Tuesday, November 3, 2020

Nursing Was a Great Sanctuary from the Forlorn Politics of the 1960's

Chicago Police vs. Demonstrators 1968

 On this election day, my thoughts turn to the days of old school political tomfoolery. Some things never change. The day to day political process in Chicago during the late 1960's was a mine field of toxic emotional response fueled by the unending Viet Nam War. There was the police riot just outside the doors of the Democratic National  Convention in 1968, followed by the mayhem  so freely sewed by Jerry Rubin's YIPPIES.

Richard Nixon's  election and subsequent inability to bring the war in Viet Nam to a conclusion, incited a renewed rift of student demonstrations. SDS or Students for a Democratic Society was the mover and shaker on college campuses and had divided over the issue of violence as a means to end the war.

In the fall of 1969, the Weathermen contingent of the SDS staged the Chicago Days of Rage. Stores were ransacked and police cars overturned. Lengths of chain, slinging case hardened padlocks were one of the weapons of choice. The police countered with batons and tear gas, bringing many of their more seriously injured customers to the ER. Some of the victims arrived at the ER strapped to the back of Harley-Davidson Servicars which were unique 3 wheeled motorcycles. A rough ride on the back of one of these contraptions was one of the social engineering experiments by law enforcement. A ride on these bucking broncos was enough to deter further bad behavior.

I was a 19 year old student nurse at the time and often came in contact with some of the hapless student demonstrators as they were triaged. These well intentioned youngsters sometimes asked me if I was going to attend the next demonstration on Halsted Street in the morning. "No, I have clinical all day on 3B tomorrow. There is no time for any of that if you are a student nurse."

Nursing was a wonderful shield from the political tumult of the day. Being present to my patients in their time of need felt so good compared to the emotional cauldron stewing within the tear gassed and beaten demonstrators. Diploma nursing schools, with instructors like Miss Bruiser on your back all the time, could be trying, but  the monastic life did have it's peaceful moments-some of which I would like to call to mind on this strained election day.

Saturday, October 3, 2020

All Nighters in The O.R. Were Real Stinkers

 

Bovie smoke carried olfactory nightmares into every 
nook and cranny


As lengthy night time trauma surgeries came to a close, nurses were often presented with a cafeteria-like  assortment  of wounds to dress. The deep stab wound on the medial thigh called out for iodoform packing which had a nice, sweet, iodine like scent. After the thigh wound was ram rodded  packed to the hilt with ribbons of iodoform, it was time to dress that monstrous midline abdominal wound. Tincture of benzoin would be applied to secure Montgomery strips in anticipation of frequent dressing changes. Montgomery strips spared the patient the pain of abrupt removal of adhesive tape; just loosen the ties to swap out ABDs.

This juxtapositioning of one scent (iodoform) on top of another (tincture of benzoin) often led to the creation of a completely new and frequently unsavory smell that I thought of as the third effect. Under this principle, when two smells are brought together, their individual effects are irreparably  altered  and potentiated into a novel, foul, lingering witch's brew completely  unlike that of the initial contributors. I think the technical name of this newly created stink fest was compound smells.

 The addition of residual  Bovie  smoke made  the foul smell penetrate every nook and cranny of  just about any object or person in it's path. Just as a syringe and needle transported medication to a site, the Bovie smoke delivered the stink as reliably as a  mailman.

Underlying scrub attire reeked of the compound smell when our impermeable surgical gowns were removed. I always thought of this as the diaper principle, because as long as the gown was intact the smell was relatively contained. Removing the diaper...OOPS...I meant surgical gown was another story as the foul odor homed in on awaiting olfactory senses like a cobra strike.

The best part of a  long night  in the O.R. was the beautiful sunrise over Lake Michigan as this usually signaled an end to the mayhem and the arrival of reinforcements in the form of day shift nurses. Fresh, kindly arriving nurses always stopped to help the  worn out, bone tired trauma victims and I'm referring to personnel-not patients.

One July morning, my friend Janess, bounced into the room as a case came to a conclusion to act as cheerleader and help us off with our gowns. I noticed her eyes and jaw roll as her eyebrows popped toward the top of her head as she assisted. She looked distressed - to say the least.

 The next day I thanked her for the moral support adding, "We must have looked pretty bad, Dr. Salmbow and I felt like we had been beaten to a pulp after that doozy of a case."  I'll never forget her immediate response, "It wasn't how you looked. It was how you both smelled."

Wednesday, September 9, 2020

Lights Out in The O.R.

 



Late night trauma surgeries were performed in  a parallel universe diametrically opposed to run of the mill, day-to-day, elective surgery. In place of the measured orderliness, gowned and gloved players were often blinkered by an all consuming bone tired, sense of fatigue that descended on the room like a choking mist. The emergent condition of the patient spurred a driving sense of expedience among the weary staff. Fatigue and the hurry-up nature of trauma surgery can have bad consequences no matter how well intentioned the staff, a lesson I was about to learn the hard way.

Delusional thinking, fueled by the infinite wisdom of youth, falsely told me that fatigue was a nonissue.  I sometimes played make believe, telling myself  that fatigue actually made me perform better by focusing on the things that really mattered.  I often felt like the grand wizard from the land of OZ. Hidden behind the curtain of mask and gown, I was just pulling on the strings and manipulating the levers to quickly load needle drivers and collect bloody sponge sticks.

My delusion of being fatigue proof was about to be shattered when the phone in the call room awakened me with an 0200 hour  emergency one early Sunday morning. The trauma gods always got restless on Saturday nights in Chicago. It was a harried nurse from the ER advising me that a hot trauma was being loaded unto the elevator for a nonstop flight to the 7th floor OR. A teen aged stabbing victim with volume depleting abdominal bleeding was our patient and the ER nurses had applied a scultetus abdominal binder in hopes of slowing things down. Not an encouraging prognostic sign.

The Lakeview  neighborhood was home to the Aristoctats, a youth gang that often meted out punishment with the blade of a knife. Firearms were thought to be unmacho and eschewed with youthful vigor. Not a bad concept in my book, as knife  wounds were more amenable to surgical repair. 

Although these kids looked menacing on the street, on the OR table they looked like the vulnerable little children they were. Their vicious behavior was often mixed with the typical adolescent sense of humor and more than one of them smiled as they related, "It's not how deep you stab your knife, it's how you wiggle it around."

I had just finished setting up my back table as the bleeding youngster crashed through the doors accompanied by the usual cast of lifesavers, pushing the gurney like it was a guided missile. Dr. Slambow had gowned and gloved himself while I quickly tossed  together a basic laparotomy setup. I was loaded for bear, complete with a boatload of Satinsky vascular clamps. My heart always did those little flip flops when an attending surgeon volunteered to gown and glove independently without the help of a nurse. Something unsettling was usually close at hand.

Dr. Slambow urgently announced that this was going to be a "Whoop-dee-doo" case. (His unique vernacular for an O.R. free-for-all.)  He  was going to start cutting  immediately without the anesthetist present. The patient was unconscious with a secured airway, but cases like this always hit me with  a feeling of raw, primal panic. Obeisance to sterile technique was tossed to that void behind the vacant ether screen and  questions like, ""What if he wakes up while we're inside his belly?; Can we stop the bleeding in time?;  Do I have all the instruments and supplies?;  What happens if that fenestrated sheet that I hastily tossed over the patient for a crude drape falls off?" I don't think there is anything more pathetic  when a drape falls to the floor exposing an unfortunate  little kid with a big hole chopped down the middle of his puny, little bread basket. Truly the stuff of nightmares, at least for me.

Things went better than expected. After Dr. Slambow carved a midline incision and  sucked out the blood things began to slow down. The inferior vena cave was intact along  with all of the other major vessels. The bleeding was brisk but confined to lots of superficial venous circuits and the spleen. After a quick splenectomy, the bleeding was pretty much under control. Dr. Slambow would clamp off a group of bleeders together and give the command to "meatball it" so the resident would tie the mess off in the shape of a little sphere. After making a few meatballs we were done cooking and the patient was doing well.

The O.R. room for trauma  was one of the oldest on the floor, selected because of its proximity to the elevator and nearby autoclave which although vintage, worked great for flashing a last minute instrument or preparing Thanksgiving dinner. We even nicknamed the old autoclave Mr. Yell N' Cuss because that's what we did when the door was unbolted and we got hit with a burst of steam due to a constipated venting mechanism.

During  the emergency trauma  surgery  I noticed, Clarence, our diligent housekeeper, peering through the porthole-like window in the door. I thought  that he was admiring our lifesaving surgery, but when the case was over, Clarence wheeled his mop bucket in with a perplexed  expression. "You folks 'spear- menting again?" he asked. "What do you mean by that Clarence?" I asked.  "You done that whole operation without the great big overhead lights tuned on!" Oh my gosh, I could not believe what we had done. I ran to the surgeon's locker room and updated Dr. Slambow on our oversight. In a tired voice he wearily explained, "Well the ambient lighting was pretty darn good and we weren't deep within a body cavity. Sometimes things work out in spite of our screw-ups."

Friday, August 21, 2020

Zomax Was an Anguished Analgesic

 "Now I know how Zomax works. My stomach aches so bad 
I don't even notice my fractured femur!" (GI  distress was a 
common side effect of Zomax.)

Pharmaceutical representatives also known as drug salesmen had free run of the hospital in the early 1980s and offered endless supplies of assorted trinkets and free lunches to all who would listen to their huckstering. A revolution in pain relief by an innovative new analgesic supposedly as strong as a narcotic, but non-addicting , Zomax, manufactured by McNeil labs was the hot new product in 1980 and the sales folks were chomping on the bit. Alas, a non addicting drug as strong as morphine was too good to be true.

Zomax  marketing was unique in that ordinary nurses were targeted by the vulture like drug salesmen. I suspect McNeil was emboldened by their success in marketing the anesthetic, Sublimaze, to nurse anesthetists. The American Association of Nurse Anesthetists even increased their case load requirement for anesthesia  students using Sublimaze after McNeil greased the skids for their product. 

Like Pavlov's dogs, every nurse was conditioned to always have a pen, scissors, and a watch. There was even an organization to recruit unsuspecting, innocent youngsters to the brutal field of  nursing known as Penwaciez which was named for the 3 things a nurse must always have in her possession: a watch, pen, and scissors.

 McNeil had this holy nursing equipment  triumvirate covered with a cheap Chinese made nurse's watch with a huge Zomax insignia on the dial. It did work well until the non-replaceable batteries bought the farm and  even had a nice white band. Most nurses were easily suckered into the corporate marketing gamesmanship because it was rare for anyone to give nurses  much of anything. Physicians were the traditional recipients of pharmaceutical company swag. Fancy golf club cover ups and writing instruments were popular. 

Zomax pens were  soon ubiquitous at every nurses station and were really nice upgrade  from the  cheap Bic stick pens we were raised on. Zomax emblazoned scissors were functional and were one of the first bandage scissors with blue plastic covered handles. We liked them a lot even though "Zomax" was emblazoned on any place available..

With nurses being the boots on the ground for Zomax marketing, McNeil came up with a battleground themed sales campaign code  named "Operation 111." The  notation represented the 111 million dollars the pharmaceutical company planned to gain in sales when the drug was introduced. A salesman summed the scheme nicely, "We're calling it operation 111. Now if that sounds like a war, well in our world of sales that's what it is." Sales memos were complete with a crossed rifle insignia as well as tanks and fighter planes. Fighting and battle themed analogies are all to common in health care, but the human body was never meant to be a battleground.

Nurses were bombarded with the mantra that 100mg. of Zomax was the analgesic equal to 10mg of morphine and there was no risk of addiction or tolerance. The centerpiece of a sales meeting with medical folks frequently featured  a small ornate punch bowl filled with single Zomax pills wrapped in colorful foil which glowed incandescent in the room light as a beacon in the fight (oops another war analogy) against the formidable foe of pain. We were invited to help ourselves to experience this breakthrough analgesic. I took one for low back pain and my stomach felt like a threshing machine left out in the pasture way too long. One dose was more than enough for me and I had a tough time figuring out which was worse my stomach distress or my back ache. 

Zomax pills were manufactured in the shape of a cute little house or cottage. The soothing green tint and image of a happy pain free home, sweet home were definitely alluring. As the big name pharmaceutical  houses began to loose patents to generic manufacturers  on their lucrative name brand  drugs the age of distinctive pill making was hatched. The most unusual of the bunch was a molded hollow scripted Valium pill. Roche had really out done itself with this design. The hollow fancy scripted "V" appeared to float in the center of the pill.

Despite the fact that most nurses were unimpressed with Zomax's efficacy, it did produce 15 million prescriptions in the first 2 years on the market. Trouble was on the horizon. In March 1983, McNeil announced the drug was being pulled from the market as a result of 5 deaths following Zomax ingestion.

It was discovered that one of the metabolites of Zomax caused an anaphylactic reaction in a small subset of users. Over time, especially with intermittent use, antibodies  accumulated  and caused the adverse reaction. For the time being the dream of a non-addicting analgesic was dead.

Sunday, July 26, 2020

Alice Was the Grand Poobah of the Operating Room

God bless dear old Alice until she eats you alive
I've posted many times about my all time favorite OR supervisor, Alice.  During these sometimes discordant  COVID times I miss her strong willed imposition of order and discipline. Alice was like a gas heeding the laws of physics.  She could fill the entire room with her  presence  by virtually wearing authority the way a meticulously attired nurse wore her blindingly white uniform. At the ripe old age of fifty something, command was hers because it was earned by spending decades in the boiling cauldrons of  operating rooms and their combative surgeons. She had dodged more flying instruments and administered more scores of painful knuckle bashings with a sponge stick than I care to remember.

Her repertoire of corrective interventions consisted of humiliation, infliction of pain and  shows of physical strength (Alice had the upper body strength of a linebacker on steroids.) Pain was usually delivered by a snapping blow to the wrist and/or fingers by the business end of a long sponge stick. The length of this instrument could deliver a blow of variable power based on where the fingers grabbed it to form a fulcrum. I usually sustained  the full meal deal for my transgressions with Alice grasping the instrument at the hinge and really winding up. Passing an instrument to a resident before serving an attending or counting sponges too fast or slow were typical transgression. Any break in aseptic technique was also harshly corrected.

While scrubbed on a long, grueling oncology case I began subconsciously doing hamstring stretches at my Mayo stand and lo and behold Alice strolled in. I knew I was in for one of Alice's lectures about how scrub nurses were supposed  to be uncomfortable and any unnecessary movement was a vector for the spread of that dreaded entity known as perineal fallout. Personal comfort and well being of her charges was as much  a priority to Alice as mindfulness was to Moe Howard of The Three Stooges. Luckily, Dr. Slambow saved my hide. As he was meticulously fileting a duct he said, "Alice can't you leave him alone. I can't do this without him." It really paid off making
your services indispensable to surgeons. I always thought of it as the best job security move a scrub nurse could make.

Alice's show of physical strength was also quite impressive. I've seen her single handedly transfer patients of her weight with the ease of an Olympic weigh lifter. She claimed that manually cranked beds were one of the best forms of upper body exercise and who would argue that point with a hulking Alice?

Alice made it a special point to mentor medical students in her own unique fashion. I knew what was coming next when one especially whiney student complained she could not see the operative field. Alice stealthily approached the novice from behind and ram rodded her lunch hook-like hands under the miscreant's arm pits and lifted her a couple of feet off the floor. She always followed maneuvers like this with a suggestion to utilize platforms instead of bitterly complaining.

Old nurses like Alice lived for nursing which was the alpha and omega to their life. Her idea of self care was a quick break for a Coke and a smoke. I never questioned Alice's dedication to her patients because it was her whole life.

Tuesday, June 30, 2020

The Emerson 3PV Ventilator (Circa 1964)

Gather round the ol' manually cranked  hospital critical care bed all ye Whippersnapperns and take a quick little quiz on the history of air becoming breath. What do you get when you combine a Westinghouse hot plate, an ordinary natural gas meter, a couple of AC delco automotive switches, a trombone slide, copper mesh and a V belt from a 1960 Chevrolet Brookwood? House them all together with an air pump in a Maytag washing machine cabinet and you have a pioneering ventilator known as the Emerson 3PV.
The control panel of the Emerson 3PV ventilator shows it's
Maytag roots. Does that black knob control the rinse cycle or tidal volume?
Although a high school dropout, Jack Emerson was an innovative young man. His 2 brothers were physicians and Jack being an inquisitive young man, asked them what they needed in their medical practice. At age 22, Jack bought a rudimentary machine shop at an estate sale and began manufacturing medical equipment. His first device was an automatic agitator for laboratory use.

The idea for a cost effective ventilator came to light when he heard one of the leading trauma experts of the day, R. Adams Cowley, complaining about the high cost and availability of Engstrom ventilators which were the standard of the day. Dr. Cowley received  a $100,000 dollar grant to research shock following trauma and had to spend most of it on expensive Engstrom ventilators. A cost effective ventilator would free up grant money for other vital research.

After some tinkering in his Cambridge, Massachusetts machine shop, the ever enterprising Emerson cobbled together a ventilator created from a hodge podge of ordinary and readily available household and automotive parts. His unique creation was the first ventilator marketed with a humidifier thanks to the hot plate and a water vessel.

 Modern ventilators have filters to prevent contamination, but Emerson's 3PV went a step further. He incorporated copper mesh in the return tubing. Copper has antimicrobial properties and actually kills bacteria and viruses by degrading the cell membrane or protein coat of the virus.

One thing missing from Emerson's pioneering ventilator was an electronic monitoring screen made by extracting toxic elements from the earth via a process that is probably slowly killing us. Old school practitioners were satisfied with watching the rise and fall of the chest and auscultating breath sounds to verify ventilatory function.

Simple devices like Emerson ventilators have an inherent beauty. One way or another we could all wind up flat on our backs with a ventilator chugging away in the background. While we are thinking, "Is this all there is?" an image of the ventilator blowing air into our wounded meatsacks appears in our peripheral vision. I know my emotional bandwidth will feel like it's been hit by a grenade if I see a computerized microprocessor controlled gizmo keeping me alive. Find one of those old Emerson's in the basement somewhere and I'll be smiling even with that endotracheal tube jammed down my old, foolish craw.





Thursday, June 4, 2020

Don't Crash That Gurney

It's all fun and games when pushing an old Gurney in a straight line.
Objects moving through space at high speed with a sense of urgency are prone to mishaps. No, I'm not talking about the space shuttle Challenger. I'm thinking of  old school hospital Gurneys which were also known as prams, trolleys, or carts. These unwieldy conveyances had tiny wheels which were really more like casters. Each wheel had an independent locking mechanism that was activated by stomping on a tiny lever.

Adding the weight of a patient to the cart  resulted in a very high center of gravity that conferred an inherent lack of stability. Vintage Gurneys had no counterweights in their base like the meticulously engineered transport devices present in today's hospital. Tiny wheels, poor brakes and a high center of gravity were the recipe for disaster.

Pushing an old fashioned Gurney in a straight line at low speed was a walk in the park. Speed, uneven terrain, sharp corners or heavy loads were complicating issues and relevant factors in Gurney crashes

Crack ups while rounding corners with a loaded hospital trolley had some of the same elements as motorcycle wrecks. I've had personal experience with both types of mishaps. High side motorcycle and Gurney crashes are among the most catastrophic because the patient I mean, rider is thrown off the vehicle ahead of the line of travel of the vehicle and risks not only the fall but the cart or bike then plowing into him. The cause of these crashes is suddenly regaining traction after sliding or skidding around a corner. In the hospital any type of liquid spilled on heavily waxed terrazzo floors is the most common hazard responsible for high side Gurney mishaps.

More benign crashes are of the low side variety where the bike or   Gurney simply skids around a corner and the conveyance  slides sideways gently spilling the patient. Thankfully, this is probably the most common type of Gurney crash and results in minimal injury because the driver is often able to contain the patient before he impacts the floor. Collateral damage from broken glass IV bottles is a common complication of low side wrecks. The Gurney driver is usually in an emotional hyper response  state with marked frontal lobe detachment  after one of these mishaps and hastily picking up glass shards can result in colorful displays. Please, don't ask me how I know about this one but the scars on my fingers are probably a dead give away.

Another factor in gurney wrecks is overloading or raising the center of gravity by personnel standing on the cart for procedures like joint reductions.https://regionstraumapro.com/page/3.  This graphic illustration of an intrepid emergency medicine physician is a good example of a high flying reduction. Hopefully the good doctor  returned safely to terra firma when the procedure was completed.

CPR perfomed on a rapidly moving Gurney always reminded me of a rodeo where a sudden fall is awaiting  the rider.  The nurse performing compressions (somehow it was always a nurse in the saddle) straddled the patient while maintaining the exquisite balance of a Brahama  bull rider as the Gurney surged forward toward more definitive care. Once again the center of mass is raised and the urgency of the situation always manages to exacerbate the propensity for a mishap. The nurse furiously doing chest compressions above the patient was the canary in the coal mine since she was likely to take a tumble before the patient fell. Caution usually prevailed when the Gurney driver sensed the CPR provider was about to take a tumble and slowed everything down befor a crash ensued.

Just like Gundam mech robots patrolling an infinite universe,Gurneys were just about everywhere in the hospital orbit. Gurneys always held a warm spot in my heart because I saw them as a symbol of unification and, oh boy,  we could sure  use some of that in these difficult times.. We are all going to take that last Gurney ride someday no matter what event terminates our earthly existence. Pay close attention to the next soul you see on a Gurney because they can show us all how to take that final ride with a dignified sense of peace. All bets are off if an OFRN like me crashes the cart.