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.
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Thursday, August 17, 2017

If President Trump Tweeted About Disease

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

Wednesday, August 9, 2017

Montefiore Hospital Pittsburgh - A Unique Design

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

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

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

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

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

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

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

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

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

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




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

Friday, August 4, 2017

Emerging Nurse Leaders - What in Blue Blazes?

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

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

Friday, July 28, 2017

The Souttar Craniotome

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

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

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

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

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

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

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

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

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

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

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

Thursday, July 27, 2017

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

Friday, July 21, 2017

A Vintage Operating Room - Circa 1930

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

So here it is; a guided tour of a 1930's operating room. Prominent in this overhead view is the unique shadowless lighting system. A very rare, explosion proof resistant black Operay. That black Sputnik-like orb contains the light sources and lenses to focus the beams of light on the reflecting mirrors arranged around the periphery. The goal: shadowless lighting.  Here is the link to an old Operay post.
tp://oldfoolrn.blogspot.com/2016/07/the-operay-1930s-operating-room-light.html

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

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

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

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

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

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

Alice was an OCD nut and insisted her charges prepare for and conduct cases in a  Kabuki Theater like style. Everything had to be planned for and conducted exactly according to her rigid authoritarian rules which was fine until something unexpected happened. There was only one way to open an instrument set or thread a suture needle in old school ORs. The scrub nurse in the photo has her left hand under the Mayo stand. A  definite no..no according to Alice and grounds for getting a knuckle slap with a sponge ring forceps. That'll learn ya to keep both hands above the Mayo stand.

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

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

Thursday, July 13, 2017

Paper Medical Records

A paper medical records trifecta; med cards, kardex
and paper chart. Med cards and anything recorded in
Kardex was tossed after their purpose was served.




The importance of the medical record cannot be overstated. Communication of patient information in a usable format has been a priority for many eons. Where else can you find a blow by blow account of surgical treatment, response to drugs, and basic diagnostic information. Whippersnapperrns complain endlessly about electronic medical records and older practicing nurses often  dream of a return to paper records.
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Paper records had a certain charm and ease of use, but there were problems with divergent formats, inaccurate data, and unauthorized access, which in some ways, mimics problems with electronic records. At least with paper records nurses were not distracted by a wheeled monster of a computer that followed them everywhere. I don't think there is anything more frustrating than communicating with a person distracted by a  computer screen.

 Most private and charity hospitals were writing progress notes and physicians orders on standard 8 1/2 X 11 size paper. Federal agencies such as the VA medical system had a very unique paper size which was 8 X 10 1/2. This was another example of that infamous VA tag line, "The right way, the wrong way, and the VA way." President Reagan established a government Committee for the Simplification of paper sizes in 1980 and the VA switched to the 8 1/2 X 11 standard.

 When a VA patient was admitted to a private hospital the combination paper sizes were difficult to stack (VA patients always had voluminous records) and the end result was a leaning tower of medical records. How acute the lean angle became was dependent on the volume of the record and the sequence of the odd sized paper. Old nurses always characterized the medical record lean orientation as port or starboard. For some obscure reason port side canted records usually foretold a very difficult patient care situation.

Everyone approached patients with leaning  paper medical records with due caution. These were complex, time consuming patients. One nurse summed it up nicely with this little ditty. "Those patients have every case but a suitcase." It was amusing until one of these patient care conundrums actually brought their suitcase with them to the hospital. It could have been much more morbid. When a patient was not expected to recover one family sent along a three piece suit. "Make sure one of the nurses gives that suit to the undertaker when he comes for Gramps," was the instruction.

Today nurses must be concerned with hacks and computer glitches upsetting the delicate order and sequence of recorded medical data. Paper was not immune from unpredictable  disorder. Old time hospitals were never air conditioned except perhaps for the director's office. This meant that nursing stations were equipped with gigantic fans capable of moving as much air as a Piper Navajo on take off roll. That prop wash at the nursing stations was capable of sending any and all stacks of paper flying off into the wild blue yonder.

I vividly recall one sweltering August afternoon  at Downey VA  Hospital when a stack of newly minted physician's orders was placed on the ward secretary's desk for transcription. Unlike patient care areas where the windows had security screens, administrative zones like nursing stations  went screenless. The massive floor fan actually blew the new orders directly out the open  window. I quipped that the records were "gone with the wind." The head nurse, Lois, had the last laugh and ordered me out of the building for order chasing duty.

Another problem presented by paper  pages was how to organize them into a format for ease of perusal by health care workers. There were clipboards and spring loaded metal chart jackets that worked the best. Later ringed  notebooks came into favor, but there were compatability problems with 2 hole or 3 hole. The VA Health system actually  came up with a  novel and unique system of punching 2 holes into the top of the record and affixing it to the chart with a metal hasp.

Data security is a big deal today with HIPPA this and HIPPA that frequently cited. Paper records did not require mixed character passwords to protect. In hospitals there was someone present by the chart rack 24/7 and physician's offices made a ritual of keeping records under lock and key. When a chart was sent with a patient for a procedure or diagnostic test, the chart was encased in a canvas bag with a locking zipper. Data security at it's finest.

Finally. since paper records were always physically close to the patient they communicated a sense of presence. Nothing tells the story of a harried trauma surgery like an anesthesia record splattered with blood or prep solution. The physical appearance tells the story better than the data recorded. Nurses frequently did their charting while taking a break for a Coke and a smoke. It was common to be ceremoniously greeted by a cascade of cigarette ashes when opening the chart to the last nursing note.
Sometimes the "presence" of paper medical records resulted in a messy situation.

Thursday, July 6, 2017

Crash Cart - Circa 1921

Inventory of ancient crash cart: Tracheotomy set, solutions of H2O2, adrenalin, tannic acid, and gallic acid. Equipment to administer a stimulating enema and if that failed, how about some smelling salts?  Sterile supplies with the notation, "If carefully done up, these will not need to be frequently sterilized."

I should probably publish  this post without pontificating about crash carts, but like the oldfoolrn that I am, here I go shooting off my old wrinkled up mouth. Mouth flapping and jaw jacking at it's finest about a subject I have no current experience with.

There is something almost talismanic, I think, about having an assemblage of lifesaving equipment and pharmaceuticals gathered together in a  mobile crash cart or trolley. The individual components assume a far greater reverence and respect than they would on their own and the ability to move them throughout the hospital is indeed  magical.  If a patient is circling the drain, it's always prudent to park that crash cart right outside the door to chase away that bad juju.

Whippersnapperns were quick to admonish oldfoolrns like me for failing to respect the supernatural  powers  of  collective resuscitation equipment, "Hey you need to have the crash cart at the bedside when you do that," was their frequent outburst. They were just shocked, and awed by my magical power to convert tachy arrhythmias to normal sinus by slight of hand vagal tricks  like applying gentle ocular pressure, a trick old nurses learned from watching the 3 stooges. There were no crash carts in the stooge era and I never converted anyone into cardiac stand still, but the youngsters had a good point and I became more concerned about access to a crash cart later in my nursing life..

Whippersnapperrns were always flabbergasted to learn there were no crash carts in the OR and we never called a code for a patient that was on the table. The rationale for this practice was the notion that anesthesia was on the ready with all  equipment at hand for resuscitation. I was explaining this in my usual blowhard, know-it-all tone of voice to a young whippersnappern and she piped up with the question, "Where is the defibrillator, fool?"  I did not have an answer as all that we had available were defibrillators with  internal paddles. "Well..I guess we could run over to ICU and borrow their defibrillatoer," was my lame reply.

Old nurses knew and practiced resuscitation without new fangled devices like ambu bags using mouth to mouth. I once performed mouth to mouth on a chap with about a weeks worth of whiskers and it felt like trying to blow up a water ballon studded with porcupine quills. Ambu bags were one of the greatest inventions for lips-off resuscitation.

This cart is so important that a nurse is obligated to check on it every shift. I knew a nurse that accrued big time trouble because an amp of bicarb was a month out of date and her initials were last on the checklist when a supervisor went through a crash cart. Nurses can get into trouble for the most inconsequential of misdeeds. It never paid to worry about supervisor admonishments because trouble always accrued from something totally unforeseen. Don't worry..be happy and carefully check that crash cart was always good advice.

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Thursday, June 29, 2017

The Metrecal For Lunch Bunch

Old time surgeries could last for a very long time as a result of their complexity, a lackadaisical attitude about anesthesia time, or unforeseen pathology. After 6 hours of standing on your feet (never, ever lock those knees) a sense of fatigue would settle in and it was tough to be at your hypervigilant  best. I always knew I was in trouble when my head started to feel heavy or my hands began to shake. I devised some strategies to deal with hand tremors and they are O.R.  tested. You can find these tips at this link. It's a common problem with some straightforward  solutions that worked well for me.
http://oldfoolrn.blogspot.com/2015/03/fools-foils-for-fasciculating-fingers.html

For that generalized malaise and heavy headedness feeling there was only one remedy and that was intraoperative nourishment. You can't eat a Big Mac in the midst of surgery although I did witness an attempt to ingest a hot dog which  was accompanied by an assortment of gastronomic complications. Those tube steaks are hard to slip under a surgical mask and difficult to properly masticate with mask ties impeding jaw movement.

Philadelphia Eagles quarterback, Mark Sanchez knows all too well the down side of eating hot dogs on the job because of the trouble he got into eating a tube steak  on the sidelines. It did not work well in the OR either. The consistency of a traditional hot dog makes it an aspiration hazard if eaten quickly. The diameter of the hot dog is the perfect size  to occlude a trachea or if further down the line, a main stem bronchus. At least in the OR, a Magill forceps is close at hand to extricate that wiener plug from an airway. For hot dogs to work in a surgical setting, the contents of the meat in the casing would have to be similar to toothpaste. Just have the circulator inset an end of the hot dog under the mask and once the scrub nurse chews the end off, squeeze the meat paste into her mouth. The Surgi Dog is born.

This illustration of Hawkeye of MASH eminence shows some of the challenges with intraoperative nutrition. The circulator, Hotlips, just contaminated the front of the surgeons gown with her nutririve ministrations. Solid food which requires sacrificing the surgical mask coverage is not prudent. The ideal mid surgical procedure meal is a liquid, nutrient dense, and shelf stable. The name of that miracle surgical sustenance was an old time product that was one of the very first diet products, Metracal.

The longing for a svelte body is not a new phenomenon. Mead Johnson came up with the diet drink, Metracal, which soon became a pop culture icon in the 1960's. Each can which required the use of a genuine can opener, delivered 225 calories derived primarily from soy protein. The consistency was a miserable watery, pasty slurry that often contained tiny lumpy glops of congealed soy protein. To disguise the unpleasant taste, novel flavors like Danish coffee and egg nog delight were offered.

Ad copy from the mid 1960s touted, "Join the Metracal for lunch bunch on a new kind of treasure hunt. Discover Metracal which tastes just like a milk shake." The ad suggested that 4 cans per day of this diet drink would trim off the pounds in nothing flat. It was a popular product and sold for 12 cents a can at your local grocery store even though it tasted nothing like a milkshake.

We discovered that Metracl was a near perfect nourishment for intraoperative sustenance. In the OR can openers were readily available for popping the tops off multi-dose vials and also  worked great to open the Metracal cans. The next step was to obtain a straight catheter (18 Fr. worked just perfect) and insert the business end into a can of Metracal. The flared distal end of the catheter was carefully threaded through the side of the anxiously awaiting scrub nurse's mask  and it was lunch time while the surgeon searched for that last persistent bleeder.

There is nothing quite like savoring the gastronomic delight of a Danish coffee Metracal while inhaling putrid Bovie smoke. That combination of gustatory delights is bound to induce an anorexia syndrome that practically guarantees weight loss. Maybe Mead Johnson should have figured out how to can and sell Bovie smoke.

Since Metracal was mainly protein, we would add a 20ml ampule of D50 ( concentrated Dextrose)after about half the can of Metracal was consumed. I just loved the loud snap-crack noise those big ampules made when they were cracked open with bare hands. The scrub nurse knew that a pick me up was close at hand when that crack thundered throughout the room. Metracal and  D50 really did enhance vigilance when lassitude settled in during a lengthy case. My all time favorite flavor was called Thahitian treat - a taste of coconut delight from the islands while sweating it out in a Chicago operating room. Life  was good.




Thursday, June 15, 2017

Whatever Happened to Sluice Rooms?

It's a conditioned response. Whenever I observe a Whippersnappern wearing gloves for routine patient care or  worse, comingling sheets soiled with scatatolgical resideue and run-of-the-mill dirty linen my anxiety mounts to intolerable levels. Someone is going to be raked over the coals for these misdeeds. Hospitals of yesteryear had unique protocols for these unpleasant circumstances.

Any sheet soiled with solid matter-what a euphemism-required a sluicing in the dirty utility room. A lovely, white 6 foot porcelain slab lined one of the walls of the dirty utility room. It was not for napping. At the elevated end of the sluice there was a massive faucet capable of unleashing a Niagra Falls torrent of water flow. The depressed end of the slab terminated at a slop sink which had a massive drain. This drain could accommodate a bolus biomass of stool the size of a bowling ball. Don't ask how I came to know that  little factoid. Someone had the foresight to install a trap on this sink which seemed to me comparable to the diameter of a subway tunnel. At least once the fetid fecal foosball facsimiles were beyond the trap they were gone for good and you could breath again.

To properly sluice a sheet place the origin of the offending substance at the lowest point of the sluice nearest the slop sink. If you enjoy inhaling aerosolized particulate matter simply reverse this procedure. Now for the fun part; turn that mighty faucet to full blast and watch that mass of olfactory offensive material sliding away on it's merry way to the waiting slop sink. Some types of residue affectionately referred to as smears, mucilaginous masses messes,  or pasty blobs require some encouragement from the intrepid sluicer and for this unsavory task a squeegee borrowed from housekeeping acted s a pusher. I always found it strange that the housekeeping personnel never asked for nursing to return their squeeges.

Suddenly, like a bolt out of the blue in the very early 1970s a memo from the nursing director came out stating that sluicing was no longer required due to improvements in the hospital laundry system and we could simply toss soiled sheets into the hamper. Sluicing like the lobotomy was gone for good and nurses were ecstatic.

This really piqued my curiosity and called for a personal visit to one of my favorite places which was our on site laundry operation. The Hispanic staff working the laundry were among the most content of all hospital staff despite working in a place that reminded me of Dante's inferno. This place was hotter than a brick oven, louder than a Pittsburgh steel mill and to top it off, smelled funny and that's putting it nicely. These folks made $2.20 an hour and were overjoyed with their pay (minimum wage was $1.65 an hour.) They were some of the nicest people in the hospital and even helped me with my lackluster Spanish skills.

When I asked about the new sluice free linen policy they happily showed me their brand new washers that had a built in sluice cycle. The washers had huge outlets that opened before the start of the wash cycle that permitted a huge flow of water through the batch of linen before the wash was initiated.

I was invited to observe a mechanical sluice cycle and it was very impressive. The mighty roar of the water being injected through the linen sounded like a 747 on take off roll in the midst of a rain storm. These giant sluice/washing machines had to be one of the greatest engineering accomplishments in healthcare history-and you thought anesthesia was an impressive invention. An open drip ether drip mask is nothing compared to these sluicing behemoths.

A few years ago nurses from my alma matter were invited to a homecoming. Changes made in the use of space at the hospital were depressing. The old OR suite, home to much drama and lifesaving (I hate that "L" word with a passion.) had been remuddled remodeled to fancy administrative offices. The beautiful terrazzo floors had been covered with Karastan carpet and pretty pictures hung on the walls. The sluice room on one ward had been converted to a data processing room filled with computer doo dads with blinking LED lights.

Crude rooms that were vital and offered maximum utility for patients  were converted to an office sitters paradise and an electronic wasteland. A depressing commentary on contemporary healthcare.

Wednesday, June 7, 2017

Operating Room Superstitions

 Old time operating rooms were fertile ground for the proliferation of  superstitions. Surgeries performed with equal technical excellence can have profoundly divergent outcomes causing thoughts of supernatural powers. Unexpected complications can occur without reason or explanation. Practices and behaviors that accompany good outcomes can be elevated to cause and effect status even when there is no supporting science. A Cartesian circle of the highest order develops. (I tossed that Cartesian word in there to try and sound smart..I'll be darned if I know what it really means.)

Superstitions have one thing  in common with science, they gain real traction with repetition. Thoughts like "Hey..the patient always does well when I use that scrub sink near the door." Pretty soon another nurse notices the same phenomenon and a "lucky" scrub sink is born. If a superstition does boost confidence it becomes much like a positive affirmation. Thinking positively was not one of my strong qualities and some superstitious actions do serve to boost confidence in nervous Nellies like me. If there is no danger to the patient and superstitions boost staff confidence a positive aspect of such non - science backed behavior becomes apparent. Without further ado, I present the magic superstitions I have encountered over the years and there is not a single full moon or "Q" word among them. No nurse would dare tempt fate by uttering the "Q" word especially when the moon is full.

Intracranial aneurysm surgery is a high stakes and nerve wracking procedure. Dr. Oddo, my favorite neurosurgeon had a couple of unusual habits for aneurysm clippings. Rule #1, No talking during the surgery and now comes the mystical  photon diminution exsanguination challenge. After the offending aneurysm is clipped, the overhead and ceiling lights in the OR are turned OFF for one full timed minute. The bone flap cannot be wired into position until the lights out test is completed and assurances of a dry field confirmed. I asked Dr. Oddo if the rationale for this test was the fact that it would be dark in a closed skull and he admonished me for overthinking the matter. "I do it because it's effective," he muttered.

Surgeons love to brag about their "bucket time." This refers to the interval from incision to when the diseased organ is ceremoniously tossed into the kick bucket. Every circulating nurse worth their salt  knows the sooner that pathology infested gall bladder or ripe appendix is bagged up and out of the room the better. If a resident wants to fool around with the specimen looking for stones or what not-do it in a scrub sink outside the room. Get that thing outta here-It's bad JuJu of the highest order! Skin approximation at closing time is so much easier when that specimen is gone and the anesthetist will thank you too when it's emergence time. Everything is just...better.

This lucky maneuver was brought to my attention by a very bright Filipino surgeon. In his native country, the surgeons would place a huge leaf from a tropical plant under their  scrub caps as an aid for cooling. Serendipitously, it was discovered that surgical outcomes improved with the tropical leaf  undercap maneuver. We don't have tropical forests in Chicago unless you count that flower shop on Belmont St. in July, but we have cabbage leaves readily available in the hospital kitchen. This green vegetable worked just fine and there was usually a head (of cabbage) in the OR refrigerator. Just look under all those blood bags-yep we comingled food, blood, and (get em outta here) specimens in the same refrigerator. Our overseers were safely hidden away in their offices and dared not even approach the double doors to the OR.

Here is an oldie but goodie that every old nurse has probably practiced. The idea of transferring this maneuver from the bedside to the OR was a stroke of sheer genius. When a patient is declining rapidly old school nurses would tie a knot in a corner of the bottom sheet usually at the foot of the bed. It's best not to question superstition practitioners, but the explanation had something to do with binding the soul to the body. If a problem developed during surgery some circulators would duck under the table under the guise of adjusting a Bovie pedal and knot the sheet covering the OR table.

If sheet knotting is such a great thing I thought maybe we should just knot the sheet before each case prior to draping. An old nurse was quick to admonish me, "It doesn't work that way Fool. The knot has to be secured after the patient begins that downward slide. You should have learned that in nursing school."  I stand corrected.

Thanks for indulging in my foolishness. My blog always experiences a marked decline in readership after the traditional school year ends. Somehow, I did not think foolishness and academics mixed, but I must have been wrong.

Thursday, June 1, 2017

Let's Stop Using These BS Terms

Calling a doctor's office an INSITUTE such as Two rivers Orthopedic Institute. When a doctor hangs out his shingle he can't be the founding father of an institute. The term "institute" refers to an entity that combines clinical practice, research, and academic endeavors under one umbrella (another BS term if I've ever heard one.)  I better be more careful.

Clever spellings of terms like orthopAedics, just to sound like a bigshot. It's orthopedics unless you happen to live in England. I interviewed  asked an orthopedic man the rationale for this nonsense and he said it was being used a  nod to the history of the specialty. That's piling BS on top of BS if you ask me.

Calling patients "consumers."  This was tried in the past by calling patients "clients." It did not work back then and won't work now because it depersonalizes sick people seeking help. History is on the side of calling sick people patients, so let's not mess with it.

Let's stop calling dense urban centers with lot's of health issues "medically underserved."  There are lots of medical folks in your nearby hospital. The problem is horrendous, intractable social problems not a lack of medicine or medical personnel.

Doctors who refer to the number patients cared for as a "patient panel." I'm not sure where this one came from, but suspect it has something to do with remuneration. How do you determine the size of your "panel?"  Maybe the number of patients you see per day times  the number of days you see patients. Patients have highly variable levels of acuity. Maybe it would be easier to categorize by acuity before assembling a panel or just say how many people can give you a phone call and be seen by a provider. Yikes, provider sounds like another BS term and that's stacking BS on top of BS. I'm getting into some really bad habits here.

Free pharmaceutical samples from your local, friendly Doc that are not free or samples. UPMC the dominant domineering health system here in Pittsburgh hands out bottles of cheap generic drugs plastered with advertisements for their brand of health insurance. It's enough to make me sick!

Physicians that promote themselves by proclaiming they are a Harvard educated medical specialist. From my experience an Ivy league education does not promise a good outcome. That sounds like a misguided superiority complex to me.

 Two BS terms for the price of one - "experience" and "journey."  Your weight loss journey begins with a surgical experience with our Harvard educated (oops) bariatric surgeon.  Weight loss is not a journey and having your gut rearranged is not an experience.

Here is a real gem. "Work needed to undergrid  healthcare  reform involves a new paradigm in perception." That "paradigm" word has been around forever. Dr. Slambow, my favorite person to scrub with, said that whenever you here that paradigm word it's someone attempting to sound smart when they don't know what they are talking about. Maybe I need to come up with a new paradigm with this foolish blog.

Friday, May 26, 2017

What is This Newfangeled Juxta Business?

Medical terminology is in a constant state of flux and I'm all for change if more concise or precise - hey it rhymes- information is provided by the new term. But what's this new fangled juxta prefix  applied to anything and everything all about?

We have juxtaglomerular, juxtacortical (brain or kidney?), juxtapyloric,  juxtavertebral, juxtachondral, and who knows what juxta  else. In the good old days we had prefixes like peri-,circum-, or in plain speak,  thereabouts. These old school terms worked very well but,perhaps lacked some of the cache of the newfangled juxta speak. However, I think the lingo from yesteryear was more straightforward and served it's purpose well.

Youngsters seem to have a preoccupation with inventing new  terms to replace old school terms that have withstood the test of time. On a recent visit to the Carnegie Museum it was a shock to find all the dinosaur names unrecognizable. A taxonomic smart aleck had pulled a switheroo with all the classic dinosaur nomenclature. The venerable T. Rex (I can't spell the full name) was renamed Tarbosaurus. I think that sounds like the name of a docile creature like some delicate avian species. It certainly does not jibe with a apex predator like the T rex.

All this terminology and taxonomy malarkey calls for some harsh correction from the Oldfoolrn  Institute for the Advancement of Medical Terminology. It's always nice to know the prognosis when various medical terminology terms ejaculate from the tongues of sophisticated medical  banterers. It's a simple matter to tack on a suffix to the medical term to indicate prognostications.

If a good outcome is anticipated the suffix is  -goodjuju which can be abbreviated GJJ. If  a  storm is brewing on the medical  horizon and the patient is juxtaing the drain-oops I mean circling the drain, the appropriate suffix is badjuju or simply BJJ. Here is a sample: Aortic dissection BJJ or erythematous skin lesion GJJ. My system is straight forward and fun. Feel free to use the next time you are typing in a diagnosis on the EMR. Maybe if enough folks use this system it will gain traction, just like that silly Juxta prefix.

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Sunday, May 21, 2017

A Tale of Two Brain Lesions

It was near the end of a long shift and  after plodding along for 10 hours or so we would run the printer on each monitor to obtain a strip for the medical record. I always believed random and routine collections of patient data had limited usefulness, but that's what the bosses wanted so I happily complied.  Suddenly, something strange happened, as I looked up to the waveform on the monitor, it looked like there were 2 or even 3 waveforms plastered right on top of another where I knew only a single waveform could  be  present.  This caught me completely off guard and I began to attribute the multi-waveform  apparition to my end of shift fatigue or some sort of whacky monitor artefact-not likely- but it seemed like an easy explanation. That little voice in the back of my head spoke up and said, "Nothing serious..probably just a brain tumor..he..he."

 As I went about my care, I noticed the monitored patient was lying there  intently listening to a CBS news report and anchorman Dan Rather was in a somber mood relating the story of  Lee Atwater, the head of the Republican National Party. He collapsed  at a public appearance and was subsequently diagnosed with a brain tumor. He was receiving radiation implants and all the latest modern medicine had to offer for such an ailment at  the prestigious Montefiore Hospital in NYC. I made a mental observation to myself that rich people always get state of the art care. I  never used much in the way of healthcare services but doubted I would have access to Lee Atwater quality of care if I was sick. Some people have all the luck.

Lee Atwater was ahead of his time with various political spin jobs  and even fake news. After elucidating the fact that one of his opponents had mental health issues a story was spun that eletro shock therapy diminished his mental capacity. During his illness Atwater found God and joined the Catholic Church. He made frequent biblical references and later it was discovered his Bible was sealed in a presentation box and never opened. Atwater kept  making his pitches and spinning right through an illness that would likely  be a terminal event. Some habits are tough to break.

As time went on more strange things began happening to me. One day I found the back passenger floor of my Subaru littered with 7 or 8 cans of NEHI non carbonated lemonade. I was a Diet Coke person and it was a complete mystery how these empty lemonade cans got there. Maybe someone broke into my car and left their Lemonade cans behind. I didn't even like the stuff.

 Then late one night on the way home from work I had an epiphany while feeding quarters into a vending machine at an out of the way K-Mart in a not so nice part of town. It was me with the Nehi Lemonade consumption. I suddenly developed a craving for NEHI Lemonade, but had no memory of purchasing this  mythical beverage. At least  I discovered how those empty beverage cans found their way to the floor of my Subaru. Oh well..chalk it up to rotating shifts and too much stress. Life sure can be strange.

A couple of weeks later things got really crazy. I began having very vivid visual perceptual distortions. When I looked upward, it looked like I was in a blinding  snowstorm. A really bad blizzard like distorted vision that occurred primarily while driving. I gave myself a mental pat on the back and remember thinking; that's one good reason for leaving the snow tires on all year. This was taking place at the end of June in Pittsburgh. I knew I was in deep trouble because it does not snow in Pittsburgh in June. That thought about snow tires failed as a rationalization for my newly acquired blizzard vision.

Another symptom began driving me nuts (or nuttier than my foolish baseline) and that was itching like I had never experienced. I tried self medicating with Benadryl without much luck. Soon I was totally disoriented and had no idea where I was at.

I don't know how I wound up in the ER of a big academic trauma center. There was  no obvious trauma although there certainly could have been with me driving around in such a befuddled state. I owe a huge debt of gratitude to whoever delivered me to the hospital. I related my complaints about having blizzard vision to the youthful ER doc and soon I was having blood drawn for toxicology studies and promptly admitted to the inpatient psychiatric ward-they had a lot of beds in psych and probably needed the business. I remembered Dr. Slambow, my favorite surgeon always saying that I was a bit different from others, but that's what made me such a good scrub nurse. I guess he had a valid argument and I was coming home to roost.

The psych ward was very nice. I had a private room and the nurses were all pleasantly chatty with chipper attitudes-so different from my sourpuss co-workers in the OR. Just when it seemed like everything was going to be OK a profound sense of tiredness came over me. The cheerful  nurses quickly shed their perky demeanor and quickly  called one of the psych residents who  had an explanation, "The toxicology reports came back and he had a trace of Benadryl in his blood." No fooling! I was itching like someone in the middle of a poison ivy patch and admitted to taking Benadryl. It was more than 25mg. of Benadryl clouding my sensorium.

As my consciousness was  quickly sliding off to LaLa land I noticed an agitated figure standing at the foot of my bed. It was a neurology attending physician and he was not too pleased that I had been admitted to the psych ward.  He ordered a STAT CT scan to be followed by an MRI if the CT was negative. Back in the early days of MRI they called them NMRIs (the N standing for nuclear.) The  neurologist was now apparently in charge of my care. Just when I was beginning to appreciate the perks of a therapeutic milieu on the psych ward, I was slapped unto a Gurney and transferred to the not so pleasant  nuero/neurosurgery floor complete with overworked nurses and overly serious physicians. I liked the psych floor so much better.

The CT scan was normal, but a spinal tap showed traces of what was thought to be an old bleed. The neurologist wanted my head inside that NMRI machine pronto. My next recollection was being stuffed into that long skinny sewer pipe of an NMRI machine. This is certainly cozy I thought as my shoulders scraped the bore of the tube. If I happened to be any wider they would have needed some melted butter to slide me in. The various booming and banging noises reminded me of a motorcycle ride and the tight quarters were just like some of the caves I squeezed myself into as a youngster. The NMRI was turning into a fun little journey down memory lane.

The fun was turning out to be short lived as I was aware of a rush of people into the room. When people started rushing into the OR to see something, it was not a good sign. I figured the same principle applied to NMRI rooms. Here we go again, I thought. Trouble  on the horizon.

Sure enough I had an "impressive"  NMRI according to the down in the dumps neuroradiologist. I remember thinking, maybe you are impressed, but I'm depressed."  What seems to be the problem I inquired and he blurted out, "You have multiple areas of T2 signal intensity in the periventricular area of your right occipital lobe. It looks like a stroke or tumor." That little voice in the back of my head was getting real chatty. "I'm dead meat."  it kept repeating.

I was beginning to regain some of my cognitive abilities and started getting cold feet at this hospital. When they began talking about an open brain biopsy, I asked them if they had heard of stereotactic head frames. They indeed were up to speed but only had CT compatible head frames and my lesion would not image on CT. I pulled my ace in the hole out and informed them I was transferring my care to the internationally known father of Pittsburgh neurosurgery, Dr. Robert G. Selker.

I had worked with Dr. Selker and knew him personally. I did not care for his ultra conservative politics but he was the best in the business. Dr. Selker reviewed my care and just shook his head. "They had you on the psych ward?" he asked incredulously. "That's just plain stupid."

Attempts at a stereotactic biopsy were never successful and Dr. Selker thought the risk of hemorrhage was greater than any benefit. I remember telling him to go ahead and give the biopsy  a whirl because I had 9 lives just like a cat. He thought about it for some time and said, "If that's true what's that pile of dead cats doing under your bed?" The biopsy was off and Dr. Selker said he was certain the lesion was a low grade glioma. "If I were to biopsy the lesion, it's going to come back a low grade glioma and I would not know what to do with it."

I was to have an annual MRI to follow the progress of the mass. The first few years there were small changes. When I had 2 MRIs that showed no change about 7 years after the onset of symptoms, I decided to stop seeing Dr. Selker.

Lee Atwater died in 1990 and Dr. Selker died in 2010. I managed to outlive them both. I guess I was the lucky one and neuro gods really do look after fools like me.  Sometimes good fortune trumps medical intervention.

Wednesday, May 17, 2017

It's Payday



So many of you have been perusing my post, "Nursing Joins the Money World" that I thought you might be interested in an oldie but goodie post about nurse compensation. It takes a reckless fool to post paystubs online, but here they are. For the shocking details click on the link below.  I calculate that for a 3 hour trauma case in 1972  I took home the princely sum of 10 bucks. Doing just about anything solely for money takes all the fun out of it. Although my paycheck failed to show it, I felt very rich while at work in the OR  and paradoxically when the going got rough, I was most fulfilled and grateful.

http://oldfoolrn.blogspot.com/2015/02/fools-gold-its-payday_25.html

Wednesday, May 10, 2017

Nursing Theory

Martha Rogers, esteemed nursing theoretician
exclaims, "Call the doctor! The patient is
deresonating his energy fields and his
helicy is dropping too fast."

Oh boy, subjects like  the theoretical basis of nursing really rub me the wrong way because they are waste  products of the nursing academic/administration/ office-sitter complex.  When my alma matter was fighting for it's life in the 1970s one of the survival strategies involved replacing operating room experience with a Martha Rogers nursing theory class. The rationale; "Anyone can learn how to be a scrub nurse, but few can master Martha's theories."  No fooling!

 If you want to drive yourself crazy check out this gem courtesy of the eminent Martha Rogers: "The integrainess of people and the environment that coordinate with a multidimensional universe of open systems points to a new paradigm of nursing:  energy fields, pattern, helicy, and resonance whereby man is always becoming."

Nursing theoreticians were in their heyday  several decades ago when diploma nuring schools were closing and nursing education was being shifted from the hospital to academic enetities. Nothing wrong with that, but educators needed a new curriculum to differentiate themselves  from diploma schools. Nursing theory and nursing research were what they came up with. One explanation of the relatedness of these two entities was that nursing research served to validate nursing theory.

I might be foolish, but I know when someone is trying to hoodwink me. Why do these highly educated academics term it "nursing research?"  If the research is to benefit patients it should be called clinical research and based on accepted fact, not unfounded theory. Facts are facts so why muddy the waters with nursing specific nomenclature. There is no such thing as pharmacist research or doctor research. Combining two entities that are not fact based or scientific does not increase their credibility. It's like stacking bafflegab on top of bolderdash which exponentially increases the inherent subjective content of any conclusions.

Conferring objective status to subjective findings never turns out well. It's how we came up with the old time surgeon's rationale for removing an organ that has no pathology. "I'm taking out his spleen based on empirical experience."  In contemporary times subjective matters like pain have been scientifcated  by pain scales. It's not doing anyone any favors to confuse subjective matters with scientific fact.

Probably the biggest failure of nursing theory was a failure to relate to clinical practice. This is facilitated by the fact that nurse theoriticians are office sitters of the highest order. My message to them is this.

Leverage yourself out of your comfortable chairs and remember it's not that difficult because once you get the largest body part moving, the rest is sure to follow. Find a sick person to help. Find a chest tube to milk, a Foley bag to empty, a trach to suction or learn how to load a sponge ring forceps with just one hand.  For crying out loud, find a patient to help! Don't just sit there..do something.

BREAKING NEWS: Office sitting nurse theoretician studying
field gradient theory becomes flying nurse theoretician courtesy
of a friendly local MRI machine. Never fear, the OldfoolRN product
development institute is working on a nonferrous theoretician's chair.


Wednesday, May 3, 2017

Secrets from the Inner Sanctum - A Scrub Nurse's Internal Dialog

For some posts, I peruse my basement collection of old nursing documents which more honestly should be called a hodge-podge of dumb notes and  old papers that I saved. My wife says they are a fire hazard and should be thrown out. I suspect she is probably right as usual. This post is going to be different as I'm just going to relate some of the thoughts that passed through my youthful nervous system when in the OR and  scrubbed for surgery. It's amazing how clearly I can recollect events from 40 years ago but what I had for breakfast remains a mystery. Life sure can be strange.

Set up time...waiting for the surgeon inner dialog

Don't let me repeat any of my past sins and screw-ups. Are the patient's legs uncrossed?? Alice,, my beloved supervisor screamed at me for days after one of the patients went to sleep with his legs crossed. What are the 7 deadly  operating room nurse sins?  Hmm.. sloth, gluttony, lust, pride, wrath, greed, and letting a patient undergo surgery with legs crossed. Never again.

Oh phooey.. I should have taped the bridge of my glasses to my forehead so they don't slide down when I sweat. This one's going to be a  long, hot one. At least I have my pant cuff restricting rubber bands in place to curtail that dreaded perineal fallout.

I only have 1 (one) Metzenbaum scissors so why the  "s"  on the end of scissors. Maybe it should be Metzenbaum's scissor...Hmmm

I hate that new fangled Betadine prep..Yucky brown.  Zepharin and Phisihex is much prettier.

I hate it when drapes are physically attached to a patient's skin with penetrating towel clips. Unnecessary trauma is never a good thing. Towel clips penetrating skin is the Catherine's Wheel of surgery for me.

It's so cold in here that poor patient's blood will never clot. I hope those lights heat this room up in a hurry.




During the case...



I hate it when Dr. Slambow gives stock market tips in the middle of surgery...I 'm lucky if I have change to buy a tuna salad sandwich from the vending machine...let alone for investments.

I hate it when Bovie smoke gets in my eyes..I wonder if breathing it has adverse health consequences?

Why does Dr. Slambow ask for stuff he never uses. Oh well that ligature reel will make a nice toy for my favorite cat, Fritz.

It's getting hot in here. That sweat bubbling up on my forehead is getting absorbed by that 4X4 under my cap parlor trick, but I guess I will have to recycle that  nose sweat/snot combo sliding down my upper lip. That salty taste always reminds me of  a Pittsburgh steel worker chewing on salt tablets with a blast furnace roaring in the background.

Hmm..Dr. Slambow operating on an old man that looks just like him. Part of the circle of life

After the case...


Yes sir no thing left behind. Even number of hemostats and needle holders. Sponge count was correct so I guess I'll be back tomorrow. (Retained object or sponge=immediate firing of OR  nurses.)

Whoa, it's unbelievable that we started this case over 6 hours ago. when you are engaged in what you love time flies, but when unpropitious events hit the fan  it hits the afterburners.

No matter how messy the surgery, nothing looks more reassuring than a meticulously laid down skin suture line....each stich equidistant and cut with an exacting centimeter tail. Kinda reminds me of those "SANITIZED FOR YOUR PROTECTION"  paper bands on hotel toilets. Sure looks pretty from the outside but who knows what's brewing down below? I certainly hope we were more careful than the hotel maids who probably just slapped that reassuring band  over the toilet seat whether it was clean or not.






I know that in today's world you had a choice of foolishness to indulge yourself. Many thanks for choosing oldfoolrn.blogspot.com over things like today's political buffoonery.

Thursday, April 27, 2017

You Gotta See This!!

I'm happily at work in the equipment room packaging delicate, specialty surgical instruments  for ethylene oxide gas sterilization. My grueling cases (hehe) for the day are finished and I'm just trying to make myself useful. Like a bolt out of the blue an excited colleague bursts in shouting, "Fool.. you won't believe what's going on in Room X. You just gotta see it to believe it." It takes quite an event to rile up an OR nurse to this level of excitement so here are some of my recollections of things you must see down the hall. Perhaps it would be better to unsee some of these sights, but memories have a very persistent nature.

Positioning patients for surgery was a true art form. Commercially made specialty positioning devices were not available back in the good old days. We used things like IV poles, sand bags, rolled towels, 2 inch adhesive tape, scraps of egg crate mattress and whatever else we could scrounge together. In my profile photo there is a length of friction tape draped around my neck. We used this stuff to tape just about anything to anything else - sounds nonsensical, but it's true.

You gotta see this positioning technique for a parietal crainiotomy. Patient's head is placed at the foot of OR table to avoid interference with table control devices. Left arm is allowed to dangle free to avoid pressure on ulnar nerve and allow for anesthesia access. Right arm liberally padded with eggcrate and flexed out of the way.  Pillow placed between legs making sure the Foley catheter is in a dependent position to drain and there is no scrotal entrapment (OUCH). There is an open area preserved laterally under left chest by a rectangle of folded towels to allow for pulmonary excursion and the finishing touch is added by tying this all together with 2 inch adhesive tape to confer stability.

It's a darn shame to cover this positioning capstone feat with drapes. I always tried to keep a snapshot in my mind of how the patient looked before draping. Yes, this is  someone's  mother or father and I better do my very best for him and his family.

Obese patients can require unusual positioning techniques that sometimes you just gotta see. I vividly recall one man with a massive pandus (the overhanging mass below the umbilicus) that required some out of the box thinking to position. It was necessary to elevate the pandus and there were no commercial pandus elevators available. We positioned 2 IV poles on either side of the table at the patient's waist. Next we used an IV pole top section as a crossbar. Three towel clips were placed equidistant at mid pandus. The loop handles of the towel clips were threaded over the section of IV pole that was secured in a horizontal position secured to the standing IV poles on either side of the patient.  VIOLA... a flying pandus. "You gotta see it to believe it."

Human parasitic illness is fodder for some genuine nightmares and luckily rare (for me anyway) in operating rooms. I vividly recall a "you gotta see this" episode that involved a  taeniasis or tapeworm induced appendicitis in a teenager. The worm apparently deposited eggs in the appendix occluding the lumen. As the nasty critter grew, intraluminal pressure was elevated within the appendix. I remember seeing  a spaghetti like creature wiggling out of the excised appendix. The surgeon was hollering, "Quick throw that thing in a specimen bag." The last thing I recall was hoping that the specimen bag contained the wiry little beast.

Some adventures in OR nursing seem like they would be a "You gotta see this!" episode, but sound much better than they see - if that makes sense we are probably both in trouble. I'm thinking of various objects inserted in assorted orifices for purely recreational or amusement purposes. These self-inserted intrusive objects are the fodder for a great urban legend tale such as the overtold ditty about the snake inserted to deal with the previously retained mouse. The RFBs or rectal foreign bodies might be worth a story, but not worth a look. Not much to see.

The one case of this nature that I attended to involved the surgeon gaining "purchase" on the foreign invader   - his terminology, not mine, by using suction. I bet this is the only case where a cigar was twice purchased, once in a smoke shop and once in the OR. Our most pressing dilemma was whether the cigar should be sent to pathology.

Uncontrolled hemorrhaging is something else I don't want to see. All that blood obliterates interesting anatomy and bleed-outs all look depressingly alike. One of the most pathetic, dispiriting sights seen at a bleed-out was an intervention by a nurse theoretician who happened to rotate through the OR. She was a big fan of "energy fields" whatever that is, to help patients. She aggressively made harp strumming motions around all the IVs and blood bags to impart this energy to the patient. It did not work and the patient died. I was mad as a wet hen because the nurse theoretician did not even help us in cleaning up the room. That's the least she could have done.

I always had the sneaking suspicion that some  nurses fled the clinical area and became theoreticians because they did not like to wallow in the big messes we frequently encountered. I always figured the bigger the mess, the more a patient needed my help. Diving into a big  mess and helping the patient recover was one of the most rewarding aspects of nursing. Nurse office-sitters don't know what they are missing.

Opps, I'm starting to ramble off task so it's probably time to wrap this up. As ever, I really do appreciate your readership of my overflowing font of foolishness.


Monday, April 24, 2017

Tired of perusing my multifaceted foolishness? For a fascinating and ruthlessly honest look at healthcare from an ER doc's perspective check out; Writingwithscissors.blogspot.com. The link is on my blog list. The latest "What I've learned" post is a classic that anyone in healthcare should read. There are many ER blogs out there, but this one is in a class by itself!

Friday, April 21, 2017

Where Did Mercurochrome Disappear To?

I've seen plenty of treatment modalities go from widespread use to complete and total extinction. Things like scultetus  binders, Phisohex, French eye suture needles,  hypodermoclysis, and last but not least; Mercurochrome which was a local antiseptic nick named "monkey blood" because of it's unusual color. When applied to skin it dried to a lovely orangey-is that a word?- red color. Worryworts used to fret that the coloration obscured inflammation, but infection cleared so quickly (hopefully) that this was a moot point.

An add from 1952 touted the child friendly nature of this first aid miracle solution: "Mercurochrome is one of the best antiseptics for first aid as  children do not hesitate to report their injuries promptly when mercurochrome is the household antiseptic because they know it will not hurt."

Every kid's mother had a bottle of this stuff readily available in the home medicine cabinet as an over-the-counter antiseptic. In the hospital it was mixed with Maalox and applied to decubitus ulcers and in the OR,  the final step after a Phisohex and Zepharin  prep was to paint the surgical site with Mercurochrome. Everyone knew when it was time to start a case because the Mercurochrome painted skin would almost glow in a radiant reddish-orange hue beckoning the awaiting team. What a beautiful site that glowing orange belly rhythmically rising falling with the Airshields ventilator chugging away. Everything seemed right with the world...It was great to be alive. Like Dr. Slambow used to say, "IT's TIME TO HIT IT."

In 1998, sourpusses at the FDA declared that "Mercurochrome was not generally recognized as safe and effective as an over the counter antiseptic," and interstate sale of "monkey blood" was prohibited. Maybe the science was lacking, but anecdotally, Mercurochrome had been around forever and did not kill or injure an appreciable number of people.

The hysterics over the medical use of mercury finally caught up with and doomed the use of  mercurochrome. What the heck?? Mercury was everywhere back when I was a nurse. Amalgym dental fillings-I have a mouthful.- thermometers to insert in an assortment of orifices, Thimersol preservative in multi-dose vials, syphgmomanometers, and every floor had a big brown glass bottle filled with mercury to inflate Miller/Abbot intestinal  tubes. These 10 foot long python like hoses tubes were filled with 45cc of mercury after the tube was in a patient's stomach and used for gastric decompression. Peristalsis moved the mercury filled balloon and tube through the GI tract like a whippet chasing a jackrabbit. Where that mercury filled balloon went, the tube was sure to follow. I heard stories about how one parapetic Miller/Abbott  tube made the complete GI tract  journey exiting from the anus. Anyone up for a round trip?

When on call,we used to play with mercury on the same table we dined from.  Dumping a glob of that marvelous silver liquid out of the brown glass bottle  and then corralling all those little BB sized  silver spheres and getting them back in the bottle could while away the time. We also thought getting squirted by an errant arterial bleeder was a badge of honor. Ahh.. the ignorance of youth when thoughts of mercury toxicity or hepatitis were far away. Dumb, but happy!

We knew nothing of the facts that mercury in sufficient doses is indeed toxic to the brain and kidneys. Although the mercury in Mercurochrome was negligible, the FDA required manufacturers to prove the benefit of their product outweighed the risk. This was never accomplished and Mercurochrome has disappeared for good.

My original title for this post was going to be: "Mercurochrome: Malicously Maligned for Malevolent Mercurialism."  Something about this aging business has attracted me to alliteration and I'm even starting to think in alliterations. Perhaps a long nap will help with some of this nonsense.  Thanks for journeying into my bottomless pit of eternal foolishness. I still worry about all you folks reading my posts so late at night. Lots of unpleasant things used to happen when I worked nights and I hope you are getting along with more grace than I did back in the day.

Saturday, April 15, 2017

Specialty Operating Rooms

No... this is not going to be one of those boring, braggadocio posts about our fancy sub- specialty  neuro room complete with  nonferrous ceramic surgical instruments to accommodate intraoperative MRI. This is about unique personality types that somehow managed to coalesce into a surgical team that functioned well despite individual quirks or personality disorders. These specialty  OR teams share a unique, unusual, and sometimes, unhealthy  bond. It's a well known homo sapiens trait to seek out others that are similar to ourselves and the OR was no exception.

Room "D," a combination general surgery and ENT suite  was well known for being home to providers (I hate that dumb term) healers, sounds so much better, that had problems with alcohol consumption. From the anesthetist to the circulator, they all enjoyed imbibing on a regular basis. Being trained professionals, they were very careful at monitoring their drink to sink time interval. According to this rubric, a  span of 12 hours must elapse between drinking  and standing at the scrub sink. After their case load was completed, they usually high-tailed it straight to the Recovery Room and I'm not talking about the post-anesthesia ward. There was actually a local watering hole about 1 block East on Halsted Street that used that clever moniker as a marketing ploy to lure hospital workers. As a group, they could carefully monitor that critical drink to sink time interval as well as get their blood alcohol level back to a comfortable range.

Although surgical masks could hide their large, bulbous, ruddy nose, they were still plagued with problems like fine motor tremors which led to the development of  many  clever and unique shake minimization  strategies. Most of what I learned about dealing with hand tremors came straight from the nice folks working in Room "D." Here is a link to some of the very best tips to quell hand tremors from the experienced experts. These tricks are OR tested and really do wonders for the shakes regardless of etiology. I am having trouble with the link, but the post was from March  2, 2015 and titled "Fools Foils for Fasciulating Fingers." Sorry about the lame alliteration, it seemed like a good idea at the time.

Although not a big fan of distilled spirits, my hands would sometimes develop fine motor tremors when called in for late night cases. Practiced counter bracing just like the folks in Room "D" were so adept at worked like a charm. You really can learn something from just about everyone.

Room "K" was famous for attracting over-thinkers and folks with profound OCD tendencies. The magnet for these folks was a highly unique and exotic OR table that had been imported from Germany. Unlike a traditional American OR table with limited mechanical controls operated by the anesthetist, this European marvel of mechanical engineering was electrically operated by the surgeon.

American OR tables have very  limited movements. This German surgical platform could execute very fine shifts and tilts in virtually any direction. German surgeons love to be in control of everything including the OR table. Why trust a lowly anesthetist for correct positioning when he did not even have a direct view of the field?  Practitioners (healers?) working in this room loved being in control of just about everything and were OCD at it's best or worse depending on your perspective.

The OR has ample fodder for those with a penchant for obsessional activities. It all starts with that 10 minute surgical scrub. If anyone dares challenge this hand washing activity the obsessive practitioner can invoke the asepsis Gods. "How dare you question my lengthy hand washing. do you want me  to infect the patient?"

Another obsessive desire is satisfied with the repetitive counting of sponges and instruments and somehow the number "10" always seems to come up. This starts to assume special significance and soon it just has to be 10 of this and 10 of that . This  repetitive practice really does double duty in that it satisfies the obsessional drive and is of vital importance in the OR. Every good scrub nurse is OCD to a certain extent.

Having that fancy over engineered table was like the  icing on the cake to an OCD surgeon. He could tweak table movements 1mm this way and 3mm that way. Somehow another tilt or yaw of the table was always necessary. A days obsessions are never done The surgeon tries to turn his attention elsewhere, but cannot. The harder he tries the more intense the table fiddling urge occurs.

The obsessive nit-pickers in this room were probably ahead of their time. The very fine OR table  positioning enabled smaller incisions with much less trauma inducing retraction. This was a time when big open surgeries were in their glory days minimally invasive was unheard of. The trouble really started brewing if a German table afficiando was stuck with a crude traditional OR table. The sweating and swearing were about to begin. I don't know who was in worse shape the drinkers sans alcohol or the surgeon without his fancy table.

I




Tuesday, April 4, 2017

I know that I'm an old foolish retrogrouch and take a perverse sort of  reverse snob attitude  regarding electronic devices. No smartphone, no flatscreen TV, but I still use a VCR. The only media platform I'm on is Blogger - No Facebook, no Instagram, no Tumblr, and no Twitter.

So a really big thank you to whoever began "Tweeting" about my foolishness on Twitter. A whole bunch of really  nice people began perusing my foolishness as a result of some kind soul twittering. I appreciate the new readers. I'm not quite sure how this Twitter thing works, but if you do like something could you consider tweeting about it?  I treasure your readership.

I used to receive quite a few readers from "Headnurse" blog, but since Jo retired from her blog there has been a slump. I should not complain, I'm happy if just one person reads my posts.

If you found me, I know it has not been easy and I do appreciate indulgers of my foolishness and those who share me foolhardy endeavors. My hats off to those of you who are conduits of my foolishness and pass it on to others.

Saturday, April 1, 2017

Downey VA Hospital Restrains Assaultive Parients

Yes, I have a personal  history with patient assaults. Here is a link with the gory details if you would like to peruse the sad tale  http://oldfoolrn.blogspot.com/2015/08/knock-out-punch.html

Part of the problem with patient vs. staff  assaults  at Downey was the lackadaisical attitude of the administrators who were supposedly running the show. Assaults were so common that the hospital director's office had a form letter that was sent to all victims. The themes of this letter were that we were dealing with very psychotic patients and such unfortunate incidents were inevitable and oh, by the way, thanks for trying to help these poor unfortunates. Next time learn how to duck. OK I made that last one up, but that seemed to be the underlying message. There was no such thing as patient accountability or accountability of anyone for that matter.

The head nurse,  Matty,  of Building 66 where I worked  was a stout pit bull of a woman who rarely ventured past the safe  confines of the nursing office. She was an office-sitter of the highest order. Of course she had strong feelings about how to manage patients on the ward, but had no experience in the clinical realm.

Miss Matty loved to pontificate about patient assaults on employees. It was one of her favorite topics and her main point was that the employee's insecurity and lack of confidence communicates a sense of vulnerability to patients who then slug them. Her favorite refrain was, "Carry yourself with a sense of authority."  This made no sense to any of the staff. Ward attendants and nurses used to discuss this while on the ward within earshot of patients.

I quickly deduced that some patient on staff  assaults were entirely unpredictable and were deeply rooted in the psychopathy of the patient's illness. See, I can use that psychobabble speak just like all those highly educated big shots! Other assault episodes seemed to follow a pattern of escalation and were somewhat predictable. Some assaultive patients even expressed regret for the incident.

After an assault the patient was always placed in full leather restraints with a robust leather cuff around each extremity which was anchored to a steel bed frame with a heavy leather belt. The cuffs had a sliding lock mechanism that required a key to release. The bed itself was bolted to the floor to prevent the patient from kangarooing the bed around the restraint room. Some of the more experienced patients knew how to bounce an unbolted bed up and down when in restraints to move about the room. "Kangarooing" was a very good, descriptive  term for this phenomenon.

Putting an uncooperative, assaultive patient in restraints was not a pretty picture. One technique involved at least 4 nursing staff members to do the dirty work. A secret code word was agreed upon and since I was always hungry, "Big Mac" did the trick for me. After hollering the code word each staff member grabbed one extremity and physically carried or in the case of a really big patient, dragged him to the restraint room and tethered him to the bed with the leathers.

The alternative  technique involved a couple of staff members grabbing a twin mattress and while holding the mattress vertically, force the patient into a corner. Once cornered, the patient usually surrendered after an interval of punching and kicking at the back of the  mattress. It required a seasoned nurse's best judgment to ascertain when the pugilistic activity subsided enough for restraint application. The attendants were fairly good evaluators of the degree of "fight" left in a cornered patient and I usually left the decision up to them as to when restraints could be used. If a patient had too much "fight" in them when the mattress was retracted, it could always be pushed back into position pining the patient back in the corner. I always thought that the sudden eruption  of the punching  fists on the surface of the mattress looked just like that carnival whack-a-mole game. When the surface of the mattress settled down, the game was over.

I really detested the drama that accompanied the restraining process. There were about 4 patients out of 40 that required restraints. The youngest, Danny, was a Viet Nam veteran and had a predictable pattern to his violent outbursts. He would scream like a Howler monkey before striking out and once secured in the restraint room, he voiced remorse for his behavior. Danny told me that he felt like striking out when he felt threatened and out of control. I assured him that he was safe and maybe the next time he felt the urge to strike out to come and talk with me and we could figure something out to avoid that unpleasantness of being wrestled into the restraint room.

Whenever Danny approached me with that rage in his eyes, I always asked him what would work to make him feel better. Sometimes he just needed to lie down for a spell and other times he requested restraints. I complied and after the restraints were on, I always said, "Just let me know when you feel like coming out and I will release you."  This worked well for Danny and we established mutual trust because I promptly let him out at his request. For Danny this worked really well, but when he made his request to other nurses, I got called out by the head nurse who thought my interventions were unwise to say the least. Oh well, at least I tried.

Danny's schizophrenia suddenly went into remission and he was discharged to live happily ever after. APRIL FOOLS on that last sentence.