Thursday, September 9, 2021

Needle Gauge Sizing Explained

Hmm...It's easier for a camel to pass through
the eye of a needle than avoid Miss Bruiser's
painful ministrations!

Sizing of most medical implements made sense, gloves were measured by running a tape measure across the mid section of the hand, the measurement in inches was the glove size. Catheters were measured in Fr. and one French was equal to 1/3 mm. a 32 Fr. catheter was most definitely larger than a 26 Fr.  Endotracheal tube diameters are measured in simple millimeters. Nice and straightforward for foolish folks like myself.

Needle caliber sizing is a horse of a different color. Miss Bruiser, my favorite nursing instructor insisted that physical discomfort (pain) was required for a  student nurse's proper education, so when she gave us a choice of needle size for injection practice sessions it was obviously a trick question. Her beady little eyes shifted like a pinball in play when she asked, "Now which size needle would you like me to use on your tender deltoid when I demonstrate an intramuscular injection technique, A 16ga or a 22ga?" Well a 16ga sounded like the best choice because the logical thought process would deduce that 16 is less than 22 so the needle would be of a smaller caliber  and hurt less when harpooned by a towering Miss Bruiser. Well we were dead wrong and had the bloody aching arms to prove it.

 Every nurse knows that the smaller the gauge number, the bigger the needle, but how in blue blazes did this come about? Up until the dawn of the 20th century there was no standard for needle size other than puny, medium, and jumbo. Thanks to the British wire industry things were about to change.

Needle sizing is a direct descendant of ye ol'  Birmingham wire gauge which was widely used as an industrial standard in merry old England. According to this standard a #1 gauge wire had a diameter of 6.26mm  which was used as a starting point for the measurement of wire diameters. The number of wires that could fit in this defined area was the gauge. It's easy to see that for an area of 6 mm diameter (or there abouts) to accommodate 25 strands of wire they would have to be much, much less of a diameter than say #12 gauge to occupy the exact same area. The greater the number of wires ram rodded into the same sized area, the lesser the diameter. So that's why the higher the needle gauge, the smaller the diameter of the needle. I'll take getting harpooned with 27 gauge needle over a 16 gauge any day!

As time went on, the Birmingham wire gauge was further improved and made more exacting for the sizing of medical needles by meticulously defining the steps between the different gauges, for 7-14 gauge needles the size increased by .025 mm for each larger size needle, to 19 gauge the size increased by .013mm, and lastly with the small needles size increased by .0064 mm. When you think about tiny needles, just a small decrease in gauge can make a really big difference so that's why the steps between gauges are so small.

The year 1955 was an occasion for old nurses to celebrate. Roeher Products introduced the disposable Monoject syringe which allowed for a choice of needle size which was independent of the syringe. The color coding of needle sizes was born and every nurse knew a bright  red needle guard signified a 25 ga needle and a blue guard meant a 21 ga. I never could figure out why a 20 ga needle and a 25 ga had the same reddish  color, although the 20 guage was of a very light shade. 

The needle that gave every novice nurse the tremblors was not a monster 16ga, but rather the mighty 2 inch long.Imferon needle with the purple guard. I shudder to think of the misery Miss Bruiser could inflict with one of these monsters as it bounced off periosteum with a loud clunk followed by an ear splitting shriek!

Tuesday, July 6, 2021

Portrait of the Scrub Nurse As an Artist

Yep...I hijacked the title to this post from that great Irish literary genius, James Joyce, whose near blindness probably enhanced his writing ability by excluding extraneous stimuli. Operating rooms, on the other hand, have loads of stimuli, but they are certainly nothing to look at. The stark, tiled walls and hard unforgiving terrazo floors almost call out for beautification and just about anything  aesthetically pleasing is a huge step forward.

Scrub nurses have a variety of artistic media available to them right on their Mayo stand and  each individual has their own style. My attempts were crude compared to some of the Rembrandt like efforts of today's youngsters.  I'll give a brief account of my lame efforts and then morph into some truly beautiful work by contemporary artists scrub nurses and scrub techs.

My initial  artistic endeavors involved cutting various designs in my sharps bag which was really nothing more than a plain old waxed brown paper container. A straight Mayo scissors was the perfect cutting tool and I began with profiles of hearts on the sides of the bag. After all, any operating room could use a little more love.

 As my skills advanced, flowing scalloped edges inspired by the Rococo school of art adorned the top of my sharps bag. Ratcheting a needle out of my driver and dumping it  in the sharps bag had a new found feeling of artistic fulfillment as I watched it drop past those lovely scallops. Simple pleasures for simple minds.

In the 1970's the hottest new innovation in surgical draping was a material called Vi Drape which was nothing more than a sheet of polyurethane with an adhesive backing. After prepping, a sheet of Vi Drape was applied to the skin and the surgeon made his incision smack dab through the Vi Drape. No cutting corners here!  The idea was to isolate the skin from the surgical site to prevent infection. Vi Drape also provided a sterile platform for plopping an organ down on it without fear of contamination.

Before the skin sutures were thrown in place, the Vi Drape was pealed off and unceremoniously tossed in the ever ready kick bucket. While removing a used Vi Drape from the bucket, I noticed how the overhead lights illuminated it, creating a stunning design. The center of the drape that had been incised glowed like a twinkling star and it was surrounded by a lovely pinkish glow thanks to the retained Zepharin prep solution. Pink tinged Zepharin was certainly more pleasant to look at than the yucky brown Betadine prep which is so ubiquitous today. The speckling added by blood droplets and minitissue chunks highlighted the brilliant center of the design.

How could I display this masterpiece? The answer was no further than an unused light box used to view X-Rays in our break room. I archivally preserved my masterpiece by sealing it in unused Vi Drape and secured it to the light box. There was mixed reaction from my fellow nurses. Some loved it while others thought I was nuts. Art is supposed to get folks talking and asking questions so I fulfilled my purpose.

Now for the good stuff. Orthopedic surgery provides whippersnapperns with a great media for sculpture, namely bone cement. Marjorie RN at bloodgutsandcoffee on Instagram has some really great work displayed on her posts. The sample on the left has even been enhanced with what is apparently Methylene blue and a surgical marking pen. How cool is that.

Orthopedic surgery also provides for brief "time snacks" while portable X-rays are taken. What a perfect time for artistic endeavors. Every moment of pseudo leisure can be put to good use in the OR. Sculpting with bone cement is surely lots more fun than gazing at that yucky blood/bone chip slurry reposing at your feet.

When I was a youngster, surgical marking tools were limited to a tooth pick and a medicine glass filled with methylene blue. To mark an area the tooth pick was dipped in the dye and dabbed in place, a crude method which did not lend itself to intricate designs or sketches.

Today, it's a different story. There are all sorts of surgical marking tools that are not only useful in marking patient's skin, but also function great as a means of artistic expression. The canvas is a surgical towel or mayo stand cover. Surgidoodle on Instagram has some of the most intricate and lovely designs I have ever seen. This "circle of time" is one of my favorites and the way the tips of a pair of Babcock clamps  point directly to the serpents head is really spooky. Maybe someone is about to snag that serpent in the jaws of their Babcock and free that omniscient eye lurking in the center. Who knows!

Surgidoodle also has a simply elegant work on her Instagram page titled SHARK ATTACK. You won't get any of that artsy fartsy sillyspeak from me on this magnificent work. It's simply beyond description. The contrast between the stark line drawing of the attack with the severed lower extremity and the ambiguity  of the bloody mottled background make us consider the complexly entangled lives we lead in the OR. Heavy stuff, indeed.

Shark Attack has all the elements of  a quintessential work of fine art: A life altering event frozen in time, the sometimes random element of trauma infliction, how trauma dissociation is based on evolutionary survival behavior, how invalidated trauma generates silent internal screams,  and an inquiry of the survivability of traumatic injury. The assorted components cohere into an elegant whole that transcends the harsh, unforgiving environment of the tiled temple. Compared with the wan, self involved art (I'm thinking of the Andy Warhol Museum here in Pittsburgh,) which strain for undeserved and unearned profundity, Shark Attack is in a class by itself!

If I have piqued your interest in operating room artists here is a listing of some of the ones I enjoy on Instagram.

ortho_artistry features some very nice bone cement sculpture work

operatingroomart shows us some lovely abstract images created by a urologist with a cystoscope and gel.  Absolutely more colorful than a meatotomy!

surgeryboxcartoons shows what can be done with a surgical head covering container.

And of course surgidoodle which is my all time favorite. Thanks for inspiring me to finally get around to posting something. 


Tuesday, June 15, 2021

Downey V.A. Hospital Signage

Dr. Scott Mastores is  a graduate of  Chicago Medical School which was constructed on the Downey VA Hospital grounds shortly after I quit working there. Thankfully, he rescued this sign from the trash and was kind enough to Email it to me to share with all those interested in Downey VA hospital.

There were lots of interesting signs at Downey and this one was on prominent display in the lobby of most of the buildings. I don't think many of the patients bothered to read them and enforcement was lax. Most of the nurses at Downey would much rather have patients lying on the floor than fighting on the wards.

Just about every ward had a pool table and a sign that stated throwing pool balls was prohibited. I broke up an unusually nasty altercation where two patients were bayonetting each other with pool cues and was promptly advised there was no signage prohibiting this activity. "If we can't throw poll balls at one another, what are we supposed to do?" was their response.

Saturday, June 5, 2021

Boo Hoo

 Lots of views, but no comments and I'm stuck in a terrible brain freeze. I'm open to any suggestions for a post. Thought about an updated nursing awards post if I can crawl out of this cognitive abyss!

Saturday, May 22, 2021

Stick 'Em Up


                                    "That's the last Bicillin shot you're ever going to give!"

Monday, May 10, 2021

Professional Adjustments Class

"All right it's time to break up into groups of two. The smokers will demonstrate
 to the non-smokers how to light up and inhale a cigarette. Return demonstration
is required and I don't want to hear any of that gagging or coughing!"

 Every  hospital based nursing school had a class motto. In my school where Miss Bruiser, my favorite instructor presided, the old adage was;  A journey of a thousand miles begins with a single step. Initially, we thought  this slogan referred to breaking down an arduous accomplishment into simple steps to achieve our final goal of receiving  that coveted pin, but after nearly three brow beating  years and constant harassment our assessment shifted. A thousand  miles was along way from home and diploma nursing education transported us to a bizarre new world with strange new rules and customs. Professional adjustments was our very last class and we were going to learn how to conduct ourselves as nurses in this strange new land.

Miss Bruiser, regal and pompous like a queen, strutted around the classroom with her cap serving as a crown. Her edicts were delivered sternly in the same tone one uses to discipline an unruly child or train a dog. It almost felt like she was deploying little bombs in the back of our heads, set to detonate sometime in our future nursing life.

Miss Bruiser  harshly intoned, "The first order of business is going to be the  use of tobacco products. Every nurse should learn how to smoke cigarettes in order to connect and relate to patients, especially on the psych wards where it's an absolute must and I don't want to hear any of your lamentations or sniveling. If the smoke bothers your throat do what I do, smoke menthols or don't inhale!" ( Hmm...I wondered if Bill Clinton was a nurse in a previous life, that "don't inhale" business sounds all too familiar.)

The finer points of cigarette smoking included the proper use of ash trays and cautions about letting the ash get too long. Never aggressively flick an ash or use a cigarette to gesture which might give the wrong impression. I never could figure out the rationale for those two rules, but like many other things, there were many mysteries in nursing. The rule about holding a cigarette between the index and second finger made sense. In Chicago only gangsters held their cigarettes between the thumb and index finger.

The opening lecture about smoking set the tone for the entire course. It didn't much matter what your personal feelings or wants entailed, you were going to be a nurse and it was way too late to question the rules. We got what we set out to get and that was the only thing that mattered.

Money was always a hot button issue in diploma nursing programs as alluded to in a previous post, we were not even allowed to carry money because it simply was not needed. The school met all your needs from food, housing, books, and uniforms.

 The third rail in any nursing job interview was inquiring  about salary or compensation. Instant death to anyone foolish enough to ask. Nursing was not meant to provide practitioners with financial stability, but you won't ever be broke and you do eventually learn to navigate desperate situations with your pride intact.

 Asking for or charging other nurses money for  just about anything will rot your pride. I think that's what makes me cringe when I hear whippersnapperns asking for payment for online education or commercial products. I realize we are in a brave new age but I'll never get used to nurses asking other nurses for financial compensation. It makes me very anxious because it makes me feel like bad things are coming and I can almost hear Miss Bruiser's howls in the background.

Working at a charity hospital highlights the unfairness in the world and careers that earn a good bit of money were seen to exacerbate the inequalities in society. Despite the financial precarity of a nurses salary there was a unique kind of ecstasy in helping those in dire straits. The overly productive lifestyle of folks with money begins to appear pointless. So instead of a class on retirement planning or investing we were conditioned to live with very little.

Although diploma nursing school did have a cognitive constipating curriculum, there were life lessons if you could see past the smoke screen. Miss Bruiser's notion of sacrificing every thing for patient care was not sustainable. A nurse's notion of self care has to extend beyond a break for a Coke and a smoke. I think whippersnapperns have a much more realistic notion when it comes to self care.

The lesson that really stuck with me was that it really doesn't require much money to generate happiness and well being. Some of my happiest days were spent in a crumbling third floor apartment with my Raleigh bicycle parked in the hall.

Lucky for me, I really never got the hang of that smoking business. If I had been a successful smoker, it's unlikely I would have survived to become an OldfoolRN!

Sunday, May 2, 2021

Do Nurses Do Windows?

 Yep! Old school nurses were window cleaning experts and I'll let you in on a secret method to make those panes glimmer brighter than a new graduate's nursing pin. Impress your grumpy old instructor and win brownie points galore. So much more fun than dealing with that balky hopper in the dirty utility room, smells a heck of a lot better too!

Step 1: Sprinkle a dash of baking soda on a gently used and lightly moistened ABD sponge. Rub the baking soda on the window and don't be afraid to add some gusto (just like the nurse in the illustration.)

Step 2: Go over the entire window with a plain, wet ABD. Central supply is usually more than happy to provide ABDs that have reached the end of their service life. One thing that does not work well for window cleaning is old, worn out student nurse aprons. I think it has something to do with all that imbedded Argo starch impeding absorbency.

Step 3: Mix equal parts water and vinegar in a spray bottle and mist the window.

Step 4: Buff aggressively with a dry ABD and stand back to admire your work. Just think what a wonderful world it would be if all things in nursing could be as fulfilling as window cleaning. Instant gratification at it's very finest. Cleaning windows sure beats scrubbing emesis crusted beds.