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.  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.

Saturday, May 30, 2020

Is Nicotine an Effective Prophylaxis for COVID19 ?

If one cigarette chases away that pesky Corona virus will a dozen smokes 
improve your odds?  Further study needed.

Sunday, May 10, 2020

Writng on Bed Sheets

Spotless white sheets were perfect for bedside note taking

I'm a diehard aficionado of the esoteric little nuances present in hospital culture. Before  I begin writing (if you could call it that,) a Google search is usually in order. If the topic I had in mind fails to show, I have a winner. I googled nurses writing on sheets and up popped, report sheets, hand off sheets, ICU cheat sheets, and brain sheets. Ahh...perfect, nothing what so ever about nurses and doctors physically writing on hospital linen. 

Seasoned, well past their prime doctors and nurses scribbled on hospital sheets all the time in vintage hospitals. The usual weapon of choice was a ball point pen, but a fine tipped felt marker would do in a pinch. Pencils simply did not cut it for sheet writing and were usually in short supply. Some physicians are inventive and I have witnessed sheet scribbling done with a broken applicator soaked with  Zepharin  solution which added an artsy fartsy touch to their scribbling  due to it's bright reddish/pink color.

Anesthetists in the OR loved to keep track of things like units  of blood or dosages by scribbling hatch marks on the sheet near the patient's head. Procedures calling for an intraoperative position change would frequently throw a monkey wrench into linen record keeping systems. The vital hatch marks could all to easily relocate to an inaccessible position. Another SNAFU was keeping simultaneous tallies such as one for units of blood and the other for ventilator settings and then confusing one recording for the other. This could lead to strained conversations such as, "Those markings are for the units of packed cells and this one over here is for tidal volume...or is it the other way around??"

Orthopedic surgeons were frequent sheet scribblers and left notes for the proper positioning of traction equipment. Before Campbell's Operative Orthopaedics became the dominant textbook, closed reductions with traction ruled the roost. All those weights, slings, and pulleys just called out for sheet side illustration.

Pioneering total hip replacements were affectionately referred to as low friction arthroplasties and required complex post-op nursing care. Hemovac drains required constant attention to maintain patency and Pehr splints to prevent abduction generated lots of twiddling. Putting an octopus to bed would have been small potatoes compared to caring for total hips.

Arthroplasty patients were to stay flat on their backs for 7 days and could not be turned side to side to make a typical occupied bed. The arduous procedure entailed suspending the hapless patient over the bed while making the bed from top to bottom. Many students sought to avoid the linen change ordeal by carefully maintaining the condition of the bottom sheet. Miss Bruiser, my favorite instructor, was always one step ahead of her intrepid students. She would make a tiny mark on the sheet in an unobtrusive spot and then check back to see if the sheet was changed by observing for the absence of her mark. If the mark was observed after the student finished morning  care a tongue lashing and demerits were liberally issued.

An  unusual sheet writing adventure occurred in the OR just prior to an induction. One of the staples stocked in our break room was canned sardines which were opened by inserting a special key into a slot and unrolling the top of the tin. The discussion among the surgical residents was how to open a can of sardines without the key. A diagram of a sardine can was scribbled on the top sheet covering the patient and the explanation ensued. "The first step is to center a knife over the crease (in the can) and make a fist around the knife. Next strike the top of your fist until it pops open." The patient thought the good doctors were discussing operative technique and let out a shriek of horror. It took several minutes of explanation to restore order and calm the patient. You can never be too careful when patients are awake in the OR!

Thursday, April 30, 2020

Corona Pandemic Hits the Nursing Culture Reset Button

A few days ago, I passed by a nearly empty hospital parking lot. The  ER entrance was backed up into the street with all sorts of emergency vehicles  so there was  no shortage of patients. Sirens screamed in the background and the place was hopping.

 The lonely vehicles present in the parking  lot were of the Ford Focus or Toyota Corolla permutation. It wasn't too hard to deduce where the BMWs and Infinitis  with  their nursing themed vanity license plates had gone. The self proclaimed  elite members of the nursing academic/administrative office sitter complex were holed up in their fancy abodes while a dedicated contingent of bedside nurses were slogging it out  in a challenging environment with a crude hodge-podge assemblage of personal protective equipment.

The righteousness of the busy body administrators at the top of the nursing administration pyramid looks especially iffy when lowly bedside nurses lack even the most basic equipment for safe patient care. Bedside nursing is a tough, often thankless undertaking and a lack of support from above for necessary equipment exacerbates the misery. Bedside nurses have a long history of facing insurmountable difficulties. Florence Nightengale lasted only 3 years at the bedside.

In years past, charity hospitals with no concern for personal financial gain were the  institutions that sanctioned and preserved nursing culture.  No patient was ever asked for an insurance card or copay. Everyone was welcome and eligible for care rendered out of kindness without a preoccupation with remuneration or the bottom line on a spread sheet. There was a strong feeling that we were all in it together for a greater good.

Money is the sand in the gearbox of healthcare today and the end result is a public health meltdown. Reimbursement for heroic, expensive  procedures without improvement in  patient outcomes grease the skids in hospitals of today. This one for all and all for one approach does not meet the needs of a population that  is threatened by a pandemic.

It's no wonder countries with readily available healthcare not dependent on an individual's wealth or yoked to employment  are doing so much better. You cannot buy your way out of a pandemic with profit centered care. In the land of the free and the home of the brave we do have the very best healthcare money can buy and it's proving to be lacking. Folks here are lucky if they can even get tested for corona virus.

Nursing is about to change and nobody is sure of the "how," but people in crisis help each other. Caring  for those near us begins widening the care net for others. Maybe the nurse office sitters will emerge from behind their computers and help others because it's the right thing to do. Experienced nurse "rockstars" will rejoin the band and help young nurses at the bedside instead of soaking   funds from a vulnerable group of nurslings for overpriced video courses. Nursing is not about being an Instagram influencer or money changing hands. It's about helping others without concern for self.

Just maybe the pandemic will  transform nurse entrepreneurialism  with it's  inner impulses geared for money grubbing and influencer prestige to more charitable  values delineating our nursing lives - duty and responsibility to our patients. Preoccupation with over indulgent, extravagant, nurse "self care" be damned. We were meant to suffer along with our patients. Oh..and  don't let me forget, sometimes at the hands of our patients.

Thursday, April 16, 2020

Smokeeters Cleared the Air at Downey VA Hospital

That coffin sized brown box hugging the ceiling of a Downey VA Hospital dayroom was one of the most indispensable elements of the therapeutic milleu; a Smokeeter. This machine droned on with an intestinal rumble as it digested hazy nicotine laden air and expelled a mountain fresh breeze from the opposing end. In with the bad-out with the good.

Downey VA Hospital dayrooms had a dismal aspect about them with bars on the windows and the walls reflecting a gloomy potatoe-y  noncolor with brown gravy like nicotine stains in just about every nook and cranny. Worst of all was the unbearable effluvium of cigarette smoke combined with the scent of men densely packed into a confined area. A palette rinse and sinus lavage was mandatory at the conclusion of a shift. The place just plain stunk.

 The lighting cast a yellowish pall over the entire unsavory mess reminding me of a Foley bag long overdue to be emptied. Smokeeters were an acknowledgement of the foul conditions and an inadequate intervention to remedy the situation, a microcosm of the mental health treatment system.

Serious mental illness does strange things to folks. Emotional channels become intricately wound together so they coagulate and strangle each other. Recreational chemicals like nicotine, alcohol, and caffeine are some how involved in the masking of the pain induced by nervous dysfunction. One of the mantras often heard on the ward was, "nicotine cuts thorazine." Patients truly believed in the therapeutic effects of smoking and would go to great lengths to ingest as much nicotine as possible.

Smokeeters worked by electrostatic precipitation and the nicotine that adhered to the electrodes in the device required daily flushing. In an addition to an electrical connection, Smokeeters required plumbing to provide a water supply for routine cleaning. This maintenance operation called for twisting open the supply valve and making sure the drainage line to a utility sink in the laundry room was patent for the final journey to the sanitary sewer system.. A kink in the drain resulted a most unpleasant blowback of the toxic brackish nicotine concentrated effluent.

Curiously, there was always a contingent of anxious, over eager patients volunteering to flush the Smokeeter. I soon discovered their strange motivation one evening  while making ward rounds. I was perplexed to see a patient whose entire upper torso was contorted into the depths of the utility sink where the foul liquid from the Smokeeter drained.

As I eased his head from the sink a syrupy brown exudate covered his lips. He had been guzzling  the foul drainage from the Smokeeter.  "What in the world are you doing?" I asked. With an ear to ear grin framed in the brown nicotine laden sludge he replied, "I'm drinking nectar from the nicotine gods courtesy of the Smokeeter.Try a swig-it's like smoking a whole carton of cigarettes in one drag. WOW..what a rush." I declined and made certain the laundry room was secure prior to flushing the Smokeeter.