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.  Is that lesion still sitting in the middle of my right occipital lobe? It's been 27 years and my PCP is recommending a follow up MRI.  Here we go again.

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.

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 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 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; 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.


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

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.

Monday, March 27, 2017

Nursing Career Choices - My Journey from the OR to Downey VA

It's so easy to get locked into one particular nursing specialty and latch unto for life. The problem is further exacerbated by seeking more education in that particular area which further encapsulates a career within one particular bubble. Stepping outside your current nursing  comfort zone and engaging in something completely different can bring a new perspective to a divergent specialty arena. Maybe if psych nurses ventured into the OR they could ratchet down some of the everpresent angst and emotional hub bub. Maybe if OR nurses tried psych, they could implement some useful interventions. Who knows? I figured it was worth a try.

I had a life long interest in OR nursing or  in the vernacular of you whippersnapperns "perioperative" nursing. I still like the old fashioned scrub nurse terminology, but then again, I'm an OldfoolRN. Psych nursing always seemed so very different. The long term custodial care of chronic schizophrenics seemed to be the exact opposite of slapping instruments into a surgeon's hand for an immediate solution to a health problem.

I thought that this  expertise, if you could call it that, could be applied to another nursing specialty like psych. Youngsters do indeed generate some foolish ideas when they are out to cure the world and I was no exception. I like dramatic quick fixes and doing something to really cure the underlying problem. Proven interventions that get sick people back on their feet and back into the business of life. Psych was to be my new alternate universe and I would somehow help those institutionalized souls with novel and pioneering interventions. I was probably as delusional as some of the patients!

Downey VA Hospital, just north of Chicago was to be my new stomping ground. I was hired and told to carefully review the employee orientation manual. They actually wanted me to start working on the very same day as my interview. Desperation does not make for clear, level headed thinking so I declined and agreed to report the next morning.

The nursing supervisor escorted to my new assignment, Building 66 ( AB  ward) in a VA facility that was indeed  providing long term custodial care to chronic schizophrenics with a smattering of manic depressives thrown in for variety. She opened the massive door which resembled a bank vault with heavy robust hinges   to "A" ward and as we stepped in, a pool ball thrown with the velocity of a Nolan Ryan fast ball whistled just over my head. In the far corner a patient was doubled over in pain after beintng "bayoneted" in the abdomen with the end of a pool cue. The blue pool chalk was mixing with a small amount of bright red blood. I remember thinking to patriotic his plain white t-shirt looked with a red and blue stain.

"Is this the therapeutic milieu  mentioned in the orientation manual?" I foolishly asked my orienting supervisor. "Not exactly," was her reply as she quickly wrestled the pool cue from the agitated patient who was brandishing it like a he was preparing for another vicious  strike to the body. The supervisor complained bitterly that she had ordered the pool equipment locked up and set about for an attendant to shoulder the blame.

After resolving that issue, she suggested that I remain on the ward to observe. There were 40 patients in the cavernous, exiguously furnished dayroom, most of them pacing to and fro muttering unintelligible ramblings. Everyone smoked and a thick blue cloud enveloped the entire scene. A huge ceiling mounted unit that whined and whistled like a 747 on a take-off roll was sucking up some of the cough inducing smoke. I asked one of the attendants about the strange device and was told that it was a "smoke eater." At least they are trying, I thought to myself.

There was no danger of anyone leaving this facility. The windows had heavy wrought iron bars that rivaled the entrance door in terms of shear mass. The place reminded me of a maximum security prison or a Fort Knox for people.

I concluded that I needed to do something physical to establish mutual trust and get the ball rolling with these guys. Attendants and other ward personnel were chatting with some of the patients, but from what I observed, this did nothing constructive. These guys had been talked to for years and it did not seem to do much for them

I noticed that they were all wearing scuffed, dirty, leather dress shoes that they had obtained from the hospital canteen. The ubiquitous athletic shoe of today's world had yet to be invented. In a supply closet there was a shoe shine set-up complete with a fancy gizmo to prop feet up at the optimal level for a seated operator to shine the footwear.

I had an epiphany. This is how I could engage some of the patients and develop some sort of therapeutic relationship with their tortured souls. I think it was called making therapeutic inroads or some other term firmly rooted in the rubric of psychobabble nonsense. Anyhow., I decided to give it a go and  when I returned the next day  I reported to the ward with some newly purchased tins of shoe polish and a couple of worn out scrub suits that I had collected from my previous nursing life. I knew from experience they were perfect for buffing shoes to a deep shine

"Shoe shine..Get your shoes buffed up to a nice shine," I shouted out toward the pandemonium emanating from the dayroom. Whenever a patient approached the door, I greeted him with a friendly smile and cheerfully offered my shoe shine services. Even some of the more withdrawn patients began accepting my services and this was a great way to learn their names. One of the attendants cautioned me to limit my shoe shine services to when the supervisor was off ward, but I did not worry about that too much. After all, I was doing a heck of a lot more than they were to help the patients.

It touched me deeply when after about a week of my shoe shines, a motley collection of disheveled patients approached me and asked to polish my shoes. I was really getting somewhere with these guys.

For my next Downey VA post, another OldfoolRN innovation: Teaching violent patients to request restraints to avert injury. Supervisors thought I was a nut, but the proof was in the pudding- It worked

Monday, March 20, 2017

A Young Jackanapes as a Scrub Nurse

Ahh.. It's Lent,  a historical time for introspection and coming clean with bad habits and misdeeds from the past. When more than one disinterested party brings attention to your personality flaws, it's time to pay attention, they probably have a legitimate grievance. One of the accusations tossed my way more than once was, "You are a blowhard." There I said it and allow me to explain.

Before a blowhard starts pontificating, it's wise to make sure your employment is secured by your job performance. I tried to be really good at what I was doing so the surgeons would need my services. Dr. Slambow used to request my services by calling the scheduler and demanding the services of that "jackanapes of a scrub nurse." Everyone knew who he was asking for. He used to describe me as the  most quiet scrub nurse he ever worked with. That was most likely another reason for my long term survival in the OR. Stress and long cases could initiate my assorted lame brain suggestions and tips for wise surgeons baloney.

For instance, one long case that dragged on for hours  involved a partial nephrectomy done by the chief of surgery. He was laboriously sewing tiny little BB sized pieces of abdominal fat to cover the excised surface of the kidney remnant. My fingers were aching,  loading one endless needle holder (or needle driver as you whppersnapperns call them,) after another. Suddenly I asked him, "Why don't you just suture one big giant fat ball onto that kidney and be done with it?" He did not miss a beat and said sardonically, "It doesn't work that way Fool!" I kept my mouth shut, but managed to walk away from my Mayo stand with a certain swagger as the circulator said with disbelief, "I can't believe you said that to the chief of surgery."

I was circulating on a portal caval shunt which is a high risk surgery especially with someone that has less than optimal clotting factors resulting from years of alcohol use. Suddenly the patient began bleeding very badly and it was my task to implore the blood bank that we needed everything they had for this patient. The technician began badgering me with endless questions about why we needed all that blood. Finally, tired of her interrogation, I said "We just really need the blood. The surgeon chopped too big of hole for the surgery." Later, I realized that everyone in the room heard my lame brained description of the surgery. But, hey we got the blood.

Bovie smoke really got to me and I had ways to minimize the damage. I frequently instructed the residents on how to use an ordinary suction to aspirate some of the smoke. I used to call these procedures "tips for wise resident surgeons" and most of the time they went along with my foolishness, but in hindsight it was just another blowhard manifestation.

At least aging has put some of a damper on my blowhard nature, I hope.

Friday, March 17, 2017

A Teeter Toter Surgeon

What goes up..Comes down..Hard
Play grounds from my youth could be very dangerous places with heavy moving objects,  very hard  unforgiving landing places, and young toughs on the prowl in search of  unsuspecting  victims to intimidate. Teeter toters were a favorite playground  implement for bullies to ply their trade. A hard wooden plank moving up and down with a  fulcrum in the middle was too much to ignore for those with devilment on their mind.

The bully's pitch went like this, "You wanna have some real fun, lets go play on the teeter toter. I'll even let you get on first." The unsuspecting victim was seduced by the bully's jubilant grin and happy go lucky demeanor.

Once the hapless victim was in position on the end of the teeter toter, the corpulent bully promptly planted his overstuffed backside on the opposing seat. The victim was suddenly thrust high into the air with amazing force. If he was strong enough to hold on, the finishing  move was about to present itself. The victim would be held captive on the elevated end of the teeter toter as the bully began his verbal torture.

"You sucker, now you are really going to get it," the bully taunted. As the victim screamed and cried the bully suddenly hopped off the depressed end of the teeter toter sending his high- flying victim crashing to the ground with a sickening thud/crash/cry cacophony.

We had an aging, well  past his prime, ENT surgeon that everyone  referred to as the teeter toter surgeon. His well earned nick name was indicative of his smooth preop pep talk followed by a harrowing experience once the patient was situated in the operating room proper.

His life long obsession was rhinoplasy and he even invented specialized surgical instruments that carried his surname. Whenever Dr. Cuddle asked his scrubnurse for an instrument, he made a point of accentuating the "Cuddle" in it's nomenclature. "I'd like the cuddle speculum followed by the cuddle elevator." was a typical command issued in his carefully modulated, stilted speech pattern. "Yes Dr. Cuddle," was the canned scrub nurse's reply.

He could convince just. about anyone with a nose that they were a candidate for rhinoplasty. His sppech, like the playground bully, was filled with false promises and fantastic benefits. I remember how he extolled the vitality benefits of his nose jobs because they increased the oxygen carrying capacity of the blood. Then he went on and on about how beautiful their new nose would look. Hollywood would soon be calling. That beautiful new look and rejuvenated persona would be too much for a movie producer to resist. Better days were as close as a lateral osteotomy fracturing the nasal bone structure to smithereens all the while an awake patient teetered at the maximum elevation of the teeter toter OR table.

For those who question my comparison of  Dr. Cuddle to the playground bully, understand this: The positioning of both victims is identical when receiving their punitory ministrations. The play ground victim receives his coccyx shattering impact sitting bolt upright and Dr. Cuddle performs his proboscis punishment with the victim  patient in the identical configuration. The OR table is positioned with a break in the middle and the back of the table raised at a 90 degree angle.

Dr. Cuddle was one step ahead of the playground bully who was content with letting his crying victim to quickly vamoose from the scene of the crime after receiving his butt busting punishment. There was to be none of that flight or fight syndrome business for Dr. Cuddle's patient who was physically restrained to the table with an airplane type belt around the waist. This served the dual purpose of arresting the patient's departure and also prevented him from throwing blows in the direction of  Dr.  Cuddle. The ankles were also tacked down with another robust belt to avert kicking. The coup d grace' was an elastic bandage wrapped  around the forehead  and secured behind the table for stabilization.

Once he had the patient in the OR, he had that same look in his eye as the playground bully. Someone was about to experience torture on the same level as the teeter toter victim. Dr. Cuddle performed all his procedures under local anethsia if you could call it that. That look on a wide awake patient's face  as they surveyed the Mayo stand directly in front of them loaded with a multitude of glimmering sharp steel instruments was eerily similar to that of the teeter toter victim.

Their was a reason for his making sure the patient was restrained on the table. Even if the local anesthetic was effective, that sound of a mallet impacting with an osteotome and fracturing your nose has to be worse than the crash/cry after a playground victim's  teeter toter free fall. The stuff real nightmares are made of.

Whenever I was anywhere near Dr. Cuddle, my nose was covered with a surgical mask. I did not want to give him any ideas about "fixing" my nose. As a youngster, I was the victim of that teeter toter free fall prank and I did not want to repeat the performance at Dr. Cuddle's crafty hands.

Wednesday, March 8, 2017

Buidling A Culture of Life - One Wound Infection at a Time

The young surgeon in this advertisement is purportedly "building a culture of life."  I would like to add one caveat based on her inappropriate OR attire. Building a culture of life - one gram positive wound culture at a time.

This ad really rankles my hackles and I don't know where to start with my diatribe. The self-righteous pronouncement of  life promotion is quenched by a paradoxical illustration of sepsis inducing operative attire. Her gloved hands are elevated way past the zone of accepted gown sterility. If she can avert contaminating them on the inferior margin of her mask, contact with her exposed scrub top will surely infest them with a host of eager microorganisms just itching to infect an open surgical wound. Could that gown even be called a gown? You can see through it and I suspect that  blood would run through it like water through a Keurig. Instant contamination. Her skin is visible on the left wrist below the glove. She must have put her aseptic consciousness on hold while busy building her culture of life.

And those wrinkled gloves are just waiting to get snagged on just about any  ratcheted instrument. Initially, I thought the gloves were an issue of improper  fitting, but on closer inspection, they appear to be crude exam gloves perhaps suitable for a surgeon's  Halloween costume. I'm all for hospital cost cutting, but it's just plain wrong headed thinking to skimp on surgical gloves. Despite the high-minded tone of the add copy, the  illustration would insult the intelligence of an amoeba.

My favorite OR supervisor, that red headed whirling dervish named Alice,  had a way of dealing with characters like this. The improperly gloved hands would have been smacked with a sponge ring forceps so hard an ortho consult for the practioner would be in order. The ridiculous "costume" of a gown would require more serious remediation.

This practioner of sepsis would be sequestered in the utility room with the task of scraping dried blood from every nook and craney of the sponge racks with a periosteal elevator that had been retired from service decades ago.  Just when she thought the unpleasant task was finished, Alice would roll in another sponge rack encrusted with enough dried blood that it could be used as a prop in a  Halloween house of horrors. When her clean up duties were finally  completed she would have spent an entire career in the cysto room hanging bottle after endless bottle of bladder irrigation fluid. At least when she retired her arms would rival the muscle definition of a weight lifter after elevating all those heavy glass bottles. "That'll learn ya,"  as Alice would shout with glee when one of her victims nurses had completed their penance.

Saturday, February 25, 2017


Open sesame or perhaps it was "open says me"  are the magical words in the tale of Ali Baba and the Forty Thieves by which the door to the robbers' cave was made to pop open. Old school scrub nurses were masters of open sesame too, and could open any OR  door with any body part excluding the upper extremities. Specific skill sets like this are in the same class as other neat tricks like learning how to recycle your own snot when scrubbed in surgery with a bad cold, but that's  a tale for another post so let's get back to the doors.

There were no self opening or side sliding  doors in old time OR's. The doors were hung on self-closing hinges that came in two different varieties. My favorite hinge type allowed the door to swing both ways and return to the closed center position by the force of gravity. The hinges had a cam mechanism that raised the heavy door about an inch or so when opened. The weight of the door dropping downward pulled it closed by the action of the hinge cam sliding down an inclined plane. This was a very reliable system because gravity never fails.

At festive Christmas celebrations these doors could also function as efficient nutcrackers. Just position the walnut or brazil nut under the door or  even in the jamb with the door wide open and quickly swing it shut. VIOLA a delicious, nutty  treat awaits, just don't try this trick when a case is in progress or you will rankle the hackles of that overly nasty supervisor named Alice. She nearly cooked my goose when a tattle tale ratted me out for cooking a turkey in an autoclave on Thanksgiving while on call.

The other type of OR door was spring loaded and would swing in  both directions and return to a closed position when the spring tension released.  The hinge springs were wound up tighter than an eight day clock when the door was pushed open  and were entwined around the  center of the mechanism. Late one night, the cacaphonus sounds of emergency surgery (hissing suction, buzzing  Bovies, chugging Airshield ventilators  and hollering surgeons) was interrupted by the loud report of a door hinge spring suddenly breaking in a most spectacular  manner. The sudden, unexpected  noise definitely resembled the report of a high powered firearm.  We nearly jumped out of our skin and the irony of this occurrence during a gunshot emergency surgery rattled our composure. Strange things happen in the middle of the night during trauma cases.

After the typical 10 minute  surgical scrub a nurse had to pass through the doors while holding their hands out from the body at chest level. A sterile consciousness dictated that the scrubbed hands touched absolutely nothing except a sterile towel after entrance to the room was accomplished.

This mandated opening the door with any body part except the hands. There were several methods to accomplish this amazing feat. My personal favorite was the "flying buttress" maneuver which involved approaching the  closed door backwards while bending over at the waist and at the proper moment exploding through the door by flexing your  backside into the closed door. I used to amuse my fellow nurses by telling them, "They don't call that thing a boomer for nothing." I have previously mentioned when discussing patient positioning that once the mid section of the body is set in motion the rest is sure to follow. It's simple physics and applies to both patients and nurses.

  It was most efficient to deliver this blow on the opposite side of the hinges.  Unfortunately, this position blocked the view through the  door window which could have unfortunate consequences. One time,  I exploded through the door and my flying buttress connected with a hapless student who was observing. The circulating nurse joked that I should be charged with assault with a deadly weapon. The student was not amused and I made a mental note to carefully judge for obstructions before opening a door to prevent mishaps like this.

Another effective door opener is the Kung phooey  Fu technique. This is a good one for scrub nurses that like to show off or exert their authority. The nurse approached the door facing forward and at the correct distance popped the door open with a thundering forward kick. I would not have believed it unless I actually witnessed it, but it was possible for a scrub nurse to perform a door kick while wearing a scrub dress. Simply amazing.

The side -  swammy  sashay was perhaps the most refined and elegant of the door opening techniques. The nurse side-stepped  her way to the door and lightly pushed it open with a slight  lateral hip movement  just wide enough to slither through. Not too flashy, but effective and stealthy when the need for discretion occurred. On very long cases we would give each other breaks and sometimes the surgeon would be so engrossed in his ministrations that he was totally unaware of the scrub nurse switcheroo and that was our intention.

Once a nurse has adopted a particular door opening technique, they are usually very loyal to it. There are very few switch hitters in this business. However, I have seen some nurses alter their technique in mid-swing so to speak. The most frequent switcheroo would be an ineffective side-swammy to a full blast flying buttress. I always figured, why waste your time and simply initiate with the big guns of the flying buttress. Think big!

If I was circulating and had a good working relationship with the attending surgeon, I would keep a lookout and when he approached after his scrub,  open the door from the inside and greet him in a friendly welcoming tone of voice. A little bonhomie can go a long way in an operating room. I always tried to do the door opening/greeting routine for Dr. Slambow, but he frequently questioned my sincerity by gruffly ordering, "Cut the crap Fool...It's time to hit it." I always knew things were right with the world when he responded like that. It was going to be another day in surgical paradise.

Saturday, February 18, 2017

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

Thursday, February 16, 2017

Now You See It - Now You Don't

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

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

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

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

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

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

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

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

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

Monday, February 13, 2017

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

Saturday, February 4, 2017


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

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

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

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

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

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

Why is the dying process so similar to a birth?

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

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

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

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

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

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

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

Wednesday, February 1, 2017

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

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

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

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

Thursday, January 26, 2017

From the Anals of Anesthesia History

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

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

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

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

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

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

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

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

Sunday, January 22, 2017

We've Only Just Begun

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

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

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

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

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

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

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

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

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

Some images really stick with you.

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.