Thursday, February 14, 2019

How Hospitals Transitioned From Chairity Care to A Corporate Cash In Culture

The land of the free and the home of the brave is home to some  the most expensive health care in the known universe. What the heck happened? The last I remember,  the  rate for nursing, room, and dietary in a big inner city hospital was 68 bucks per day. The charge was known as the hospital NRD fee and it covered just about everything except for OR fees and pharmaceuticals which were dirt cheap.  A visit to the ER was 28 bucks if you had it and no patient was ever out of network or even asked about insurance.

 Hospital superintendents were paid slightly more than nurses and there were no big bonuses for anyone. We were all in the same boat and everyone knew and respected frugality. This is my anecdotal account of what happened during the transition to the current cash-in culture of today's healthcare. One caveat, these notions have been filtered through what's left of an ancient nervous system that remembers old school nurses who never expected to own much of anything and lots of MDs were content with an apartment.

It's easy to rattle of a list of culprits in the stratospheric rise of healthcare cost. Entrepreneurially motivated physicians and nurses wth the notion that I worked hard and deserve bountiful financial compensation for my work is a part of the story. Patient care in of itself was the old school compensation and material deprivation produced a sense of solidarity among nurses with everyone looking out for one another.

Old nurses like myself really had it easy compared to the all for one, and one for all whippersnapperns of today when it comes to salary. Our basic needs were met without worry and there were no school loans or financial demands. If we needed medical care any MD would gladly see us as a professional courtesy and if a hospitalization was required, our diploma school had a private "alumni room" for our exclusive use. It was the only room in the hospital with genuine Karastan carpeting. Nurses lived the good life without money changing hands. It's no wonder we affectionately referred to our hospital as "Mother."

Explosive growth of technology and electronic record keeping consumes lots of dollars. So do mindless Press Gainey surveys. Old school physicians would argue until they were blue in the face that patients are not qualified to make judgments about the quality of their care. I can see their point. Some of the very best surgeons I worked with were not very touchy-feely, and that's putting it nicely. Dr. Slambow would visit post-op patients with part of his breakfast and/or lunch spilled on his tie and shirt. I can see why folks would question the credibility of a surgeon wearing his breakfast and lunch, but he was one of the best when it came to minimizing post-op complications.

In the late 1970s my humble school of nursing was closed down for good after being in existence for almost 100 years. The building functioned as an oncology clinic for a couple of years and was then razed for the construction of a multi-level, monstrous parking garage. Fancy hospital parking facilities are given short shrift when considering how corporate interests made health care such an expensive commodity. This is where the rubber meets the road (or parking garage) in my woe filled tale. Parking garages are at the root of the problem.
Parking garages became the welcoming mat for hoards of greedy go-getters

Very few nurses owned cars when I was toiling at the bedside. We made do with the CTA, bicycles or good old fashioned shoe leather, those Clinic shoes were made for walking, It's interesting to note that our nursing school was way ahead of the curve when it came to alternative transportation. The first object to greet someone approaching the school was a massive bike rack, usually at least half full. There were no worries about locking your bike. Who would even think of stealing a nurse's bike?

Physicians and the fortunate few that owned autos found ample space on the street or small unregulated surface lots. Patients arrived at the hospital by taxi, bus, or walk-ins. There was no EMS, and trauma patients frequently arrived in the back of police cars or paddy wagons. Chicago police operated unique,  three wheeler Harley-Davidson motorcycles  which could be ridden just about anywhere. I vividly recall a drowning victim from Montrose Beach being hauled up to the ER secured to the back of a police officer's tricycle motorcycle. The officer even went so far as to suggest the road bumps jostled the water out of the victims airway. The patient survived with quite a story to tell. Maybe the cop had a point.

Hospital parking garages dramatically demonstrate the ridiculous profusion of administrative busy bodies, clerical, and unnecessary hucksters attempting to sell everything from pharmaceuticals to medical equipment. Visit just about any hospital parking facility on a Sunday morning to observe first hand how few workers are  really necessary to take care of patients and it's not because administrative big shots and pharmaceutical representatives are attending church. The Sunday morning deserted parking garage syndrome is even more acute at government agencies such as VA Hospitals.

Hospital parking garages are like a beacon to pharmaceutical hucksters. In the old days drug reps were a non-entity. No one needed to sell penicillin because it really did kill strep and everyone knew it. Much of drug pricing today is done with blatant extortion. A marketer of Zyprexa might claim that his drug will negate the necessity of long term hospitalization saving untold tens of thousands of dollars, hence,  his product is worth a ridiculous charge.

Epinephrine was dirt cheap. Everyone  knows what Mylan's Heather Bresch did with exorbitant charges for that "lifesaving" drug. I betcha if drug reps had to ride a bicycle to hospitals they would be few and far between.

Parking garages and the influx of money seeking hucksters changed how doctors and nurses thought about their patients. Money changing hands at every corner of the hospital amidst a bean counter culture changed who people were. Mega bucks doled out in bonuses to administrative big shots who never helped anyone except for themselves became the rule. It was so  much better when all I had was a Raleigh Super Course bike to ride to work and to heck with all those monstrous parking garages.

Sunday, February 10, 2019

What Blood Loss??

 What blood loss? That's all irrigation in the suction bottle. At least 2 liters.

A good scrub nurse always agrees with the surgeon even if the patient lost a unit or more  of blood. I felt just like Nancy when concurring with a surgeon understating the blood loss. I always felt there were 3 categories of blood loss estimates: ABL, anesthesia estimated blood loss -  EBL, estimated blood loss by the surgeon  and NBL negotiated blood loss after the surgeon vs. anesthetist argument concluded. Actual blood loss was one of the great mysteries.

I promise this is the last of my political foolishness. Blame it on my brain freeze.

Thursday, February 7, 2019

Euphmistically Speaking

I overheard a group of whippersnapperns discussing the advantages of rewording the term "terminal wean" to "compassionate extubation" when discontinuing mechanical ventilation and  allowing nature to take it's course in a critical care unit.  Over the years lots of terms were changed: Directoress of Nursing is now Chief Nursing Officer, Hospital Superintendent is now CEO, Janitors are Environmental Engineers, and Personnel became Human Resources.

All this got me to thinking, which is always a dangerous proposition. I'm  in the midst of a midwinter brain freeze when my thoughts are too incoherent for a typical post. Anyhow, here are some terms that could be reworded to be more politically correct or incorrect, depending on your perspective.

Suicide to euthanasia from unbearable emotional pain.

Bathroom privileges to free range bathrooming?  That sounds dumb, but anything is better than B.R.P.

Doctor's orders to physician's proposals.

Physical restraints to boundary maintenance aids.

Near miss to near hit

Drug addict is a label loaded with lots of pejorative connotations. I've never really had to deal with this issue because old school discharge criteria mandated that a patient be relatively pain free upon discharge. There were very few legal narcotics outside the controlled environment of the hospital. So..lets start referring to those poor souls addicted to drugs pharmaceutical aficionados

I'm saving the best for last. An oldie but a goddie; Emesis to feedback. The simplest ones are always best.

Monday, January 28, 2019

The Smoking Finger

No, I don't have one of those fancy new fangled phones
that take photos, so I put what's left of my index finger in the scanner.
Surgeons and nurses toiling in an operating room become habituated to a very controlled environment where everything from lighting to air quality is subject to rigid regimentation. Unpredictable events throw a monkey wrench in the midst of this enforced order, often times, leading to a cascade of adverse events  which can result in personal  injury to staff.

Voice modulation morphs into a surgeons unduly harsh verbal  admonishment of the offending party. Harried nurses, desperate for a resolution to the problem throw caution to the wind and find themselves in a precarious situation while attempting to solve the problem. Desperation seldom leads to reasoned thinking. The ensuing pandemonium is enough to flummox a pope.

Operating rooms can be dangerous places. Surgeons waiting for someone to fall asleep before cutting them might, at face value, seem unsavory, but the notion of live by the sword; die by the sword holds true in the OR.  Those sharpened chunks of stainless steel do not discriminate when inflicting their trauma and Bovies don't care what  tissue they roast.

 As a circulating nurse I was known for constructing elaborate platforms for height challenged scrub nurses. My colleague, Janess, loved my elevation tactics and was so enamored with one of my creations she failed to notice an unusually low hanging overhead light. As she emergently  ascended my stairway to operating room heaven for an urgent trauma case,  the crown of her head struck the low hanging illuminary with a sickening THUD..CRASH. After finishing the case, a close inspection of her cranial vertex revealed a hematoma the size of the distal end of a Babcock. After a quick neuro check and 15 minutes with an ice pack she was back on duty. I've witnessed several intraoperative injuries to staff and not a single nurse or surgeon broke scrub, no matter the extent of the injury.

Karma can be a cruel mistress and I soon received my payback for contributing to Janess's unfortunate mishap. I was finishing up a case with Dr. Oddo that entailed resecting a menengioma. These tumors are outside the brain and with removal have an excellent prognosis. I was in a great mood thinking about how we were actually being  of some service to the poor soul suffering from this nasty,  neoplastic malady. One thing I've learned over the years is to be wary of those euphoric Kumbaya moments when everything seems to fall in place because a true shitstorm is often in the works.

Dr. Oddo had been using a foot pedal actuated Mallis bipolar cautery during the case. This nifty little device looks like a pair of tweezers with an electric cord attached to a high voltage generator. When Dr. Oddo tramped on his foot pedal electricity flowed between the tips of the tweezer like device cauterizing anything in between. It was a great little gadget for controlling bleeding in small vessels.

Dr. Oddo loved to instruct the anesthetist to lighten the anesthesia near the end of a case. One  of his favorite phrases in the post-op report was, "The patient was able to transfer from the OR table to the awaiting carriage independently." This sometimes made for exciting moments near the end of surgeries when the patient took ambulatory surgery to a new level and decided to bail out before the final skin sutures were in place.

Sure enough, just as Dr. Oddo started closing the skin flap the patient began to emerge from general anesthesia. As he came to, his right leg spasmed into a mighty lateral kicking motion impacting Dr. Oddo's leg poised with his foot just above the Bovie actuating pedal. I was tidying up by clearing off the operative field and was preparing to wipe down the distal, business end of the Bovie forceps. The patients kick to the good doctor's leg turned the Bovie forceps ON and as the juice flowed a sickening burnt flesh/charred rubber glove malodorous scent filled the air.

The Bovie had cooked my right index finger on the distal phalange. As the smoke cleared I requested a new glove and plunged  what was left of  my smoking finger into a fresh sterile barrier. There must be some truth to the notion the body releases pain killers when traumatized because initially I was pain free. Upon finishing the case and pealing off the second glove the extent of the injury became apparent. The end of my finger had extensive "remodeling" with the distal aspect about 1/3 AWOL.

Dr. Oddo helped me remove the melted latex glove from the wound and suggested wrapping the finger with iodoform gauze. Dr. Slambow was consulted and said "welcome to the club" while showing off a massive scar on his right palm. After about 4 weeks, it was time for the unveiling. Dr. Oddo involved himself in a spirited debate with Dr. Slambow questioning whether  the nasty blackish tissue around the wound was eschar or scar tissue.

After the unveiling and the scar/eschar mess was pealed off I had a functional but rather disfigured index finger with a square tip and missing 1/2 the nail. I never missed a day of work and today I regard what's left of the end of that finger as a badge of honor. It's better than thinking of it as a living monument to my foolishness.

Sunday, January 13, 2019

What if Pathologists Performed Surgery?

A pathologist's Mayo Stand.  " Pass me the hack saw, nurse."

Delay of game is not limited to football. Action in the operating room can be subject to breaks in the action too. Waiting for a frozen section report to come back from the pathologist  or a time out while the circulating nurse scrambled to flash sterilize an esoteric instrument that the surgeon just had to have were common interrupters of what had been feverish goal oriented action in the tiled temple.

I liked to busy myself with buffing surgical instruments until they shined in the overheads or wrestling with wiry twisted chromic suture in a vain attempt to get the kinks out during these postponements. Dr. Slambow did not like my heightened activity during these surgical layovers. One of his life lessons was to take a break whenever you have the opportunity, and as an oldster, I've put that lesson into practice way too many times.

As the intense intraoperative activity ground to a halt, he dropped his usually tense voice  an octave or two as  he admonished, " Take a break Fool, and rest those oversize lunch hooks of yours, I've got a little joke for you; In a perfect world the English would be police officers. The Germans would be engineers, and the French would be the cooks. In a more ghastly universe things would be different. The English would be cooks. The Germans would be law officers and the French would be engineers." Ha..Tee..Hee.

Every scrub nurse knows the obligation to laugh at the surgeon's jokes and make a comment about his clever wittiness, but my mind sometimes wandered and thought about what would happen if physicians other than surgeons performed surgery, just as the characters in his joke switched roles. Standing at my Mayo stand in a post joke moment, I came up with an off the wall  idea that made the notion of German police officers sound like a good thing.

What if pathologists performed surgery? The instruments they would bring to the table are enough to shiver just about anyone's timbers. I had never heard of a #60 knife blade because it's exclusive to the morgue. This monster blade made a meat cleaver seem like small potatoes. It's the only scalpel blade I'm aware of that has an edge sharpened along it's entire length. This blade eschews attachment to an ordinary scalpel handle and prefers mating with an autopsy handle that resembles the throttle of a Harley Davidson Electra Glide. This sabre like snickersnee  reduced cutting to it's most barbaric level. In surgery millimeters mattered. A pathologist's  mindset was calibrated in meters. Monster incisions were OK in the morgue, but wouldn't make for a happy ending in the OR.

A pathologist is experienced with slicing through chilled skin that doesn't bleed. I wonder how the novel experience of dealing with those little bright red bursts erupting from the yellow subcutaneous fat would be dealt with. I wonder if a foul smelling liquid like formalin would cauterize a bleeder. There certainly is an abundance of that nasty stuff in a morgue, but surgery is no time for foolhardy experiments. I suspect they would have to learn how to use a Bovie like everyone else.

That's just about enough of my foolish ramblings. I don't want to even think about those giant hedge pruner implements found in a morgue would be used for. Pathologists are conditioned to simply cut structures  out of the way to expose anatomy. Could they adapt to using retractors for accessing organs?

I pondered that last notion while sipping bean soup for my midday sustenance. Glancing down at my fasciculating fingers and realizing I forgot to take my Sinemet, the thought suddenly occurred to me. Dr. Slambow was right, I do have oversize lunch hooks for hands.

Thursday, January 3, 2019

When the Human Body Works Like a 3D Printer

Here is a case of human reproduction that does not involve a gamete, egg, or mitosis. I would have mentioned "ploidy" too, but I'll be darned if I can remember what that involves. A 35 y/o man who was critically ill had a vigorous  coughing fit which was so  productive that he hacked up this blood clot which formed in his right main stem bronchus; a near perfect anatomic reproduction of the airway cast in blood.

Hemoptysis in the extreme, which formed a perfect casting demonstrating 5 branches of the bronchial tree. The clotting cascade was a real challenge to memorize and about the only thing I can remember  is the cross linking of fibrin forming the framework for the clot. It certainly out performed it's intended purpose in this case.

 The right main stem bronchus is like a grease trap in a fast food restaurant because almost anything that goes down the trachea winds up here. It's the first bronchial segment to branch off and has a larger lumen than the left main stem bronchus. It's also more perpendicular making it the perfect exit ramp for just about anything coming down the trachea. Anesthetists always checked for bilateral breath sounds because it was so easy to selectively intubate the right main stem bronchus. An absence of left sided breath sounds?  Time to pull the endotrach tube out a bit to clear the right bronchus.

It's difficult for me to understand how a clot of this size could form because the most likely scenario would be a clot occluding the upper segment and blocking the filling of  the middle and lower branches.  This perfect cast of the bronchus jolted my memory and brought to mind another memorable anatomic replica produced by the human body.

Fecal impactions were a miserable experience for all parties involved and were common in old school hospitals as a side effect of prolonged bed rest combined with opiate analgesia. With the passage of time, pressure from the upstream accumulation of stool in the sigmoid colon  numbed the nerve endings of the internal sphincter. The end result was a massive hardened bowel movement firmly lodged in the sigmoid colon.

Removing these forbidding fecal accumulations was no easy task because the stool hardened to a consistency of Sakrete concrete. The first step in the unpleasant (to say the least) removal process was the rectal installation of warm mineral oil  in an often times futile attempt to soften the painful putrid plug. The final step was similar to a Roto Rooter operation whereby the mass was manually extracted.

One of my colleagues, Ann, was especially proficient at removing fecal impactions. Her fingers were lithe and she had the unique ability to curl the distal metacarpal at a right angle to the rest of her finger resulting in a hook. Her fecal impaction removal technique involved twisting her index finger much like a boring brace to gain entrance to  the tenacious turd. Having bored inside the monstrous mass much like an African dung beetle  she hooked her finger and gently increased traction until the massive mess slid out.

After the patient's  screams of agony subsided, the oows and ahhs began as attending staff members marveled at a perfect sculpture in brownish stool  of the sigmoid colon. The distal part of the colon is lined with haustral markings which delineate colonic saculation.  As the stool hardened a perfect colonic cast was formed.

Most nurses chipped away at fecal impactions which resulted in a hodge podge collection of fecal shreds. Ann's technique of rmoval in toto resulted in an anatomic model not  unlike the cast of the bronchus. Simply amazing!

Saturday, December 29, 2018

The Most Popular Post of 2018

For the life of me, I can never predict which one of my foolish posts makes for a good read. I tend to favor outright goofiness and venturesome tales that lend themselves to entertainment purposes. Imagine my surprise when a dull, uninspiring fact laden account of the disappearance of genuine glass IV bottles was the most viewed post. Go figure! I got that last bit of lingo from listening to whippesnapperns. Who says you can't teach an Oldfoolrn  new tricks

One of my favorite posts received less than 10% of my boorish IV bottle post. Operating room  nurses tended to have somewhat of a twisted sense of humor. I guess it went with the territory. It was all business in the midst of a case but at the end of the day buffoonery showed it's prankish  face. Arguments are for the surgeons so nurses had special little ways of settling disputes. One of my favorites forms of arbitration was the ring stand race. This contest was used to determine clean-up duties and delegate unpleasant duties like clearing out floor drains or troubleshooting clogged suction machines. Maybe I favored ring stand races because I could slither myself through that hooped demon with as much speed as poop flows through a goose. Here's the link in one of my cheesy attempts to solicit readers.