Monday, February 19, 2018

Major Operations and Thoughts and Prayers

A long, long time ago the mere mention of a major operation had genuine meaning for surgeons and nurses. It commonly referred to entering the peritoneum (abdominal cavity,) chest, or cranium. This was big time intervention and "major operation"  was a call to arms.  Hypervigilance and extra care were to be expected when it came to aseptic technique and surgical procedure.  Damp dust the overhead lights with alcohol soaked rags and be extra diligent with those hard to reach areas.  Buff those instruments to a nice shine with that trusty 4X4 during the case. Implement hypervigilance when it came time to count sponges.

"Major operation"  as a call to special action began to lose luster as more aggressive open procedures became commonplace. The term was tossed about casually and soon devolved into jocularity. Say, have you heard about Lansing Michigan? that was a major operation.  As a nurse scraped that brown crud from a coffee percolator (remember those?) someone was bound to wise crack, "That looks like a major operation." At the end of my nursing life  in the OR, the term had fallen into extinction. That was the end of the blathering about major operations.

Lately I have been thinking about all those thoughts and prayers platitudes extended to the victims of mass violence. Mass killings have been occurring with the regularity of a Circadian Cycle and the predictable avalanche of thoughts and prayers has likewise crescendoed.  Mass killings...thoughts and prayers, rinse and repeat.

I betcha God has had a bellyful of these thoughts and prayers when they become a substitute for accepting responsibility and taking meaningful preventive action.

It makes my head spin when I consider the logistics of treating so many gunshot victims. In the good old days, which in reality, were not all that good, a couple of  Chicago style gunshot wounds would upset the apple cart. Rounding up appropriate staff  at all hours and disrupting OR schedules for the next day. Thoughts and prayers has become the linguistic equal to major operation.

Tuesday, February 13, 2018

A Slide Rule Life Lesson

As a quiet young high school student, I had all the personality traits of a nerd, but lacked the mental horsepower to lay claim to the moniker. Siting in a class room, I found myself staring in horror at a gigantic model of a slide rule. Keuffel and Ester was the intimidating logo plastered on the mysterious looking device. Numbers on scales that moved laterally as the thing was expanded. I could not make heads or tails of it.

"Looks like a warning not to take physics class," I muttered to myself  under my breath. Mr. Green, a beloved teacher overheard my mumblings and immediately disagreed. "You can learn how to do calculations with a slide rule if you put your mind to it. Anything worth while is worthy of your time and effort."

Mr.  Green was one of my very best teachers. The concept of being a life long learner had yet to be recognized, but whatever the notion was called back then came through clearly in his lessons. He really was interested in my answers to physics problems and made tests interesting with references to Red Ryder BB guns and bowling ball pendulums.

To study waveforms, Mr. Green constructed home made ripple tanks and I spent more time admiring the elegant simplicity of his creation than learning about waves. The time and effort he invested in making physics interesting communicated the importance of learning. It's amazing how much easier it is to learn when the importance of the subject matter is recognized.

Yes, I did learn how to use that intimidating looking slide rule and can still recall the "C" scale is on the slide and the "D" scale is on the body....I think. At least my long term memory is clear as a bell, now if I can only recall what I ate for lunch. That's a post for another day.

In nursing school calculating dosages and solutions required lots of multiplication and division. I resurrected my old trusty slide rule and even taught a few of my classmates how to use it. They were impressed with my lickety-split calculations, but the real thanks belonged to Mr. Green.

Working from multiple instrument trays as a scrub nurse could really get my dander up, but I always thought of Mr. Green and reminded myself that I could learn how to manage the task, after all, I was able to master that blasted slide rule. Thanks, Mr. Green

Thursday, February 1, 2018

Cats vs. Dogs, ADNs. vs. BSNs, and the Ultimate O.R. Conflict: Burners vs. Knotters

These are certainly disunited times and there are many divisions among  nurses. The  endless ADN vs BSN debate has a life of it's own. Being an old time diploma graduate, I don't have a dog in this fight and will stick to conflicts I have direct experience with. When it comes to controlling bleeding in an operating room there are two very distinct and different types of nurses with profoundly diverging  ideas.  One group, the Burners,  just love to support surgeons using offensive, humming and smoking  electrocautery devices  or "Bovies." The  opposition composed of older, more  wise thoughtful nurses likes to cut ligatures for manual ties. I affectionately refer to them as the Knotters because nothing maintains hemostasis like a tightly secured and knotted ligature.

Opening an abdomen is done in sequence and when you are waiting for someone to fall asleep before you scar them for life, it's prudent to take a thoughtful, careful approach to minimize the inherent barbarism. Compassion is always best delivered person to person rather than nurse to patient so it's a good practice for the scrub nurse  to stop and think if this is how you would like to be treated lying on that cold, skinny table. Can you imagine your naked derriere  plastered against that gooey, mucilaginous, ice cold  Bovie  grounding plate smeared with conductive gel while the surgeon makes like Smokey the Bear and burns every bleeder in sight?  The alternative, silently tying off bleeders with ligatures is more appealing to the senses and exudes a kinder, gentler, more considerate approach.

 The buzzing behemoth  of a  Bovie  unit is the  Burners favorite piece of OR furniture (back in the day we had furniture, not equipment.) Bovies were an electrocautery device that looked like a Maytag and had connections for three electrical cords. One was plugged into the wall socket, the other connected to a large metal grounding plate the size of a cookie sheet which was smeared with conductive gel and unceremoniously scooted under the patient's buttocks right before they  fell asleep. the third cord was connected to the business end of this buzzing monstrosity of a machine and resembled a ball point pen.

Some of the Burners were frustrated artists and made the application of conductive goop to the Bovie grounding plate an exercise in self expression. That big metal plate was their canvass and the goop their medium. I noticed one of these Burners with her bouffant cap on sideways to mimic an artist's beret scribbling away with the goop and mentioned her sketch looked like it was part of a freight train. "Oh no...It's a caboose for the  patient's caboose," she haughtily replied. Never interrupt a burner at work on her art.

I always shuddered when I considered the last conscious thought  a patient had before anesthesia induction  was what it felt like to land their  keister on an ice cold, gooey piece of ice cold  metal. It reminded me of someone sitting in a giant tub of Jello. YUCH!

The Bovie generated a high frequency alternating current that was passed through the patient's body. There was minimal resistance at the grounding plate on the rear end, but lightening in a pen at the business end controlled by the surgeon operating a foot switch. There was big time electrical resistance at the Bovie tip: enough to occlude a vessel in a jiffy.

After the skin incision, venous bleeders begin to appear as little dark blue puffs of blood. The glistening white fat tissue forms a beautiful background for the little  pops of blood as the veins are cut. This part of the surgery always reminded me of those old 12 O'clock High TV shows with Robert Lansing. The puffs of blood resembled the bursts  of the anti-aircraft flack exploding near the vulnerable B-17s. "Hey doc we have a bleeder coming up fast at 12 o'clock," I sometimes felt like hollering out. The Bovie smoke further added to the flack resemblance. Members of the Greatest Generation made us Boomers look like slackers and surgeons from this vintage were very proficient Knotters.

Burners were very fond of simply snatching a bleeder in the jaws of a hemostat and then tapping the ringed handle with the Bovie. A puff of nostril bludgeoning smoke and that was that, no more bleeding.

For the knotters this was a time to pause and hand off meticulously cut strands of ligature. Back in the day I could take an endless spool of 3-0 silk and in the twinkle of an eye cut it into 18 inch lengths all exactly the same. These ligatures were held out like an offering to the surgical gods for the good doctor to  grasp and masterfully tie around a vein that had been lassoed by a hemostat. The scrub nurse then trimmed away the excess suture a millimeter distal to the knot with a straight Mayo scissors and it was time to move on to another bleeder. There was a reassuring rhythm to the process that was like meditation.

Hand tying did take longer than using a Bovie, but I always thought that tying off ligatures was a good way for the surgeon to limber up his fingers  before tackling the more serious stuff inside the abdomen. A time to reflect on the future course of action.

A knotter happily unwinding a tie from a ligature spool.
Ties and non-swaged  sutures were so revered they deserved
a dedicated table with 4 spools on the right and 4 on the left
Now for that burning question: Which of these tribes do I self identify?  I  survived long enough in the OR to beat those nasty Burner impulses into extinction and am an old foolish Knotter.

Wednesday, January 24, 2018

Infant Incubators - An Amusement Park NICU

"Step right up..for one thin nickel see pint sized preemies in their incubators"
Vulnerable patients seeking care and hucksters with remuneration on their minds are collisions of opposites. Contemporary hospitals have been corporatized and proud professionals have been turned into mere employees along for the ride. Balance sheets and office sitting bean counters rule the roost.

Health care  finance took an unusual course around the turn of the 20th  century.  Dr. Martin Courey, a pioneering OB physician  who was equal part showman had a brainstorm. "Incubator Baby Exhibits" were initiated at Coney Island Amusement Park adjacent to a roller coaster. This venture was so successful that it spread to many expositions including Luna Park here in Pittsburgh.

Dr. Courey was as adept at showmanship as he was in his medical endeavors. He dressed the premature infants in oversize gowns to emphasize their miniature size and preferred nurses with the stature of a football linebacker to minimize the size appearance of the babies. A hybrid physician and carnival showman.

The amusement park exhibit resembled a typical hospital ward with nurses providing care 24/7 behind a glassed partition. After paying their 5 cent admission (inflation later increased the price of admission to a dime) the public could position themselves so that the distance between them and the babies was the length that the wrist is distal to the elbow.

 At the time of the exhibits the babies were referred to as premature which had a different meaning than preterm. Medical literature of the day described the infants as "weaklings" and viewed them as lacking energy or vitality. There was much debate about the etiology being hereditary vs. immature development.

Most babies of this era were born at home and cared for by the mother. It was common practice to keep babies warm by placing them in a laundry basket warmed by hot bottles. The invention of the incubator involved a transition of care from the mother to an institutional setting. Low birth rate babies were soon transferred to the amusement park incubators for care. HIPPA regulations were many moons away in a distant future.

The amusement park shows were really a celebration of technology and the promises of hope for premature babies. Some things never change and today the publics' expectation of medical technology is stoked by images of robotic surgeries and laser beam miracles. You pay your money and take your chances.

Thursday, January 18, 2018

Are Patient Lifting Devices Inhumane?

Cecil, a 26 year old quadriplegic reclines in bed waiting for a pair of nurses to transfer him to his waiting mobility device, an electric wheelchair. Standard operating procedure calls for the nurses to wrestle him to a sitting position with his legs dangling over the bedside.  The nurses then assume a position on either side of Cecil with their muscled arms hooked under his armpits.  A  Cape Canaveral countdown commences and at the conclusion we have a lift off as the stalwart  nurses heft Cecil's limp body into the wheel chair. A solid plop down completes the mission. The source of that ominous cracking noise is a toss up - a nurses back or shoulder joint popped.

The sensitive nurses recognize Cecil's vulnerable state of affairs and take measures to minimize the progression from helplessness to hopelessness by understating the difficulty of the manual transfer. No complaining or grunting and groaning by the nurses when the critical lift is at the peak of their muscular endurance. Pseudo smiles mask the aching backs and burning biceps. Cecil replies with a heartfelt "thank-you," as the nurses ignore their wounded backs and secure him to his electric chariot of a wheel chair.

When hospital administrators could reward nurses with service pins and non-monetary tokens there was little concern about nurse's damaged intervertebral discs or wrenched shoulders sustained while lifting patients. Angels in white were there to serve without concerns for remuneration.

Change was about to come when nurses had financial benefits like workman's  compensation and paid sick leave. Nurse's manual efforts to overcome gravity for their patients suddenly became an expensive commodity and red ink on hospital balance sheets demanded immediate action.

Hospitals began to institute a no lift policy and resorted to devices like the Hoyer mechanical lift for patient transfers. This handy dandy device had a hydraulic pump much like a car jack to lift patients. Straps or a sling were applied under the patients arm and legs and the operator initiated the lift by pumping a lever which resulted in having the patient suspended in mid air.

Cecil and most all patients that were accustomed to human lifts hated these mechanical monsters and pronounced them "inhumane." The herkey - jerkey movement of the Hoyer was offensive to some patients, but there was more to their aversions. Cecil related that here was nothing to hang on to and the feeling of being suspended in mid air was frightening.

I tried to understand Cecil's objection and related the lift experience to my climbing adventures as a foolish youngster. Climbing open structures like fire towers was indeed much more terrifying than scaling a solid rock face. Having a fixed object in front of you  as a reference took some of the fear out of the elevation. It's the  reason that mountain climbers don't necessarily make good workers on cell phone towers. The tactile presence of the nurse lifters added a measure of security to the precarious gravity defying adventure.

Old time nurses like me were falsely advised we were capable of lifting just about any patient if  "proper body mechanics"  were used.  Keep your back straight and let your legs do the work was the mantra. Science does not support this whacky notion. The spinal vertebrae can take only a limited amount of stress and damage to their fibrous structure is cumulative. Nurses have one of the highest occurrences of musculoskeletal injuries of any occupation.

The only inhumane aspect of lifting is  the high injury rate of manual lifters.

Saturday, January 13, 2018

A Scrub Nurse's Prayer

May your Mayo Stand rise up to meet you.
May the Bovie smoke always be at your back.
May the overheads shine glare free upon your sterile field,
and until the skin margins meet again,
may God load your needle drivers with 3-0 silk.

Wednesday, January 10, 2018

New Year - New You Thanks to Tapeworms

A penny in the fuse box solution for weight loss. Maybe I can launch a new career in retirement as a tape worm sanitizer by training the little critters to jump into a bottle of Phisohex.