Monday, August 29, 2016

Stop the Epipen Madness

This story has all the usual elements of a Big Pharma vs. patient drama but with a few twists. We have the usual villainous CEO but this time it's a female Martin Shkreli in the form of a person named Heather Bresch who runs Mylan. She boosted the price of an auto injector device for epinephrine to be used for treating anaphylaxis by a gazillion per cent.

Rather than piling on this greedy CEO it might be easier to cease using her overpriced product. There is a simple alternative called a needle and syringe. To make this novel device fool proof simply preload it with the correct dose. You can jab that needle into your thigh just as you would with that auto injector gizmo and save yourself big money.

You are only going to frustrate yourself by trying to reason with Big Pharma CEOs. Most of them are hard core, dyed in the wool sociopaths. Ms. Bresch even attempted to claim she possessed an MBA degree that she never earned. Stay away from people like this. They are nothing but heartache and trouble. Epinephrine is dirt cheap and syringes are easy to use. Problem solved. Next on the agenda those leaking Micro Cool Surgical gowns profiled on 60 Minutes. I've got a simple fix for that one too.

Sunday, August 28, 2016

I'm Not Florence

When I started this blog on a cold Winter day, I really did not know what I was doing and not much has changed, I still don't. I was in the basement perusing my collection of ancient nursing care plans, yearbooks, photos, and assorted nursing  paraphernalia. I heard a voice in the distance, " The first thing I'm going to have to do after your funeral  is rent a dumpster to get rid of all your junk." That gave me the brilliant idea of starting a blog, you cannot haul a bunch of electrons in cyberspace off to some landfill. The OldfoolRN blog was born.

The "about you" description of me was reasonably accurate. I'm old, foolish, and a  long ago retired nurse that fantasizes about scrubbing "one more time." When I came across that lovely, graphic, pure, black and white image of Florence Nightengale, I went for it. It never occurred to me that people might think it was really me. When only a few people read this blog, Florence's image seemed like a minor, unintentional deception. As more and more people began reading my foolishness it began bothering me and then I started to think that I might be making light of Florence. My real intention was quite the opposite.

Anyhow, I took down that lovely image of Florence and put up one that is not so nice, but accurate. Yes siree  that's me in one of my all time favorite places. Dr. Slambow was always kidding me about looking "bright eyed and bushy tailed" even after long  cases. I always protested that I was fatigued and one day after a long trauma case he called out to me just after I ripped my mask off. He then snapped this photo and presented me with a copy as evidence of my indefatigability.

Dr. Slambaugh always carried two things in his black MD's bag. His ancient Argus 35mm camera and his cigars. When he asked one of us to run up to the lounge and "get my bag," we knew he was either preparing to smoke or take a picture. When he snapped that photo of me I was telling Nancy (the back of her head is in the foreground) that I would grab some hydrogen peroxide to help remove the blood from the overhead light. There had been a mishap involving a blood pump and a loose IV connection. Nancy said she could handle it and to meet her in the lounge for a well deserved break. I was attempting to figure out what to do when Dr. Slambow snapped the picture.

I have also reviewed and removed a couple of old posts because they were not truthful and more fabrication than fact. Google should invent a BS meter and introduce it as a new blogger tool. Any how I will try to be more honest in the future. Thanks for indulging in my foolishness!

Monday, August 22, 2016

This is Your Time

Nursing certainly has it's share of soul sucking moments. Sometimes when times got really tough I felt like back-up singers or a pep talk would help. Dr. Slambow actually made a recording of that speech from the early 1970's movie Patton and told us to head up to the lounge and listen to it to renew our energy. I always thought he was eccentric, but the trick really worked. If I happened to be a down-trodden nurse of today, I would head to that secret hiding place under the table for a moment and then head up to the lounge and listen to this 4 year old. Just substitute "nurse" for hockey player. It should work like a charm.

Friday, August 19, 2016

Obesity in the OR - Problems Beyond Your Wildest Dreams

Everyone is acutely aware that obesity is unhealthy and can compromise recovery from just about any illness from cancer to cardiovascular problems. Dr. Slambow frequently quipped that surgery on obese patients is like changing the spark plugs in your car engine while standing on a ladder. Some risks of obesity in the OR are subtle and not well known. Here are a few of the obscure risks.

Obesity dramatically increases the depth of that well known lint trap the umbilicus. The deeper that belly hole becomes the more area to accumulate lint, oil, and down right nasty,  foul smelling dirt. The depth of the hole not only increases the volume it can hold, it also further isolates it from oxygen in the atmosphere. Anaerobic bacteria have that characteristic foul smell that any sewer plant worker knows all too  well. Doing a surgical prep scrub on one of these deep, foul holes dislodges sludge that has probably been there since childhood. Unfortunately the patient is 38 years old. That belly button sludge has been fermenting longer than fine, aged cheese. I don't think that I will ever see Roquefort cheese in the same light after doing a prep on one of those coal mine belly buttons.

I'm not on the skinny end of the spectrum and when I required abdominal surgery one of my main fears was of those oversize instruments. My last memory before the Brevital clouded my consciousness was of those foot long pick-ups and how they would look buried in my sore belly. They looked plenty threatening from a patient's perspective and reinforced the humane practice of keeping instruments out of sight until the patient is asleep. I made a note to myself to keep that back table covered whenever the patient was awake in the OR.

 It's not those retractors that are big enough to hold the Grand Canyon open or those very long pick up forceps. Its the mindset they induce in the operative team. Surgeons and nurses see these huge instruments and then subconsciously adopt a Dr. Hulk or Nurse Bruiser mindset. Just because people are big doesn't mean their tissue is tough as nails. An obese patient's pancreas is just as friable as a beanpole patient. Bigness does not translate to toughness. A light, gentle touch benefits all surgical patients. Don't go roughly yanking on things like gall bladders and liver beds. "See with your fingers and lightly touch with your eyes." as Dr. Slambow often said.

Anesthesia personnel seemed to favor spinal anesthesia in some obese patients and after witnessing difficult intubations I can appreciate why. I once witnessed an intubation of a bull necked patient that involved attaching the laryngoscope handle after the blade was inserted. The patient's neck was simply too large to accommodate the laryngoscope handle and blade while it was assembled.. The problem with spinal anesthetics is that while sensory nerves are blocked, pressure sense remains intact. That poor patient can feel the hapless surgeon leaning against him with all his might while he is tying off that bleeder deep down in that wound. Anesthesia always seemed hesitant to heavily sedate obese patients and being awake while the surgeon takes out his frustration on the scrub nurse and leans into me would not be my idea of a good time.

About the only positioning aids available to us in the good old days of big open surgeries were 3 inch adhesive tape, bean bags, sand bags, and assorted permutations of rolled up towels and wash cloths. Lateral positioning of obese patients always scared the devil out of me because wherever that big belly went, the patient was sure to follow. That table was so narrow and that massive belly preparing to slide off was the stuff nightmares are made of. One of the safeguards  I used was aggressively taping the patient's  arm on top to the ether screen. Anesthesia always hated this maneuver because that giant ham hock of an arm could partially  obscure their view of the patients chest. Before all the fancy electronic monitoring aids were available, anesthesia constantly watched the patients chest rise and fall. Flexing the side lying patient's legs and running another course of 3 inch adhesive around the ankles and thighs was added security.

Distractions in the operating room are not a good idea. The surgeon and circulator often begin the "How are we going to get this guy off the table?" discussion just before closing the wound begins. They should be more concerned with sponge counts than who can bench press 150 pounds or more or how many people will be required to complete the table to litter transfer.

Even a dolt realizes that it is much more difficult to properly illuminate a surgical site that is essentially a valley in the middle of 2 mountains of fat. After carefully positioning the lights for optimal illumination of a deep wound things might not look quite the same as they would in a lean patient.. Dr. Slambow was an amateur photographer and had this mystery solved. The yellow fat tissue that surrounds the surgical site was actually changing the color temperature of the lighting. Instead of that nice, neutral white color the lighting had a yellowish cast.

Here is another way obesity may be a boon to the surgeon at the expense of the patient. While the patient is in the consent signing stage, the nurse is certain to mention that obesity confers additional risk to the procedure. This can be used to the surgeons advantage to explain almost any complication of the surgery. Instead of saying something like "That tie was not secured well enough on your cystic duct," the surgeon can dodge the issue and blame everything on the obesity.

This post has really stimulated my appetite and there is a cold Big Mac in the refrigerator. I am so old that if Big Macs were lethal that they would have certainly killed me by now.

Saturday, August 13, 2016

Riding the Rails with Old School Operating Room Lights

An old school operating room  light source the size of a pitcher's mound riding on extruded
steel rails. Look out here comes Casey Jones.
I just love operating room lights especially ones with unique features like this super-adjustable rail mounted beauty.  The rail mounting provides for the ultimate in adjustability. This baby can be moved up and down the full length of the table which is ideal in trauma cases that cover a wide territory.  This is what I would call a "fill' light" to complement the pedestal mounted smaller main light visible just below and to the left. Modern surgeons and scrub nurses probably look down their masks  on these old pole and rail  mounted lights, but they could be moved virtually anywhere to illuminate any operative site from any angle. Try that with your super duper overhead LED modern light.




A modern operating room light after being attacked by a
weighted speculum swinging surgeon who was frustrated
that it could not properly illuminate a vag hyst. Next time
try a pedestal mounted light.
One of the general surgery rooms that we used for trauma had that massive rail mounted overhead light. Trauma surgeons move around a lot and that rail mounted ball of sunshine can follow them up and down the table as they tend to wounds in various locations. Modern trauma surgeons frequently substitute with  those fiberoptic forehead mounted lights, but they really don't know what their missing.

Dr. Slambow even taught me some non surgical uses for operating room lighting systems. When
that call room phone rings at 3AM and you can't seem to clear out the cobwebs, just drag your keister out of bed and into an unused OR. Now the fun begins, switch on that overhead monstrous OR light and stare straight into it. Those brilliant photons will travel directly to the target organ (your snoozing brain) immediately jostling it awake. This works better than holding your head under the scrub sink faucet and blasting it with  cold water. I know because I have tried both and would opt for the light treatment every time. The bright light treatment even leaves your hair doo intact.

If it's Winter and your frozen fingers need thawed after that cold stroll to the hospital, just try holding them a couple of inches above an operating room light. A minute or two and that much needed dexterity returns. The scrub nurse has the warm water from the scrub sink and the circulator has the lights. Both methods are equally effective. It is not considered good form to use a patients body heat to warm your hands. Dr. Slambow told war stories about how he could not wait to warm his hands digging the shrapnel from some poor soul's belly. It used to give me the creeps thinking about war injuries  and made me grateful for warm water and lights. Dealing with traumatic gunshot wounds in Chicago was enough of a challenge for me and really made war time doctors and nurses seem like a very special breed.

Every important event requires a dramatic start; The Indy 500 has pace cars, track stars have guns and operating rooms have brilliant overhead lights. When that rail mounted illuminating source was fired up it was time to cease that useless chit-chat about that  funny smelling Roquefort cheese like substance you just removed from the patient's belly button during the prep scrub. Everyone knew when that big light glowed that it was all business.

I used to love that smooth hum of the ball bearings as the light moved up and down the rails over the table and then there was that reassuring clunk noise as that brilliant monster locked into place. For your enlightenment, the Oldfoolrn acoustic research laboratory has discovered a way to replicate the noise sound of one of these glorious OR lights being adjusted. Simply visit your friendly Home Depot Store and proceed directly to the appliance department. If a helpful employee approaches (not likely at my local store) just ask to see the KitchenAid dishwashers. Open the appliance and pull that top rack in and out a few times. The stainless steel interior of the dishwasher  acts as a sound board and amplifies that purring of the ball bearings. Now to replicate the OR light locking into place just slam the dishwasher door shut, You have just experienced the melodious sounds of a massive operating room light being adjusted and locked into place. If you want to experience the noise the rail mounted light makes when it slams into one of the bumpers at rails end be sure to stop in the hardware section and pick up a heavy rubber mallet. To simulate that bumper thump just drop the mallet  onto the floor with the business end toward the floor Now you whippersnapperrns really have something to tell your  mother about.

When you hear the surgeon proclaim, "That operation went just like a shopping trip to the Home Depot store," you know where his terminology came from.
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Monday, August 8, 2016

Secret Hiding Places to Avoid

I tried to think of a catchy title for this post, but had one of my frequent brain freezes. Oh well, clarity is better than smart alecky titles. I really meant to include this with my last post, but better late than never.

With the corporatization of health care, I suspect it is getting more challenging to find a suitable secret hiding place (SHP)  to renew your  nursing spirit. These contemporary hospitals view every square foot of space as a money maker and have little in the way of wide open spaces.

Old hospitals had many unused areas. One hospital I worked with had an entire floor of patient rooms that had been abandoned in the 1940's. It was a really cool place to visit. The thing I liked best were the ornate old wooden wheelchairs with the big wheel in front and the tiny pivoting wheels in back. Maybe they could not cure anybody, but the wheelchairs sure were classy.

Nurse's lounges sound like an appealing secret hiding place, but they are actually terrible places to hang out. If the dense cloud of cigarette smoke doesn't kill you, the endless jaw-jacking and mouth flapping will. Supervisors used to plan their personal attack strategies after their nurses' lounge visits. I once heard one of the meanest of them planning an assault, "Let's go after that nurse Jan on the ortho ward, she had the temerity to secure her cap with black bobby pins instead of the required white ones." Stay out of the nurses' lounge at all cost.

Meetings sound like they might be a nice break, especially in the Summer when the only air conditioned section  of the hospital is the administrative wing. As a na├»ve  young nurse, I volunteered to represent the operating room at the head nurses meeting. It was one of the worst mistakes of my nursing life. Imagine a cage at the zoo filled with angry howler monkeys at feeding time and you are locked in. That head nurses meeting was simply unbearable and I quickly deduced which head nurses would make good bar fighters; all of them. As a general rule of thumb for bedside nurses; AVOID  MEETINGS AT ALL COST.

Medication rooms are readily available on all patient care units and at first blink might appear to be suitable for a SHP. Med rooms are poor choices for secret hiding places for a couple of reasons. When they asked Willie Sutton, the notorious bank robber why he robbed banks he quickly replied, "because that's where the money is." When they asked a nurse with a drug problem why she was always in the med room, the answer was, "because that's where the drugs are."

Another issue that makes medication rooms a poor choice is because every nurse knows that med rooms are ground zero for releasing embarrassing intestinal gas. I really don't like crude language but one med room I worked in had a huge sign reading "The med room is not your personal fart box."  We all ignored the signage, but some foolish jokester posted an additional sign cautioning "NO OPEN FLAME"  It was advice well worth heeding. The best policy regarding med rooms was to prepare the medication, pass gas, and quickly depart while slamming the door shut to contain those nasty vapors.

Unoccupied patient rooms might look like a tempting SHP. The problem is that every hospital department from dietary to housekeeping environmental services knows the location of every vacant patient room. These hiding places with a tempting bed to stretch out on are not very secret. Every loafer in the hospital knows about these not so secret hiding places. This SHP quickly surrenders it's charm when you come to the realization that you might have to give a big burley janitor the boot before you can use the room for a SHP.

Although somewhat different than the SHP strategy the mental reframing of the hospital sometimes works if you really dislike your job and need to buy some time before finding something different. I really disliked working in psych and came to view the psych unit just as a place to rest between bike rides. It worked well in the Spring and Summer when I could bicycle to work and when Winter came I was back to the OR which was my first love.

Thanks for indulging in more of my foolish tales!

Friday, August 5, 2016

Bedside Nursing - Survival Tips

Bedside nurses are favorite targets for abuse from patients, doctors, and administrators. One of the local hospitals here in Pittsburgh is known by the initials AGH. The nurses there swear the initials stand for "always getting Hell." Nursing can also drive you nuts with profound questions like, "Why did 2 similar patient problems end so differently?" One patient recovers, the other experiences every known complication. Every bedside nurse devises strategies to deal with these soul sucking matters.

One of my favorite sanity maintenance tricks was to find secret hiding places or SHP. These were places to catch your breath, regroup, and refresh. Sometimes just a minute or two in a SHP worked wonders.

I mentioned this one before, but it was one of my favorites. No matter how stressful or lengthy the surgery one arena of profound peace is that under the OR table sanctuary. The drapes form a cozy tent in the middle of the forest feeling and even the harsh noise and lighting is muted. The most challenging trick is to find a reason for crawling under there. My favorite ploy was to tape down the foot pedal of the Bovie. Unfortunately, this only worked in the neuro room where a Mallis bipolar foot actuated cautery was used. The old " I'm going to have to investigate and make sure there are no kinks in the suction line running under the table," worked well in a general surgery room.

Sometimes when everyone is hypervigillantly involved in a tricky procedure the circulating nurse can simply duck under the table sans explanation. If someone does ask where the circulating nurse is simply reply "I was just checking for sponges under the table, You can't be too careful."  While under the table take a few deep breaths in time with the Airshields anesthesia ventilator and you wil soon feel renewed and refreashed. Those old Airshield ventilators used to make the most soothing inhale - exhale noise as they cycled.

Remember that peaceful  John Denver tune, I think it was called Annie's Song. Well that song used to run through my head while enjoying that under the table peace. John's lyrics were "You fill up my senses like a night in the forest." I used to hum his tune and think, "You fill up my senses like a spell under the table."  Ahhh, peace at last.  Now I'm refreshed and ready to face all the mayhem on the topside. "Four units of blood STAT? Coming right up Dr. Salmbow."

Scrub nurses had  a SHP that was in plain sight. The good old scrub sink. That soothing warm water cascading down and the rhythmic scrubbing was as good a relaxation technique you could find. Nurses always scrubbed long before the time pressured surgeons showed up so enjoy this not so SHP before each case and pick a sink with a view. Your nerves will thank you as soon as the surgeon starts complaining about how obese the patient is and why don't you have extra long needle holders.

The operating rooms were serviced by an old non automatic elevator that was manned by a whacky operator during the day and whoever was on call during off  hours.  There was always lots of drama in the elevator car with a hot trauma case or as Dr. Slambow used to refer to them as a "good" trauma.  I never could figure out what was "good" about trauma, but that tale will have to wait.

 I remember one patient that had a laryngeal injury from a car wreck on Lake Shore Drive. A trach had been performed in the ER, but air was leaking past the trach creating a nightmarish bubbling noise. It really jangled my nerves. As soon as the patient was in the OR, I noticed how peaceful the vacated elevator car was. All I had to do was run the car down 1/2 floor to prevent interruptions and indulge in that relaxing purr of the old brass ventilator fan. Ahh.. Serenity at last.

Linen closets were also a perfect SHP. The quiet was insured by the muffling action of stacks of sheets. The scent of clean sheets was also a nice contrast to that GI bleeder passing stool that would peal paint or make your nostrils burn. Linen closets were often centrally located on the wards so as to be easily accessible. I rate linen closets 4 stars as SHP.

What could be better than a field trip combined with a secret hiding place? After a shift in the OR fighting with surgeons it was always a pleasure to journey down to the basement with a load of trash to be incinerated. The incinerator room was impressive. It was  a concrete block building with a glowing hot guillotine type door. This glowing hot door was operated by stepping on a foot pedal.

The best part of this SHP was the incinerator operator named Ernie. He was a huge black man that was always in a jolly, uplifting mood. Ernie acted as though I was one of his best friends. He said encouraging words like, " You must really be a good nurse. You are working with the top surgeons at Chicago's best hospital." What a nice change of pace from Dr. Slambow complaining about how I cut ligature or that my Babcock was too short.

Ernie was always drenched in sweat and I could never figure out why he was always so euphoric. What a wonderful change of pace.

This post is getting too long and my arthritic fingers are acting up. It must be time to seek out my secret hiding place. Thanks to you for reading more of my foolishness.