Saturday, February 18, 2017

When an avulsion type injury occurs to a lower extremity like a foot why is it called a  degloving injury?  (I even checked with the ICD 10 code)  Pardon my foolesque nature, but  it might be more accurate to call it a destocking injury.

Thursday, February 16, 2017

Now You See It - Now You Don't

Every surgeon is acutely aware of the risks associated with surgery and will rarely operate on poorly defined pathology except in dire situations. This usually works out very well; the X-rays show an arthritic hip and it's replaced or studies indicate a diseased gall bladder so take it out. Every now and then a red herring swims into the picture to muddle things up. This is a tale about preoperative evidence of pathology that could not be found after the patient was opened up, an unusual occurrence, but it sometimes happens and throws everyone for a loop.

A very pleasant, matronly seamstress was out shoveling snow from the sidewalk at  her place of business and experienced the worst headache of her life and collapsed. She was rushed to the hospital and cerebral angiograms revealed an anterior communicating artery aneurysm.  There was also blood in her spinal fluid, but there was some question that a traumatic tap could have accounted for this  finding. Given the conclusive angiogram the spinal tap was not repeated. The only treatment at the time  was an open craniotomy and clipping the offending aneurysm removing it from circulation. This procedure was pioneered in the 1930's by neurosurgeon  Walter Dandy (google him for a fascinating life story.) He is one of my personal heroes.

Dr. Oddo scheduled the surgery which was commenced on a  January afternoon. Everything was proceeding smoothy until Dr. Oddo gently exposed the offending artery and lo and behold there was no aneurysm to be found. Anesthesia always catches the blame when something without an obvious cause occurs and this was no different, "What did you do to her blood pressure?  She must be in shock because the aneurysm receded," Dr Oddo hollered. Anesthesia reported that vital signs were normal and stable much to Dr. Oddo's consternation.

Desperate situations are not conducive to good decision making. Dr. Oddo requested anesthesia for a pharmacologic boost in blood pressure. If there was a weakness in that anterior communicating artery he was going to find it. Remembrances of my uncle stuffing sausage popped into my head as the blood pressure escalated. "You can only stuff so much meat into the sausage 'til the casing breaks," was one of his admonishments. I began to worry Dr. Oddo was going to pop this ladies sausage aneurysm. Even with the pressure boost the artery held. No sign of the offending aneurysm.

The next victim for Dr. Oddo's high pitched screaming  would be the circulating nurse as Dr. Oddo shrieked, "Get those angiogram films up on the view box - pronto!" After what seemed like an eternity studying the films, Dr. Oddo was really discombobulated. The X-rays did indeed show an aneurysm and it was definitely involving the anterior communicating  artery.

It was finally time to take a lesson from Old King Cole so he called for his head mounted fiber optic light, he called for his loupe, and any neurosurgeon that might be free. Dr. Oddo's skeet shooting partner and fellow neurosurgeon, Dr.Penfield, made one of his usual grand entrances and the surgical site was unveiled  with the ceremonial removal of saline soaked sponges. Dr. Penfield was equally bumfuzzled by this bamboozling series of findings (no visible anteriot communicating aneurysm) and sauntered away from the table muttering something about a miracle being the only possible explanation.

Dr. Oddo quickly and very meticulously closed the craniotomy all the while contemplating what to tell the family. He finally concluded that if he told them the absolute truth, they would be angry eith him for ripping the ladies head open for nothing so the story he related was that the aneurysm had been "taken care of." This seemed to satisfy the anxious family and the lady was wheeled of to the neuro ICU where the nurses were enthralled by the incredible report of the surgery.

The neuro ICU nurses cared for her with a devout sort of respect reserved for those touched by a divine  being. Who knew what supernatural or celestial  power purged that aneurysm from her cerebral circulation? Churches have  lots of  stilted verbalizations  and relaxing  music, but God probably does most of his heavy lifting in hospitals.

This was the only miracle I have ever witnessed and this ladies wounds healed in an unusally brief period of time without any complication whatsoever. She walked out of the hospital four days later with a festive red scarf covering her bald head, a big smile on her face, and a twinkle in her eye. I always had the feeling that she knew more about what had happened than any of us ever realized.

Monday, February 13, 2017

Thanks for thinking of me, but I'm sticking with Preparation H

Saturday, February 4, 2017


I've been experiencing one of my mid winter brain freezes and had difficulty coming up with a coherent post so I stuffed a bunch of  3X5  index cards into my pocket and wrote down thoughts as they jumped into my  head. These were some of  the  nursing related thoughts that came to mind. Please don't ask about the non- nursing thoughts. You really don't want to go there!

A nurses (often twisted) sense of humor is inversely related to their proximity to mayhem, misery and tragedy. Utilization review nurses are a dour, unfunny bunch. OR nurses especially after a long messy case will have you laughing like a  hyena. By the way, have you heard the one about the surgeon's daughter and the itinerant autoclave repairman?

Any dropped needle or sharp object will roll or slide to the most inaccessible location with the bevel or sharp side up.

I probably mentioned this previously, but it bears repeating because it's a very reliable prognostic indicator. If the overhead lights are adjusted more than 3 times for a surgery on the same site, the prognosis is grave. The rule is invalid if a technical problem occurs such as a burned out bulb or the light fails to maintain position.

The likelihood of a glass IV bottle breaking is directly related to the stickiness and/or messiness of it's contents. Albumin and plasma are prime candidates for breakage.

Alcohol causes more pain and suffering than cancer and heart disease. Alcohol, gun powder and gasoline do not mix.

Why is the dying process so similar to a birth?

If you are working just for money all the fun and rewards of life are gone.

The higher up the nursing hierarchy you ascend; the worse clinical nursing skills become. A new highly educated nursing supervisor was bragging to us in the OR  about her credentials and one of my co workers hollered out "Yup, you are educated, but can you load a sponge stick with one hand?"
Nope she could not. That put an end to some of the BS.

No sales people are needed for a truly effective drug. When was the last time you heard a sales pitch for penicillin or digoxin?

Hospitals today are loaded to the gills with a plethora of personnel that never touch or directly help a patient. Office sitters and self proclaimed big shots in every department with computer geeks interacting exclusively on  flat screens. If you want a graphic  indicator of how many superfluous people are employed in hospitals observe the difference in how many cars are in the parking garage on weekdays vs. weekends. VA hospitals are the most dramatic.

Regardless of personal religious views, always bow  your head when a patient asks you to pray with them.

You will never know how much it meant to that patient you stayed over past your shift to do something special for, and that's the way it was meant to be.

Never force an intramedullary fixation device into position - use a bigger mallet

Wednesday, February 1, 2017

Today is my  Mom's  birthday. She graduated from St. Anthony's Hospital in Rockford, Illinois during the 1940's. She was a genuine coal shoveling nurse and liked to boast how quickly she could fire up the hospital boiler. As a child I remember encountering her blood splattered Red Cross nursing shoes one morning after her return from work. When she caught me with my eyes fixated on them she cheerily replied, "Don't worry my patient was really sick last night, but he is going to be fine."

I was also really impressed by the curved glass drinking straws she brought home from work. She explained that they were bent at the exact angle so someone could drink while in bed. I marveled at how nice it was for someone to help a sick person drink. That notion totally fascinated me as a child and when things got rough for me much later in life in the OR, that image of  a glass straw helping a sick person to drink always popped into my weary brain. Things were not so bad.

I remember her stories of caring for young polio patients in iron lungs. That really scared me to death and I remember her joy when the polio vaccine was developed. Although my mom had other options she worked decades at the bedside. I think that for her, hospitals were church and the patients bedside the alter. She was not keen on  Sky Gods, but I'm certain her spirit lives on in the many patients she helped over the years.

If not for my Mom, I would have probably become an auto mechanic (shop was my favorite high school subject.) Instead of looking down upon my Bovie burned finger, I would be gazing at scarred knuckles from slipped torque wrenches. Strange how things turn out!

Thursday, January 26, 2017

From the Anals of Anesthesia History

This photo was snapped in 1909 and immediately piqued my curiosity. At first glance, I guessed that this must be an old school exercise device, perhaps an inversion table or tilt table, but further investigation revealed that it's a set up for the rectal administration of ether anesthetics. This sounds like a high risk technique bordering on medical misadventure based on the flammability and mucosal irritating nature of ether. Here is what some of the physicians of the time had to say about colonic ether.

"The fact that the intestinal mucosa is especially efficient in transfer of gases to and fro from the blood, prompted the colonic administration of ether. The head of the operating table is depressed after the patient is placed on the table. The afferent rectal tube is inserted past the bulb and efferent tube. The anesthetist then opens the efferent tube to allowing bowel contents, if any to escape. The etherization should then commence by forcing the ether mixture into the bowel by pressing on the bulb until an intracolonic pressure of 20 mm Hg is obtained. Every 15 minutes the efferent tube should be opened and the cycle repeated. The colon should be inflated with oxygen after venting the superfluous ether at the conclusion of the procedure."

The prep for this anesthesia was brutal. NPO for 24 hours prior to surgery. Cleansing enemas the evening before and again in the AM prior to surgery. I was trying to deduce the rationale for the Trendelenberg (head down position) of the OR table and came up with a couple of guesses. Ether was notorious for inducing cardiac arrhythmias. An old school trick for converting arrhythmias was to place the patient in Trendelenberg and tell them to hold their breath or possibly the position helped in the retention of the ether. Who knows?

I was curious as to the nature of the ether used and learned that an ether generator was used. This was a crude vaporizer that created etherization by passing room air or oxygen through the liquid ether. Who knows what they did with the ether vapor that was vented off via the "efferent tube" but somehow I suspect that it was just vented out a window. This was a common practice many years ago and one of the reasons ORs were always on the top floor of old  hospitals.

One of the early axioms in medicine was the more primitive the procedure, the more sophisticated the lingo describing the action. That must be how the "afferent" and "efferent" rectal tubes came about. The clever old docs hijacked a term describing the autonomic nervous system and applied it to their backside buffoonery.

I don't think their notion that the intestinal mucosa is an effective means of gas exchange is accurate. "The patient is desaturating...get that rectal tube hooked up to oxygen said no one!" There is very little gas exchange along the GI tract as anyone who has erroneously intubated the esophagus knows all too well.

Although butts and gas go together like tweedle dee and tweedle dumb this procedure was inherently dangerous because ether was so flammable. Another complication was (surprise) rectal bleeding. This procedure looks more like a colitis simulator than an anesthesia agent.

Anyhow, the next time I have surgery it's going to be a spinal or regional.

Sunday, January 22, 2017

We've Only Just Begun

My affinity for medical devices was shattered to the core when this glimmering silver coffin-like
machine with all  it's doo dads, dials, roller pumps, and bubble machine up top was wheeled into a room. Someone even had the audacity to attach an anesthesia dispensing Halothane vaporizer into one of the circuits. It hung off the end of this beast with all of the grace of a man who had an encounter with cowboy justice. Unconsciousness was the modus operandi of this device - no anesthesia augmentation necessary. Waking up was the real challenge.

Dr. Nutsy, our one and only heart surgeon was in charge of this splendid piece of medical equipment and did he ever have clout with the purse string controlling, office sitting bigshots. The hospital had just spent $835 to have his baby air freighted fron Ohare in Chicago to Texas to install a state of the art entertainment system that consisted of an 8 track tape deck. Two speakers one on each end amplified the tunes. I shudder to think what he paid for the installation for this state of the art audio device. We were too blown away by the air freight charge to even think about installation fees. This was a surgeon who got what he wanted. Few hospitals did open heart surgery  and retaining Dr. Nutsy was essential to maintaining bragging rights.

Early open heart surgery was not pretty. Dr. Nutsy once lost 8 patients in a row and the nurses that lost  big money betting on number 9 were consoled by the fact the young patient was only 7 years old and had an easily repaired septal defect. I remember how delighted we all were when his young patient did so well that she walked out of the hospital a week later. Even a surgeon with borderline surgical skills gets lucky now and then.

The heart room had a dedicated team so I never had the pleasure of working with Dr. Nutsy. His shovel like lunch.hooks hands wielding sharp metal objects, some them under pneumatic power near a beating human heart looked like something out of a horror movie. All that blood coursing about to and fro in clear tubing added to the creepy ambience. Dr. Nutsy had mutton chop like bushy  sideburns and it used to creep me out watching dandruff particles flake off and lazily float like snowflakes into the surgical site. His patients survivors did have low infection rates so this must have been aseptic dandruff if there is such a thing.

I remember one of the early myocardial revascularization techniques involved dusting the heart with talcum powder in hopes that the irritation would stimulate new circulation. Maybe Dr. Nutsy and his shedding of intraoperative dandruff was unto something.

Sometimes uninvolved and disinterested observers have a different perspective that initiates questions that the so called experts never consider. I intuitively thought that medical devices that mimicked the way human organs functioned were best. After all, early ventilators had a sigh mode where the device delivered a deep breath from time to time. That rock steady non pulsating output of a heart lung machine was nothing like the squirt - squirt output of an actual heart. Blood flowed from a heart lung machine like soft ice cream from a soft serve machine. The heart provided intermittent squirts of blood  that a trauma nurse knows all  too well from observing an arterial bleeder. How could this be?

When I asked Dr. Nasty about this, he claimed that he never thought of it and mumbled something about capillary perfusion. I was always afraid to even speak to him with his belittling demeanor.

His love of music was limited to an early 1970s pop group, The Carpenters. I clearly reollect the lovely contralto tones of Karen Carpenter flowing from the side speakers on the heart lung machine.
"We've only just begun.. We've only just begun to live, so much of life ahead... A kiss for luck and we are on our way." Unforunately the lovely music was often interrupted by lengthy bitter diatribes and outbursts from Dr. Nasty because so many times while the beat of the 8 track tape player in the perfusion machine went on, the patients heart beat did not..

I never could stand listening to the Carpenters after spending time in Dr. Nasty's heart room. When the Carpenters tunes were played I felt instant waves of fear pass through my body and visions of that 8 track tape sitting on top of that heart lung pump as the patient was wheeled out danced in my head.

Some images really stick with you.