Monday, January 16, 2017

When Air Becomes Breath - A Historical Perspective

"After 8 more arm raise cycles, It's time to check her ABGs"
A 1910's critical care nurse has just found her patient apneic and beginning to turn that dreaded inky, cyanotic color. All is not lost. It's time to initiate artificial respiration. Of course before all the heroic measures start, it's always prudent to check the upper airway for an obstruction. Every old nurse knows the time honored mouth opening trick of placing a thumb on the mandibular arch and the index finger positioned above on the maxilla and then rapidly crisscrossing her fingers. The other hand  finger is free to probe the oropharynx for obstructions. If you encounter a hot dog segment, Brazil nut, or hunk of steak all you have to do is yank it out and  hope for the return of spontaneous breathing.

If the chest has ceased that comforting sight of rising and falling, it's time for artificial respiration. Pull your supine patient to the very  head of the cart, table, or bed and get a gorilla grip on her forearms. To initiate expiration, pull her arms down and adducted into her chest with her fists at the base of her lungs. Now for the fun part. Rapidly pull her arms overhead and below her body for inspiration. One caveat: just as modern CPR can crack ribs, this old school method can wreak havoc with elbows dislocations. Just how do you explain that to the family? This complication is also not favorable to Press Ganey Satisfaction Surveys so be careful lest those pesky patient relationship builder consultants  appear on the scene. (As an Oldfoolrn, I give thanks everyday that I never had to deal with that!) Hats off to you bright, whippersnapperns that are forced to submit to this nonsense.

There was one other old school artificial respiration trick  procedure done with the patient prone. The nurse jumps up into the bed or litter and straddles the patient. The patients arms are flexed at the elbows with forearms at a right angle to the body. For expiration the nurse pushes down and forward at the base of the lungs and inspiration involves grabbing the flexed elbows and pulling them toward and into the head. This was the popular Red Cross method taught to 1960's lifeguards. These techniques probably moved just enough air to clear the dead space in the pharynx, larynx, and trachea.

Unfortunately these techniques ignored one of the most basic anatomic characteristics of the chest which except for some intercostal movement during respiration is a very rigid, unyielding  cage like structure. When the diaphragm moves down the volume of the chest increases, lowering the intrathoracic pressure causing inspiration. A very clear example of what happens with a non rigid chest occurs with traumatic injury breaking ribs causing a flail chest. Not a pretty picture when the chest wall is mobile and it's really time to head to the OR.

An Engstorm in action. Who needs piped in
Oxygen with those handy dandy "J' cylinders?
Moving them around was like wrestling a
Sumo Wrestler.

A lifesaving (oh, how I hate that term) innovation for critically ill patients was the introduction of  volume respirators such as the mid 1960's Engstroms. These precision machines from the Karolinska Institute in Sweeden cost $8,000 USD in 1960 and had the capability of expanding the lungs at the alveolar level. This was the birth of PEEP (positive end expiratory pressure.)

These early ventilators were impressive looking machines. The control panel looked like something from an airplane cockpit and was ingeniously tilted to prevent nurses from stacking anything on top of it. I can tell you from personal experience this was no place to temporarily set down that Albumin bottle.Cleaning up the sticky substance laced with glass shards is a lesson that sticks with you.

As much as Oldfoolrns love old, familiar analog medical machines, they could have some truly vexing and potentially fatal problems. Being a 100% mechanical device the Engstrom had zilch in the way of electronic alarms. A nurse could be lulled into a false sense of security by that reassuring whoosh/whoosh as the macines bellows appeared to inflate the patient's lungs. Without a continuous monitoring of pressure in the breathing circuit, a patient's trach tube could disconnect from the ventilator tubing without an audible warning. Nurses really had to be right at the bedside watching for the rise and fall of the patient's chest.

I cannot resist the segue to a foolish tale from yesteryear. Ventilator supported patients in the times before oximeters and capnography required frequent arterial blood sampling (ABGs)  to monitor respiratory status. If the patient had an arterial line in place this was no problem. Without an arterial line nurses had to tap a radial or femoral artery for a sample inflicting pain and trauma. We hated doing these on a frequent basis and if the critical care fellow ordered ABG's too often we threatened to put a plastic trash can liner over his head and draw his blood gases in 30 minutes. The young physicians were conditioned so that whenever a nurse began removing a  plastic trash can liner from the waste basket, it was time to rethink the blood gas order.

Tuesday, January 10, 2017

The Disappearance of Darkness

Before PACUs there were recovery rooms and yes they were nocturnally
illuminated by 15 watt nightlights and nurses penlights

Over countless millennia,  human behavior has been influenced by the 24 hour cycle of sunlight and darkness. Evolution has imprinted our nervous systems with the notion that daylight is for vigilance and night is for peaceful rest. Fooling around with nature's rhythms produces an unpleasant emotional response. Just ask any night nurse how they feel leaving the hospital when all the daylight personnel file in all bright eyed and bushy tailed. I used to feel nauseated after working nights and the bright sun provoked a throbbing headache. Hospital patients don't feel well to begin with and keeping them up all night with bright lights adds fuel to their emotional distress.

Modern hospitals are brilliantly illuminated inside and out at night. The brightness of the helipad can be seen from miles away. Florescent lights bombard halls and patient rooms with artificial daylight 24/7. This photon bombardment is definitely NOT patient centered.

One local hospital here in Pittsburgh actually had signage (don't get me started on hospital signs) offering eye masks to patients. Just ask your local friendly nurse for one if the bright lights prevent you from sleeping. Maybe they should be also be in the ear plug dispensing business. There is certainly minimal resources contributed to promoting restful sleep. I guess this is one more attempt to force patient participation in their care. "No.. we cannot dim the lights at night so here is an eye mask to cover your face with." said the caring nurse.

From personal experience, I can tell you hospitals do not promote restful nights for their patients. I don't know which was worse, the bright overhead lights or the nurses clip clopping around in their noise producing clog footwear. I believe they are called Danskos, but a more accurate name would be Decibels for all the racket they produce. Old nurses valued quiet footwear. There  was nothing like a well broken in pair of Clinic nursing shoes for stealthy moving around at night.

Old school hospitals were serious about patients getting their rest. Sleep was actually recognized as an important element for the patient's recovery. At night the hall lights were dimmed by a switch at the nurse's station so they were barely on. All areas occupied by patients contained one tiny night light that was louvered and close to the floor. Nursing personnel all carried flashlights or tiny penlights and these were only switched on at the bedside when providing care. There was a cache of tiny 15 watt bulbs at every nursing station. Darkness was an important commodity.

I have been attempting to write about something other than operating room tales, but it's difficult to shift gears at my age. So here I go again with a story about lights out in the OR.

There was an unusual, but very good vascular neurosurgeon that I occasionally worked with. After clipping and removing a potentially life threatening aneurysm from cerebral circulation his routine orders were for the circulator to turn off all overhead lighting for a full 2 minutes. He asked the nurse to carefully time the lights out interval, but by instinct, he could tell exactly when 2 minutes were up.

His explanation for this practice was that the brain was housed in the light tight cranium. He wanted assurance that there would be no occult bleeding in the dark intracranial cavity after he closed everything up. If anyone questioned this practice he always said in a haughty, judgmental voice that he was doing this based on empirical evidence. I guess his point was that this trick seemed to work, but there was no science to back it up.

I always thought that after having a brief lights out interval, the surgeon's eyesight was more acute and sensitive to any bleeding after the lights were fired back on. Anyhow, his trick seemed to work. Nurses see some whacky things!

Thanks for reading my foolishness.

Sunday, January 1, 2017

Not on My Back Table!!

Don't even think about lobbing that ovarian cystic teratoma on my back table.

Old school scrub nurses work from 2 horizontal surfaces, a Mayo stand which is positioned just South of the surgical site and a back table that sits at the patient's feet at a right angle to the patient. Every scrub nurse likes to keep an organized Mayo stand with a minimal amount of instruments. When it's time to close all I kept on the Mayo stand was a pick-ups, needle holder, suture  and straight Mayo scissors. This can lead to the back table assuming the role of a dumping ground which got me  angry as a surgeon with a non-functioning suction. Here are some things to keep away from my back table or I will pinch your keister  with a sponge ring forceps. I am experienced with doing this without breaking sterile technique, so beware! I know from personal experience that sponge ring forceps can leave one heck of  a mark and the pain can give you something to really think about.

I don't like basins of water or solutions sloshing around on my back table. This is an OR, not a trout farm. Whatever happened to ring stands for basins of water? When I see photos of contemporary ORs the ring stands have disappeared. Where does all that unused OR  equipment wind up? Probably in the same place as sponge racks and table-side light stands. Bring back the ring stands and get that aquarium sized basin of water of your back table. It's a hazard every time you move or bump the back table. A wet back table is a contaminated back table.

Another thing I hate on my back table is oversize specimens. Trying to land a huge pandus or teratoma on my back table is like landing a 747 jumbo jetliner on an aircraft carrier. Don't do it. Big hunks or globs of tissue should be handed off to the circulator. If the circulator is busy and the surgeon insists on lobbing that Big Tuna of a specimen your way, just drop it in the kick basin. The crash/splat noise it makes when it hits the target will remind everyone not to pull this trick again. Think of that sound as resembling a church bell ringing in a slaughter house as that big side of beef is placed on a cutting table. It's a  very memorable sound like a newborn's first cry or the rales and rhonchi of a patient on his death bed; an acoustic experience that really sticks with you.

Kudos to the person who invented sterile operating room light handles. Surgeons are like patients in that the more they can meet their own needs, the better for all parties concerned. Savvy scrub nurses do not keep sterile light handle adjusters on their back table. Before you set out an instrument, take a couple of seconds to thread those sterile light handles in place. Get them off the back table.  When a surgeon bellows to the circulator for a lighting adjustment you can curtly reply, "The adjustment handles for the lights are sterile, monkey around with them at your leisure." Multiple adjustments of lighting on the same surgical site can be indicative of a poor prognosis. I wrote a post about unusual signs of a bad prognosis, I think it could be located by typing "Prognosis" in the search box. In the new year, I promise to figure out links!

Anything that has the potential to dangle over the edge of the back table does not belong there. Only the very top of any table is considered sterile. Get rid of that suction tubing and potential dangler early in the game to be on the safe side.

Here is something that I have had some painful encounters with. Loaded needle holders on the back table are a real danger to hurried hands. They will stab you right through that glove.  Why do bright, young whippersnapperns wear gloves when handling needles? Gloves provide no defense when it comes to needle sticks and dull tactile sensations. It is hard for oldsters like myself to make sense of healthcare today.

Enough of my foolishness. Thanks so much for indulging in my silliness and I hope the New Year brings you peace and fulfillment in all that you do.

Wednesday, December 28, 2016

Venereal Disease Patient Enlightenment (Old School)

Old, hardened, and down right mean nurses were enough to stimulate the worst in terms of nightmares. Bad dreams that could bestir me from my deepest sleep were close at hand when thoughts of these brutal bats in white arose. They were as tough as they come and capable of smoking an unfiltered cigarette  in two deep puffs. It was an amazing experience watching a cigarette burn down 3/4 inch with a single puff. Their perpetually brown, nicotine  stained fingers always looked like they were involved in a messy code brown. At least one can hope that it was nicotine stains.

 Years of witnessing adverse and unfair outcomes in their patients while working for poverty wages was a catalyst for the formation of a bitter, righteous, and judgmental personality profile. If these tough, white starched gestapo nurses suspected a patient's behavior had a causative component to their health predicament; look out because someone is about to be taught a painful lesson by these old "That'll learn ya" nurses.

The hospital where I trained was a designated facility to treat referrals from the public school system for a variety of infectous diseases. Students that suffered from run of the mill  bacterial infections received very good care unless they had the misfortune to be diagnosed with either syphilis or gonorrhea.  These ailments  were termed venereal diseases before the current terminology of sexually transmitted diseases came about. Venereal disease was loaded with stigma and negative connotations which made it a perfect target for corrective actions at the hands of these painful practitioners with punishment on their agenda.

These old nurses had witnessed the gruesome complications of secondary syphilis with tertiary symptoms such as profound dementia from nervous system involvement.  Infected  students needed to be taught a lesson for their own good. The accepted  treatment for these venereal dieases consisted of a series of painful Bicillin injections administered over a two week course and these old nurses used to get involved in heated arguments over who had the pleasure of inflicting this painful punishment treatment. A stroll through the outpatient waiting room often revealed a trembling youngster curled up in a chair while in the background a couple of nurses would be heard claiming their next victim patient.
Bicillin given with care, is a painful experience. The medication is a thick gooey substance with the consistency of toothpaste that burns like fire when forced into a muscle. These old nurses had ways of making the injection even more memorable painful. As students, we passed through the outpatient area frequently. A common sight was a tearful youngster hobbling from one of  the treatment rooms while vigorously rubbing a wounded rump. The elderly, smirking nurse soon followed twirling the spent glimmering  Bicillin  Tubex  injector like a proud drum major with a baton. We always wondered what was going on here.

On our senior rotation some of these punishment minded ancient  nurses let us in on their  pain inducing trade secrets that were truly bone  chilling. In nursing school we learned tehniques to minimize injection pain, but these old bruisers had quite the opposite in mind for their hapless charges.

The sadistic, aged nurses  said one of the best techniques to enhance injection pain was to inject the viscous Bicillin into a tense muscle by having the victim patient bear weight on the hip being injected. Exposure to cold with open windows in winter enhanced shivering which induced even  more muscle tension. Cold was also an effective agent to make the Bicillin even more thick and irritating.  According to these old nurses, a tense shivering buttock was ripe for injecting with thick ice cold Bicillin. These punishment minded nurses also claimed to have Herculean hand strength that enabled them to inject the thick Bicillin with enough speed to actually tear the   gluteus  muscle. "If you can hear above the crying and screaming, you can actually listen to the muscle tearing," one of them related. Ouch, I envisioned the thick Bicillin acting like the business end of a hemostat being opened while buried in the muscle. That must really smart.
Luckily for the infected students, the Bicillin was made available in prefilled cartridges with a fixed, non-interchangeable 18 guage needle or I am certain these old nurses would be looking for a 16 gauge monster needle. Dulling of the needle did increase pain during skin penetration and this was done by deftly inserting it through the tough rubber on a multi-dose vial a couple of times prior to injection. These punishment minded nurses thought of everything. "If you can see the skin around the needle insertion site retract 1/2 an inch in or so before penetration, you have achieved an appropriate level of needle dullness. This should elicit an audible response from the patient," was the nurses explanation of the procedure.
The ubiquitous isopropyl alcohol foil wrapped pledgets so common today were not available for skin prep  40 years ago. These old nurses were fond of cotton balls soaked to the point of dripping for their prep. Wet alcohol that remains on the skin prior to the injection can be tracked deep into the tissue with the  injection which really stings. Most nurses carefully dry the skin before injecting, but not these punishers that dreamed of alcohol soaked and  quivering buttocks awaiting their painful ministrations.
Nurses were taught to carefully rotate injection sites and make a note of this in the medical record. Punishment nurses followed the same principle as WWII pilots that "bombed on the leader." They carefully administered subsequent injections in the exact same tender site as the previous "leader"  nurse. Recipients of this type of treatment often carried lumps the size of golf balls in their hips from the painful repeated injections.

As a youngster, old nurses could really creep me out. I could see where their mean spiritedness came from but doubt that it benefitted anyone. I guess the most kind way to describe their actions would be to say they were misguided. I sometimes wondered if these aging nurses faced consequences for their self -induced lung cancer from heavy smoking. What's good for the goose is good for the gander.

 I'm thinking about a future post explaining overdose  enlightenment protocols that these punishment minded nurses used.

Wednesday, December 21, 2016

Left to their own devices, just about everything deteriorates into a ridiculous hodge-podge of disorder. Entropy truly rules the world. Scrub nurses love order and nothing bothered me more than a cluttered Mayo stand. I am trying to bring some order to this blog by using labels to establish some crude organization to this blog. I really do appreciate indulgers of my foolishness and appreciate your readership.

Happy Holidays, Happy Hanukkah, Merry Christmas, and may your  sponge counts always be correct as your Babcocks shine brightly in the overhead light!

Friday, December 16, 2016

"Twas the Night Before Surgery"

'Twas the night before surgery when all through the OR
Not a Bovie was smoking, not even a bipolar
The drapes were assembled on the back table with care
In  hopes that Dr. Slambow would soon be there

The patient was all narcotized and snug in his bed
While floor nurses insured that nothing was fed
And his roommate in a cast and him on a snooze
They just settled down like a drunk on cheap booze

When out on the expressway arouse such a crash
Bodies thrown from vehicles became  victims of a bash
Away, away, to the hospital they were hustled in a flash
Patients off to St. Profit's to be stripped of their cash

 Half their blood volume lie on the new fallen snow
Not a great thing for hemodynamic flow
When, what to my wondering eyes should appear,
But a  young paramedic with an 18 gauge  spear

With a little old tourniquet so lively and quick
I new in a moment he  would feel a big 'ol stick
More rapid than a sump pump in a flood
They pushed in more of that red stuff called blood

Now volume expanders! now lactated ringers!
Pump that fluid in 'til we see color in his fingers
Raise that bag to the top of the pole
Pump away..Pump away.. til his vitals roll

And then in a twinkling straight up to the OR
The elevator cliked and claced from floor to floor
Wheel him right up next to the table
Call in the nurses and transfer if able

He was covered in blood from his feet to his face
Better lay out a morgue pack just in case
A sucking chest wound was making such a sound
If we don't tube him really quick he'll be moribund

Tell that elective patient all narcotized in bed
His gall bladder has to wait, we have a trauma instead
The scrub nurse and surgeon are fatigued and half dead
Better wait on that cholecystectomy till the nurse gets a bed

Tuesday, December 13, 2016


Old time surgeons were at the top of the hospital food chain, the captain of the ship, and sometimes misguided blowhards with overstuffed egos. Overconfidence combined with a condescending, paternalistic attitude toward patients  added up to surgisplanations which minimized operative risks and the true extent of surgery, overstated benefits and touted the operators surgical superiority. If anyone questioned these surgisplainers their response was "I just explain procedures in the language a patient can understand."  They were elderly and often wore expensive wool suits that smelled of moth balls.  I think these are the surgeons Dr. Slambow had in mind when he pontificated that, "The only surgery that really benefits the patient is repair of traumatic injury."

A semi-demented old coot of a surgisplaining  gynecologist always explained a D&C with the same practiced, scripted, delivery, "I'm just going to do a little bit of Dusting and Cleaning in there." This was delivered in a demeaning and  condescending tone of voice to rightfully frightened ladies from an obese, imposing man. He was a jerk of the highest order and if he had been accurate in describing his operative method it would have sounded like this: "I'm going to visualize your cervix by inserting a weighted speculum that tips the scales about as much as my overhanging pandus, then stabilize your cervix by piercing it with two converging sharp points of a tenaculum. While I yank put traction on the tenaculum, I will ream out dilate your cervix with stainless steel cylindrical devices called dilators that progress in diameter to the size of my stogie  so I can scrape the inside of your uterus with a curette. I learned the finer points of curettage by mimicking my cat pawing like a sabertooth tiger at his scratching post. You don't have anything to worry about.

A foreign body  be it a stray sponge or rogue instrument found in a patient after surgery meant that the scrub nurse and circulator on the case would be immediately fired and the surgeon had to come up with some surgisplanin regarding the need for re-operation. This situation presented itself when I was working in neuro ICU with a patient that had undergone a spinal fusion.   I was so tempted to make a copy of the X-ray report and anonymously mail it to the patient, but never did. If I had it to do over, I think that I would have made that copy. The neurosurgeon's surgispanation; "the X-ray showed us something that was not visible during surgery (yeah..because you did not see it and the nurse could not count to 10) that we need to go back in and correct. When I was a scrub nurse, nothing made me feel worse than re opening a partially healed surgical wound. Incising healing tissue just goes aginst the grain. Things like that are just not supposed to happen. The patient had the sponge removed and did just fine post-op. She walked out of the hospital none the wiser of the errant sponge that was left behind during the initial surgery.

There was an old geezer of a neurosurgeon well past his prime  that always had a clever surgisplanation for his patients. His description of a crainiotomy went like this, "We are going to make a little trap door in your head so we can fix you up as good as new." That's it. Now it's time to sign the consent.

If there was a prize for the most understated surgisplanation this one would win the grand prize. Here is what the truth of the matter amounts to. We are going to shave your head bald and after anesthesia induction you will be  positioned in a very dangerous upright  sitting position where it is possible for ambient air to enter a major vessel and cause serious disability. Then I'm going to cut through your scalp which will bleed like the dickens and you better hope the scrub nurse can load Raney clips lickety split. When we get to that nasty AVM, I will try to remove it from vascular circulation before it bleeds too badly. Then we will close and finally, I will drill holes in your bone flap to wire it back in position, Most patients that have there brain handled like this have serious personality changes but don't worry you have good health insurance.

Thankfully these surgisplainers are extinct. The last time I had a procedure, the surgeon carefully explained all possible complications. It was really hard for anyone to trust old time surgisplainers whether they were patient or nurse. I know they used to creep me out.