Saturday, February 25, 2017

OPEN SESAME

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

Foolishness...Sparks....Sputters

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!