Monday, September 18, 2017

Nurse Motivators - Paying a Debt

Intraoperative X-rays meant the gowned and gloved were huddled face-to-face behind that protective lead curtain off in a distant corner. Personal space dissipated more rapidly than Bovie smoke as we sought to guard our gamete giving gonads from gamma rays. (Whew... I was able to stop myself this time before that darned alliteration got out of control.)  I found myself  squeezed into an eyeball to neck position with Alana, the young student nurse I was mentoring. I could not curtail my stares to her neck and sub-mandible.

Now that was one impressive mass of scar tissue stretching from her clavicle and encircling her neck before terminating just below her jaw. A matrix of jagged spider web like connective tissue stacked as if one web was piled  on top of another. I started to ponder what her skin graft donor sites looked like. Despite her sunny demeanor she had been through some significant suffering. Every minor turn of her head against that scar tissue looked like an activity resembling a taffy pull. No wonder she rotated her entire upper torso when scanning the operative field.

As I briefly pondered the backstory here, our eyes made contact and I quickly diverted my gaze, wondering if I should apologize for my crude fixed gaze. Maybe I could come up with a foolish excuse blaming it on the X-ray and being forced to position myself eyeball to neck. I never was known as a very subtle person and it was probably time for some soul searching. Maybe I could make it up to her by teaching her how to load a sponge stick one-handed. She was one of the most gung ho students I worked with.

After the case in the OR lounge I was bumbling and stumbling through a summary of the case while complimenting Alana on doing so well. When I  started my uncomfortable mumbling regarding  the indication for the intraoperative X-ray she sensed my uneasiness and simply replied, " The burn injury happened on a camping trip near the Wisconsin Dells when I was 8 years old. The fuel tank on the cookstove leaked and sprayed me with burning fuel. The nurses on the burn unit at County saved my life and I always felt in debt to them for their skill and many kindnesses. I decided to be a nurse on the day I walked out of that hospital."

Student nurses had diverse motivations for studying nursing, but decades ago it's a fact that money was not one of them.  Alana's motivation was pure and simple, she was repaying a debt and it had nothing to do with remuneration.

How it became a debt for Alana is  not too hard to understand. She felt the nurses on the burn unit at County gave her life back and she owed that much to others. In a fictional account, Alana would return to the County Burn Unit upon graduation and care for patients she could  directly identify with.

The truth of the matter - Alana really like OR nursing and made that a career choice. Whenever I was weary or cynical with negativity barking at my heals, Alana's pure and simple motivation set me straight. As long as I was still vertical on the outside of the siderails, I owed a debt too. It brought tears to my foolish eyes when Alana related she decided to become an OR nurse after her very first scrub-in which happened to be with me.

As time passed, I tried to watch Alana in action every chance I had. Her hands were half the size of mine, but the way she spun a curved instrument in midair to pass it to either side of the table or police her Mayo stand was a mirror image of my technique. We even cut ligatures and wringed out lap sponges the exact same way. I simply loved watching her scrubbed and I never stared at her scar again.

Tuesday, September 12, 2017

Tonsillectomy According to Peter Ponsil

This cheery little musical interlude from the 1950's starts out with a chipper chorus of "Have you heard of Peter Ponsil?" A jaunty xylophone riff with breezy notes ascending and descending reinforces the carefree, whimsical mood.  Pete himself then chimes in with an upbeat tale of having his tonsils ripped out removed by the good ol' Dr. Sneeze&Blow. A pretty nurse cheerfully dressing the patient in a "Johnny Coat" also is described in Pete's upbeat, sing-song voice. It's an engaging little song that I hear repeating in the back of my head when I'm engaging some high minded activity like watching the Three Stooges. It was played for us in grade school as part of health class and it stuck with me all these years.

It's probably one of the pioneers in patient education, but the rosy picture it painted of tonsillectomy was bending the truth more than a triffle. Pediatric patients were told many half truths and outright fibs to gain their cooperation. Every old peds nurse knows that sneaky  trick of telling little Peter Ponsil that it's time to check his temperature and then administering a painful intramuscular injection. That old Vistaril pre-op shot used to burn like a branding iron  Misleading youngsters to gain their cooperation was just plain wrong, but I never had much of a say with older nurses.

Peter Ponsil conveniently neglected to mention some of the complications and post op pain discomfort associated with tonsillectomy. The procedure involved outlining the margins of the tonsil with a #15 blade, looping a snare around the offending tonsil and squeezing the mini beartrap of a snare closed to finish the -ectomy.

The most unusual complication I witnessed involved removing the uvula along with a tonsil. The surgeon told the family not to worry because the little thing hanging down in the back of the throat was unnecessary and just got in the way. He was half right - it did indeed get in the way of his snare.

Another youngster had to make an emergent trip back to the OR for a bronchoscopy because the eschar sloughed off a tonsillectomy wound and lodged in his  right main stem bronchus. I think our friend Peter Ponsil would be singing a different tune post-bronchoscopy.

Our pediatric unit was divided into 3 separate wards: pre-op, post-op, and isolation which was affectionately known as the diarrhea ward. The unsuspecting kids in pre-op frolicked about in their Johnny Coats consumed by blissful ignorance courtesy of Peter Ponsil and his ilk. Post-op was where the reality of the situation reared it's ugly head. Kids howling in pain suddenly aware of how deceitful their friend, Pete, had been. The more rambunctious were even restrained on papoose boards. Peter Ponsil was a spin doctor of the highest order.

There was a great deal of deception in old school healthcare and Peter Ponsil bunches it all up in his little song that represents an entourage of  hospital falsehoods. From nurses telling patients that a Bicillin injection would feel like a mosquito bite to surgeons obscuring an ominous finding, half truths and outright deception was everywhere. The pain word was beclouded by referring to it as discomfort. Of course this was all done for the patient's own good.

Thursday, September 7, 2017

Surgery Themed Establishments

DATELINE: Cairo, Egypt....Practicing surgeons have opened a surgery themed restaurant named D.Kebbda  in mid-July where they are festooned in surgical scrubs and prepare their sole offering, grilled beef liver sandwiches behind an enclosed glass kitchen. Kebda is a popular street food in Egypt, but a vector of food poisoning if not  prepared with caution. "We  tried to take our career values and apply them to another field," said Mostafa Baisourny one of the owners. "There is no contradiction here, we are still practicing doctors."

This news item got me to thinking about other possibilities for other surgery themed businesses such as a surgical amusement park. One of the attractions would be to take a spin, so to speak, on the orthopedic traction table. Adduct an arm, abduct a leg and add some acute hip flexion and pretty soon you are twisted up like a pretzel. If you want to spend some time in that unique position just ask the friendly ride attendant to apply the plaster. What fun!

A carnivalesque side show might include an amazing sword swallowing act complete with an old school rigid metal bronchoscope. Those things were brutal and don't forget to duck the flying bits of mucous.

How about a combination buffet and Bariatric surgical center. Everyone enjoys one last big fling before their problem is addressed. Welcome to Stuff N' Cut where after enjoying a 9,000 calory last meal, bypass surgery is performed.  Don't fret we wait  out the prescribed time interval to avert aspiration.

I better cease this foolishness before it gets out of hand. Thanks so much for indulging in my outright preposterousness and a special shout out to you high minded academic types. My readership surges when school is in session.

Saturday, September 2, 2017

PAIN (Purposeful Affliction Isn't Nice)

Nursing presents the practitioner with an assortment of mind boggling difficult and unpleasant (to say the least) circumstances. Putrid and pungent odors, horrific sights of blood and gore along with unimaginable suffering. Every nurse has an Achille's Heal of a hospital situation that brings forth light headedness, tears and a cold sweat.  For some it was blood and or trauma, Bovie smoke got to others, and odors elicited a vaso vagal response in many.

My weak spot was seeing patients in pain, all pain was blood curdling to my soul, but the inadvertently inflicted avoidable pain was what really what got caught in my craw. Needless suffering was the  stuff of real nightmares for me. So in a lame attempt to unburden my tortured soul here is a laundry list of completely avoidable painful events I witnessed over the years. When I have trouble coming up with a coherent post on a single subject, laundry lists are my best friend.

This one really rankles my hackles and I always tried to put a halt to it when I was a circulating nurse in the OR. Eager beaver, out to impress, surgical residents sometimes jump the gun with inserting Foleys or starting lines before the patient is anesthetized. "Whoa not so fast, Dr. Speedy, how would you like that done while you are awake?" usually put a halt to the proceedings.  Keeping Foley trays and other pre anesthesia induction paraphernalia out of sight until the patient was asleep was another effective tactic.

Last minute pre-op exams involving probing wounds or orifices could be stoped dead in their tracks by a good hard smack to the back of the hand with a sponge ring forceps. I never had the temerity to do this, but Alice my beloved supervisor was an equal opportunity sponge stick smacker. Anyone committing a wrongful act was fair game for aching knuckles. A crude but very effective deterrent that I have personally experienced. OUCH!

Hair follicles share the same neighborhood as sensory nerve endings so extricating hair really does smart, a fact some girls know all too well. My usual place to hang out in nursing school was in the lobby right next to the elevator. Occasionally nursing school stressors promoted disagreements among students which then led to hair-pulling donnybrooks. Standard procedure involved forcing the combatants into the elevator and hitting the down button for student nurse Fool to break up by squeezing the hand of the aggressor. I never knew what to expect when that elevator door opened but screams emanating from the elevator shaft was never a good sign.  Somehow I was able to peacefully resolve the altercations, but the clumps of hair on the elevator floor always  turned my stomach.

Every nurse is well versed in the inexcusable pain inflicted by aggressive adhesive tape removal. Kind hearted nurses knew that moistening the adhesive/skin interface zone with acetone helped minimize the hair pulling. Whether to remove adhesive tape slowly or rapidly was a hotly debated topic  in nursing school. I always thought that giving the patient a choice was best and if they expressed a desire self removal, let them have a go at it. At least I was not the culprit inflicting pain.

Here is an unusual and little known unjustifiable hair pulling event that can occur in a very sensitive anatomical site. Pelvic exams place the patient in a vulnerable position and novice physicians have been known to entangle and twist pubic hairs out with those old metal speculums adjusted with set screws. The hair gets caught in the inclined plane of the set screw and subsequent  adjustment yanks pubic hair out lickety-split. One of the reasons nurses were taught to always carry scissors was to cut free entangled hair.

Of all the surgical instruments, it's not those ghastly saws or chisels on  top 10 lists that elicit revulsion in any sentient being - my vote goes to misused towel clips.. These innocent looking devices have two very sharp points that can be engaged by opening and closing the clip like a scissors. They were designed to securely attach towels to each other while draping. The practice of surgeons affixing towels directly  to patients skin  was history, but anesthetists found a use for towel clips that was unsavory at best.
Towel clips are for towels - not patients skin

The tips of the towel clip were engaged  in the patient's skin at various levels to gauge the level of spinal anesthesia. When the patient screamed it was obviously  the limit of the spinal's effectiveness.   There were few of these towel clip wielding anesthetists, but just one is far too many.

Although never witnessed, I have heard horror stories of old time OB practitioners engaging the points of towel clips in a patient's hip to test their saddle block causing new mothers to wonder what demented doctor depredated derieres -  developing devious deep puncture wounds (please excuse the alliteration, it's one of my very bad habits.)

Surgeons from my generation simply loved silk sutures and some even proudly bragged about being a "silk man." Surgical knots never slipped on silk sutures and they never assumed a coiled or unwieldy shape. The nature of these suture's surface was akin to a lattice-like structure owing to the fact they were braided from many fine silk strands. As tissue healed, it became enmeshed in these tiny lattice spaces. Removing silk skin sutures was like trying to pull a bone from a dog's mouth - lots of resistance and growling.

Surgical staple clips put an end to the misery of silk  suture removal but many older surgeons wanted to remain loyal to the history of surgery and refused to accept them. Previous surgeries could be easily identified by the archaeologic artifacts  left behind by black silk sutures. They were highly visible and always a sure sign that man had been in this wound before.

I'm getting off track so it must be time to wrap this post up but minimizing discomfort or aiding a patient in pain is something a nurse can do to minimize hopelessness and promote healing and recovery. A trauma patient will never notice how carefully a scrub nurse cuts ligatures but will always remember if they were patient and caring when transferring them from a Gurney to the table.

Friday, August 25, 2017

Skeptical Scalpel (on my blog roll) has an interesting post regarding the end result of connecting an oxygen tube to a Foley catheter. Even Oldfoolrns know there is very minimal gas exchange across the bladder wall.

Wednesday, August 23, 2017

Bridles Are for Horses - Not Patients

This post is about nursing interventions with nasogastric tubes from  many decades ago and filtered through my aging nervous system so don't count on relevance. It's foolishness of the highest order for entertainment purposes only. With the advent of PEG tubes and a more enlightened attitude, hopefully bridlers are extinct.

Nasogastric tubes (NG tubes) were handy little devices. They were used post operatively and connected to low intermittent suction to decompress and keep the operative area clear after gastric surgery. Another use involved feeding patients that were unwilling or unable to take nourishment and this is where the problems showed up.

NG tubes were dangerous devices in the hands of an inexperienced practitioner and complications related to wrongful placement were sometimes devastating. The most common misplacement was in the lung via the right main stem bronchus  (It's more perpendicular and bigger than the left bronchus) We always added a dash of methylene blue dye to feedings  and if your patient coughed up blue mucous, it was a sign of trouble. The pleural regions are not known for their ability to assimilate nutrients and likewise there is little gas exchange across the stomach wall. It's best to respect these barriers and that's the understatement of all time!

Skull fractures involving the cribiform plate invited the disaster of  the NG tube winding up in the brain as shown on the right.  Old time physicians hated to come clean with mistakes and I can just hear an old blow hard doc from the1960s coming up with a clever explanation that the NG tube in the  X-ray  could be used as a ventricular shunt, "after all it did course straight up the ventricle. Now we don't have to worry about complications like  hydrocephalus."

Blogger, Skeptical Scalpel has a fascinating post about an internal jugular vein cannulation by a misplaced NG tube. I think the person that accomplished this amazing feat  blunder would have to fess up to the mistake. Who in the world ever heard of  gaining vascular access via the nose? That phony excuse is just plain unbelievable.

Nurses commonly inserted NG feeding tubes and were responsible for keeping them in place. Post op patients were usually very cooperative as a result of vitamin "D" (Demerol) and did not tamper with their NG tubes. Placement of these NG tubes was also a short term affair of just a couple of days. It's much easier for a patient  to put up with a short term nuisance than a long term festering aggravation.

Having an NG in place for a couple of weeks is a miserable experience that I have had personal experience with. Occluding a nostril for the tube results in forced mouth breathing that makes your throat dry as the Sahara dessert. Dried mucous referred to as snot in less formal arenas dries up around the tube and picking it off results in red sore nares.

Tubes like Foleys are out of the patient's view. NG tubes of yesteryear were a bright red in color and were like the matador's red cape to a bull - always annoying and always in sight. It's no surprise that patient's liked to remove their NG tubes. I always figured these poor  old souls were trying to communicate something to us - they did not want tube feedings and their feelings should be respected. Leave the NG tube out and place a glass of water within reach.

Old nurses from the greatest generation had other ideas and I learned never to argue with these gallant geezers. All too often their interventions reflected their  rigid, authoritarian personality and not the reality of the situation. They did not tolerate fools like me and their answer to patient self removal of NG tubes was a brutal but effective trick called NG tube bridling. Somehow these determined oldster nurses  always prevailed when imposing their idea of therapeutic intervention.

Bridling involved inserting the NG tube via the right nostril until the tip of it was visible just below the uvuala (that funny thing hanging down between your tonsils.) I've been criticized for not writing clearly for non-medical folks, so that crude explanation is one of my lame attempts to be more broad based.

The old battle axe of a nurse then grabbed the NG tube from the back of the throat with a Magill forceps and gracefully pulled  yanked  the tube out the mouth. Some of these old Marquise de Sade nurses had tiny hands which meant they could skip the forceps and yank that bad boy NG  tube out with their fingers. Once pulled all the way out via the mouth the NG tube was looped around and reinserted in the left nostril into the stomach.

The end result was the NG tube anatomically anchored because the loop went completely around the ethmoid bone and maxillary sinuses before it's descent back to the stomach. Pulling on the end of  the NG tube resulted in excruciating pain which was an effective deterrent to removal. From my perspective, bridling was the stuff of nightmares with the poor patient yanking his nose and maxillary sinuses loose along with the offending NG tube.

I always tried to empathize with the patient. Dying patients just wanted peace and quiet on their lonely journey and before the hospice concept arrived this was rare. I always found a way out of the bridling NG tube business and only wish I could have had more influence on bridlers.

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.