cutting thorough that bony barrier, the skull. The Souttar crainitome  consisted of   a solid 6X1 inch stainless steel post with an adjustable expanding  base, a pivoting arm that moved around the post, and a cutting wheel that resembled a plumbers pipe cutter.

Dr. Oddo was more than delighted to explain the operation of the Souttar craniotome which was invented in the early 1930's. It was designed to cut a perfect circle in the skull in whatever diameter the surgeon desired. Asking dumb questions was one of my signature moves so I asked Dr. Oddo what's wrong with a square or rectangular opening into the skull. "Intersecting lines never work in neuro surgery. If there is pressure building up under a square opening there will be greater pressure in the corners. An oval or round opening heals best and permits pressure equilibrium beneath the bone flap."  Thanks for the enlightenment Dr. Oddo, but can bone wax be used to polish a surgical instrument? Can ambulatory patients receive care at Chicago's Lying In Hospital? How normal is normal saline? Do blood gases smell funny?  Oops, those dumb questions never cease when Oldfoolrn is on the case. It's time to get back on task.

Henry souttar was an engineer before he took up medicine so maybe his skull opener was inspired by circle cutting devices from other discplines. To the left is an arts and crafts circle cutting device that is a dead ringer for the Souttar craniotome.

In Souttars version a burr hole was manually drilled in the center of the intended skull opening. Burr holes were drilled using a device that resembled a boring brace and the bit was attached to a clutch mechanism that ceased the rotation of the bit when it was through the bone.

The next step involved inserting a stainless steel post in the burr hole. The post was rigidly secured in the burr hole with a set- screw activated expanding base which was identical to the manner a bicycle stem is secured in the top of the fork.

Once the pivot post was secured in the burr hole, an arm with a cutting wheel was attached. The size of the circular skull opening could be varied by sliding the cutting wheel on the arm. As the cutting wheel was moved out the radius of the circle increased making a larger opening. The pressure of the cutting wheel on the bony skull could be increased by tightening a screw atop the wheel. When Dr. Oddo demonstrated the device in action he compared it to children frolicking around a Maypole. The action was similar, but the analogy gave me the creeps. What in the world do innocent children have to do with chopping a hole in someone's skull?

The old school neurosurgeon stopped frolicking  the  cutting action just before the skull was cut through to protect the underlying dura. The final removal of the bone flap was done with a mallet and chisel.

You can count on Oldfoolrn Blog to bring you the latest in little known, esoteric, meaningless information. I Googled, Binged, and Medscaped "Souttar Craniotome" and came up dry. This post is based on memories sifted through an aging nervous system so reader beware.

Thursday, July 27, 2017

Skeptical scalpel has information regarding the possible ultimate solution for that unsavory perineal fallout issue. There is a link to his blog on my blog roll.

Friday, July 21, 2017

A Vintage Operating Room - Circa 1930

When I started this blog I envisioned it as a  museum of nursing history with an emphasis on life in the OR. After reviewing some of my previous posts,  I came to the realization that my endogenous foolishness has resulted in a blog that more accurately resembles a carnival side show. It's time to put the foolishness on the back burner and restore some credibility with a straightforward post.

So here it is; a guided tour of a 1930's operating room. Prominent in this overhead view is the unique shadowless lighting system. A very rare, explosion proof resistant black Operay. That black Sputnik-like orb contains the light sources and lenses to focus the beams of light on the reflecting mirrors arranged around the periphery. The goal: shadowless lighting.  Here is the link to an old Operay post.

This old photo  illustrates one of the problems with Operay surgical  illumination.  Shadowless lighting failed to live up to it's hype and the folks in this OR augmented it with a floor stand pedestal spotlight which is visible in the upper left hand corner. Unlike contemporary operating rooms that are filled to the hilt with electronic equipment, Old ORs had plenty of floor space for pedestal lights that could be moved about on wheeled platforms. If a light bulb element went kaput in the middle of a case, no problem, just wheel it to the corner and bring in another light.  Pedestal mounted lights were very versatile and  tons of  fun until you stubbed your toe on that unyielding massive pedestal. OUCH.

One of the mysteries in this photo is the use of the black explosion resistant Operay in a room that could never be used with flammable anesthetics. Cyclopropane gas anesthesia was in vogue back in the 1930s, but despite the correct Operay for an explosive environment, that beautiful  ceramic tile floor could never be condutive so as to minimize static electricity. No Cyclo allowed in this room.  Ether and chloroform were popular agents and you can see the agents being delivered by mask on the laterally positioned patient. Intubation was yet to come.

Old school hospitals were very cost conscious and you can see the scrub nurses using an old wooden pallet to gain some necessary elevation. It would have been considered fiscal recklessness to splurge on a fancy metal platform when old wooden pallets could be had for nothing. Function trumps form anyday in this acient OR.

The twin scrub nurses suggest a training situation. As an eager  youngster learning the trade, I had the opportunity to scrub with a veteran nurse only once and  then I was thrown to the lions surgeons. I spent many happy evenings perusing Alexander's Care of the Patient in Surgery and mentally planning my cases for the next day, praying that I wouldn't get yelled at or forced to duck a thrown instrument.

Where is the back table in this old time OR? My favorite OR supervisor, Alice, loves yammering on about this feature of vintage  operating rooms. "We used one massive curved back table that was stocked with all of the supplies and instruments for a full day's caseload. The curve facilitated corner placement of the table with maximum usable surface area," she explained.

"Old school nurses were motivated and did not sashay in and out of the rooms like you youngsters are so fond of doing. Once that back table was stocked, we stayed put in the room until the day's caseload was finished. Between cases the circulator carefully covered the back table after the scrub nurse fetched her instruments. It was considered bad form for the scrub nurse to need an item from the back table once a case started, so we had to use our head's for something other than a hat rack."

Alice was an OCD nut and insisted her charges prepare for and conduct cases in a  Kabuki Theater like style. Everything had to be planned for and conducted exactly according to her rigid authoritarian rules which was fine until something unexpected happened. There was only one way to open an instrument set or thread a suture needle in old school ORs. The scrub nurse in the photo has her left hand under the Mayo stand. A  definite according to Alice and grounds for getting a knuckle slap with a sponge ring forceps. That'll learn ya to keep both hands above the Mayo stand.

What's missing in this old OR? There are no electronic monitoring devices or piped in medical gasses. Anesthetists monitored vital signs using a precordial weighted stethoscope that was taped to the chest. An earpiece connected to a stop cock enabled toggling back and forth between the stethoscope and blood pressure cuff. Anesthesia sans any type of electronic monitoring.

These old time ORs were places to have something removed and every case was an -ectomy of one type or another far removed from the repair and replace surgery of today.