Wednesday, October 10, 2018

Drinking Bile

No, that's not bile in a T-tube drainage bag. It's a bilious beverage 
just waiting to wet your whistle. Bottoms up!

Waste not / want not was the mantra in epoch hospitals. This philosophy led to events like performing sterile procedures with 2 fingercots and overly judicious rationing of utilities. There were almost no lights on after dark so night nurses always had a flashlight on hand. Recycling and reuse were common with "disposable"  equipment having an almost infinite life span.

Recycling was not limited to medical equipment. Gall bladder surgery was a brutal and miserable experience  with a huge subcostal incision in close proximity to the diaphragm so every breath exacerbated post-op pain. A T-tube was usually placed in the common bile duct during surgery and drained the greenish yellow unsavory goo in a nearby bag.

Bile is a vital component in the digestive process and works to emulsify and break down fat. A deficit of this greenish gooey fluid results in an unpleasant condition known as steatorrhea whereby fat passes through the intestines undigested. An unusually putrid scented diarrhea is the end result.

To avert steatorrhea old school surgeons had a very direct and straightforward solution.  They ordered the night nurse to save the contents of the biliary drainage bag and serve a glass of this gruesome green goop to the patient prior to breakfast. Hospital breakfasts were notorious for their high fat content. Just about every meal was a permutation of that All American staple, bacon and eggs which was a steatorrhea stimulator of the highest order.

The disgusting bile beverage was best served in an opaque vessel such as a coffee cup so as to obscure that yucky green visual stimulation. Minimal explanation was also important. The nurse never drained the bile into the serving container in view of the patient. Optimal bile bag emptying was done with the patient sound asleep and unaware of the impending tortuous tipple. Old school nurses were masters of deception and were even known to ask patients to turn over for a temperature check. While they were prone a painful and totally unexpected intramuscular injection was hastily administered.

The bile drinking gambit  was not much different than the stealthily plunge of the 18 gauge needle during the temperature diversion injection. Either experience was misery of the highest order no matter how it was presented. Bile had a unique earthy/nasty scent to it that could not be masked and the bitter salty taste was cringe worthy. Oh..And be sure to offer mouth care after bile consumption. It promoted dental decay.

Did bile recycling help patients? That's a tough question. Perhaps the diversion of consuming the vile liquid distracted them from their symptoms. It's always prudent to maintain a high level of suspicion when offered just about any beverage from an old nurse. Better safe than sorry.

Wednesday, October 3, 2018

High Tech Hemorrhoid Surgery Meets Old School Positioning Techiques

The advances in modern surgical technique always amaze me. I recently found myself fascinated by a  newfangled hemorrhoidectomy procedure. The surgeon was working with a high tech laser device and magically zapping the 'rhoids into submission while an assistant struggled to manually pry the buttocks apart with the patient flat on the table. High tech meets low tech in the totally unnecessary and difficult manual retraction for operative site exposure. Leave it to OFRNs like me to offer tips to improve the bottom line.

Old school hemorrhoid surgery was a backward, crude sort of affair. A surgical assistant grabbed the offending hemorrhoid with a Babcock and pulled it skyward. At this point Dr. Salmbow would give the command, "Meatball it!" The stretched pile was quickly tied off with a ligature and cut free with a Metzenbaum scissors. Then it was on to the next 'rhoid. At the conclusion of the case some wise guy was sure to proclaim, "We really Wrecked EM." Nurses were always advised to chuckle at a surgeon's attempts at jocularity.

Proper positioning was key to this procedure and there was none of that  struggling or manual prying of the offending, shielding nature of the site occluding  buttocks. Old school OR nurses were adept at exposing just about any body part with the use of sandbags, rolled washcloths or towels, airplane belts,  and  3 inch J&J adhesive tape. The secret ingredient was tincture of benzoin which was the old time equivalent of modern super glue.
Hemorrhoid surgery began by placing the patient in the jack knife position as shown above. The buttocks were then liberally painted with tincture of benzoin which usually brought out the Picasso in me although  I suspect he never had a palette like this. The benzoin served to affix the adhesive tape aggressively to the skin. Next a 3 inch by 2 foot section of adhesive tape was applied to the buttock and then pulled laterally like a piece of taffy. When the "pull" was sufficient the opposite end was wrapped around the under table rails of the OR table. An additional strip of tape could be applied at a right angle to  this main "spreader" for oversize patients. The end result; a perfectly exposed operative site.

Abrupt removal of tincture of benzoin secured adhesive tape frequently enhanced a patient's emergence from general anesthesia. That stuff was a real challenge to separate from the skin in a civilized manner.

I often thought that the Preparation H folks should advertise by showing snippets of forcible hemorrhoid removal. Hemorrhoid surgeries were enough to convince me of the value of topical treatments.



Monday, September 24, 2018

Fun With Operating Room Kick Buckets


My recent visit to Pennsylvania Dutch Country rebooted a long dormant memory of an unfortunate incident  with that wheeled dervish, an operating room kick bucket. The Amish eschew internal combustion engine powered transportation devices in favor of things like foot powered scooters. One foot remains firmly planted on the scooter platform while the opposite lower extremity propels the device with intermittent kicking motions. As we shall see, that mode of propulsion is not exclusive to Amish scooters.

Kick buckets in the OR are similar to Amish scooters in that they share the ability to move through space on wheels and are about the same size. My tale begins as another long case comes to a conclusion and I am involved in the usual post-op prattle with Janess, the exhausted scrub nurse. As she descended from the artfully OFRN designed scrub nurse  platform her foot landed smack dab in the middle of a carelessly positioned  kick bucket. The wide opening at the bucket top guided her foot into the much smaller base firmly entrapping and immobilizing her leg in the contraption. Luckily the bloody sponges had been removed from the kick bucket or the situation could have been rather messy.

The ensuing commotion soon aroused the attention of our hypervigilant supervisor, Alice, who added to the cacophony with one of her bitter diatribes. "Look what you've done now you clumsy little goofus. I've got a mind to teach you a lesson that you won't soon forget," shrieked Alice.

Janess was now a hostage of her sympathetic nervous system which activated the flight or fight instinct. Alice was a contentious character with a military background so the only viable option was flight without further ado. With one foot entrapped in the confining but mobile kick bucket, Janees used her free extremity to propel herself through the open door with all the skill of an Amish scooter driver. Alice was not up to speed with her arthritic knees so Janess was able to open up a substantial lead and soon disappeared into the locker room. The ensuing laughter soon took the wind from Alice's sails and we all lived happily ever after...sort of. Folks that work together in stressful environments like operating rooms often transforms themselves into one big dysfunctional family. It did not seem like much fun at the time but in a strange way, these were some of the best years of my life.

Sunday, September 16, 2018

I'm unplugging ( Tee Hee - as if Oldfoolrns  like me can be plugged in) and heading to PA Dutch country for a week or so. I just love being around the Amish and maybe I can think of some new posts worth reading.

Thursday, September 6, 2018

Ring Stand Challenge Racing

An official makes last minute preparations to the race course.
Old school operating rooms were brimming with an assortment of unsavory, unpleasant and downright dangerous tasks; from unclogging floor drains occluded with who knows what to running test firings on  hissing and sputtering behemoths that passed as autoclaves. Who cleans up the room after a trauma case and who tends to the patient?  We used to draw straws with discarded suture for the equitable assignment of these nasty tasks. For the athletically inclined, the alternative to games of chance like the drawing of straws  was ring stand races with the winner awarded the undesirable  task of their choice.

Ring stands were a piece of operating room furniture designed to hold large basins of solutions used during the case. Before the advent of modern  disposable surgical gloves ring stands were used to rinse talc off reusable gloves. This ubiquitous piece of equipment was a favorite plaything for old school OR nurses. Contests of skill involving the tossing of various objects through the ring stand gradually evolved to attempts involving the passing of  an entire nurse's entire body up from the base of the stand and out of the elevated dastardly top disc that served as the finish line. The contest obviously favored the petite, lithe, thin contestant. Since I met none of these criteria, I was an almost certain loser and frequently found my self with a ring stand stuck on my ample waistline. My buffoonery quickly transitioned to outright embarrassment as the laughing of my colleagues crescendoed .

An official race began with 2 nurses facing the race course ring stand. On the "GO" command the nurses slid down to the floor like a limbo dancer and contorted their way up through the opening in the ring stand. The next stage of the contest was the hard part and involved slithering your body all the way through the ring stand with the victor emerging free of that confining circle. Older nurses always positioned the ring stand parallel to the OR table and leaned against it for assistance. Lithe youngsters could use their upper arm strength to rise above the confining circle. Victory was sweet with the winner having a justified sense of power knowing the choice of unsavory tasks was their choice.

For my next post, I'm thinking about another piece of OR furniture that could be more fun than a barrel of monkeys - the kick bucket.

Monday, August 27, 2018

Caring For Amputated Limbs

The brave new world of modern healthcare culture continues to dumbfound, agitate, and get stuck  in my old foolish, wrinkled up craw. The latest outrage?  I was reading an expert's answer  on Quora that amputated limbs are treated as "medical waste" and are disposed of by encasing them in a red sealed plastic bag marked with a biohazard symbol and sent on their merry  way to a landfill or incineration.

Self respect starts with caring for others in a dignified fashion.
Don't even think about tossing this in the trash!

Since everything in healthcare is governed by money, I suppose this is the cheapest  most cost effective means of limb disposable. Preoccupation with money when it comes to caring for people leads many in the wrong direction. Patients are never clients or accounts and caring for them is not an "industry."  That amputated limb was once a part of someone who is going to have a tough time, to say the least, of dealing with a new body image and learning a new lifestyle. An amputated limb is not an inflamed appendix or a gall bladder full of stones to be tossed in a kick bucket and tossed aside, it was part of someone and their identity. Who knows? Maybe an integral component of the patient's spirit was living in that limb. Treat body parts with the respect they deserve.

Alice, my favorite OR supervisor taught me how to care for an amputated limb many years ago. Alice could be a mean, cantankerous taskmaster, but I agree with her wholeheartedly about showing care and respect for an amputated body part. Despite their harsh appearances, old school nurses had and an innate sensitivity and were determined do-gooders.

When it came time to care for my first amputation patient in the OR, Alice was on hand for direction. "The first order of business is to line up 2 carts just outside the OR. One cart is for patient transport ant the other is used to transfer the amputated leg to the morgue. I don't ever want to see one of my nurses toting a large specimen through the halls like it was a suitcase. You will reap enough negative Karma to burden you forever with that trick." That last line said with Alice's all-knowing conviction made me shiver in my OR shoe coverings as I imagined an amputated limb coming back to haunt me. You better believe I conducted myself with dignity when showing respect to that amputated leg.

I carefully placed the amputated leg smack dab in the middle of the cart and carefully covered it with a white sheet. The trip to pathology was uneventful until I nudged open the door to the morgue and found the pathologist in the midst of an autopsy. He had just plopped a liver on the overhead scale when he noticed me and nonchalantly asked, "what can I do for you?" I stuttered and stammered that I was here with a large surgical specimen. He called  over to  a resident and advised , "Take aerobic and anaerobic cultures and some tissue for microscopy then show the nurse how to put the leg at rest."

One of the hospital  board members was a funeral director and donated a very nice metal casket to the hospital for one specific purpose; the dignified burial of amputated limbs. After the path resident obtained his specimens the amputated leg was wheeled over to the elevated casket in the back corner of the cooler. I gently raised the substantial lid of the coffin and gently nested the  severed limb inside. There were a number of other limbs resting comfortably in the ice cold  casket and when I was finished with the transfer I covered them all back up with a hand knitted shawl lovingly crocheted  by a dedicated member of the Ladies Auxiliary. The limbs were at peace.

The hospital purchased plots at a nearby cemetery where the limbs were carefully buried when the casket was full. I was curious how often burials occurred and was advised it was an annual event complete with a religious official and a few of the path personnel to show their respects.

Years ago I entertained myself with notions of working again as a nurse, but as I thought of the money grubbing corporations running the show my mind did an abrupt 180. My values come from a different place in time and although I failed many, I think my heart was in the right place. I plain just don't believe in nursing the way it's practiced today and the image of treating limbs like trash haunts me.

Tuesday, August 14, 2018

What Was the Official Cigarette of Your Diploma Nursing School?

There were so many diploma schools of nursing in the 1960s that each class adopted their own unique motto, school colors, and slogans. There was no formal mention of the fact that each class had their own preferred brand of cigarette. Brand loyalty was the byword and everyone wanted to feel part of the same "club," so there was minimal deviation from the standard brand of smokes.

I dug out my old nursing yearbook from my basement  junkpile archives and refreshed my memory. Our class colors were light blue and navy blue, class flower was a white rose, class moto was A journey of a thousand miles begins with a single step, and the class philosophy was "I have no yesterdays ,tomorrow may not be--but I have today." Last, but not least the class cigarette was KENT. Student nurses tended to mark their territory and Kent cigarette butts were virtually everywhere. Favorite ashtrays included the orthopedic beds with big gaping holes for attaching traction bars and even unused suction bottles on the Gomcos used for demonstration.

Cook County School of Nursing students lived up to their hardcore image by smoking disgusting unfiltered Phillip Morris Commanders. You could always identify a Cook County Nurse by her nicotine stained brown fingers.

Ravenswood hospital was bicultural when it came to cigarette usage. Both Kools and Winstons were in vogue here. I guess the nurses could not come up with a consensus which was a frequent problem in nursing when critical decision making was required.

When I relocated to Pittsburgh the official cigatrette custom was in full force. At Montefiore Hospital all the nurses smoked Salem Light 100s. I think the 100mm length was a thoughtful choice because it served as a break extender.
I betcha Nurse Bonnies classmates were Red
Apple Smokers. An apple a day keeps the Dr. Away??