Wednesday, July 12, 2023

Gastric Freeze-A Cold Hearted Idea

A stomach freezing machine. That eggplant size balloon
in the MDs hand was inserted transesophageally and zero
Degree F. ethyl alcohol circulated via a double lumen catheter.

 Whoever came up with that old medical adage stating if there are 3 or more treatments available for a single ailment, none are effective, was likely talking about duodenal ulcer treatments of the 1960s.Whacky dietary regimens featuring half and half or whole cream as the main ingredient, antacids, and of course tranquilizers because nervous folks suffered from ulcers were medical interventions of the day.

About 15% of ulcer patients had a dismal response to medical treatments and required surgery. The operation of choice was a gastrectomy with or without vagotomy (cutting the nerves that stimulate acid secretion.) This was big time surgery of the day and carried about a 5% mortality rate along with patient dissatisfaction from digestive problems. Every old nurse was acutely aware of the dreaded dumping syndrome where high carbohydrate foods entered the duodenum like greased lightening causing dizziness and occasional fainting.

Intractable medical problems like gastric ulcers often produce nonsense like this textbook edict, "The disease is easy to treat but difficult to cure."  (That classic was from our Brunner's Nursing textbook.) About one in ten Americans harbored an ulcer and the disease favored men. The combination of lots of suffering folks and the medical mind set to do something... anything... for a cure frequently produced disastrous results. Medical breakthroughs touted on newspaper front pages sometimes proceeded to the obituaries as time passed. Certainly, this was readily evident with frozen stomachs and their hemorrhagic complications.

In 1960, a group of surgeons headed by the famous Dr. Wangensteen, inventor of the lifesaving intermittent suction named after him came up with the notion that gastric ulcers could be cured by freezing the stomach.  General hypothermia (lowering the body temperature to 86 degrees F. (or 30 degrees C.) was occasionally used to help patients survive brain or cardiac surgery.  Under general hypothermia, gastric acid secretion was noted to decrease.

Dr. Wangensteen questioned, instead of cooling the whole body, what would transpire if only the stomach was chilled? He took the notion one step further and wondered about not merely cooling the stomach, but actually freezing it. I guess he never thought about what happens to a frostbitten ear; it falls off.

Desperate for an ulcer cure, freezing the stomach seemed worth a try. A balloon shaped like the stomach and a double lumen catheter to circulate freezing cold ethyl alcohol (zero degrees F.) through the balloon was devised. Experimental trials in animal trials commenced. I could never, ever work in an animal lab with dogs whose internal organs were rearranged and fooled around with in the dubious name of science.

One of the bizarre demonstrations of the frozen stomach efficacy was to oxygenate a frog and lower it into the stomach of a live dog. From an untreated stomach the completely digested frog was pulled up 6 hours later. From the frozen dog's stomach the frog would emerge hopping away at a lively pace. Yikes.. and I thought watching my cat vomit mouse parts was disgusting!

The May, 1962 Readers Digest ran an article, (They're Freezing Ulcers to Death,) and thousands of patients began demanding the treatment. Maybe they should have renamed the magazine The Digesters Reader! Sorry, blame that one on my foolishness.

The medical industrial complex quickly responded and stomach freezing machines were manufactured for eager hospitals and physicians despite the reservations of more conservative practitioners. This was not another innocuous pill that could be discontinued in the event of complications, but an anatomical alteration with the potential of real morbidity and mortality.

The gastric freeze did eliminate symptoms for some folks, but the ulcers always returned with virulent ferocity. A few unlucky souls experienced immediate separation of the lining of their stomachs and uncontrolled bleeding which required emergency surgery with sometimes catastrophic loss of life. The gastric freeze treatment lasted about 5 years (1963-1968) before practitioners gave it up. Too many complications with loss of life.

A bona fide cure for most gastric ulcers came about when a 1985 article published by Warren and Marshall in The Journal of Gastroenterology described a bacterial infection by H. Pylori as the cause of ulcers. The good doctors proved their point by infecting themselves with the bacteria. an antibiotic regimen proved to be the bonafide cure for gastric ulcers.

Saturday, May 20, 2023

Happy Armed Forces Day!

 To all those amazing folks on active duty and veterans, you are deeply appreciated and there is really no way to thank-you for the sacrifices you make. I think of you folks daily!

Tuesday, February 14, 2023

On Tenterhooks with Atrial Fibrillation!

 Despite the pledge I made to myself to refrain from personal health related complaints, here I go with more foolishness about my recent hospitalization. The nurse-turned-patient phenomenon can be fertile ground for peculiar insights into the illness experience.

I've had episodes of atrial fibrillation now for about 13 years. They are usually no big deal, but combined with a Klebsiella sepsis, the last one was tough to shake off and required more intensive intervention. I was minding my own foolishness in the ER holding area, awaiting an inpatient bed to avail itself when all of a sudden it felt like there was a kettle drum pounding away in my chest. I was going to say that it felt like an elephant sitting on me, but my wife is right, I tend to exaggerate. The medical resident was close by so I told her that my chest was feeling "funny." I really don't like to disclose that I was a nurse to providers so I understate and use foolish vernacular to illustrate my plight. My nursing experiences are too dated to be relevant today.

She took a quick listen with a fancy electronic doodad festooned stethoscope and shrieked to a nearby nurse to put me on a monitor. The nurse hastily applied the electrodes, gazed at the monitor with that avian eyeball intensity and flipped out, shrieking to get the crash cart. I was doing just fine up to this point, but in all the ensuing drama, I felt panicked-not a good thing when you are in atrial fib.

The arrythmia was promptly converted to normal sinus, but I felt guilty for all the excitement my predicament caused.  I was perusing some of the tips for novice nurses on atrial fib that Kati Kleber RN MSN had on her nurse education site, FRESHRN. One of her suggestions really hit home, "Put on your nurse face when caring for a patient in atrial fibrillation." From a patient's perspective, I offer up a hearty AMEN to that one!

For all you bright whippersnapperns out there take a gander at FRESHRN. I really admire Kati's fine work and it's a wonderful resource..

Wednesday, January 11, 2023

WHAT...Trauma Surgery Cancelled? It's Time for a Fable

 Every long time nurse is acutely aware that nursing can be a leading cause of "fun" deficit. After so many hours standing behind or in front of your Mayo Stand nothing seems to bring about that good feeling that unabated fun provides. (Maybe it's just my foolishness, but I never could deduce if I was in front of my Mayo Stand or hiding behind it.) It's sorta like that chicken and egg quandary about what came first, but when the surgeon is bellowing, I think it's best to be rearward of your Mayo Stand. Boundaries can be a real asset.

It happened more often than you would think, the on call gods were restless and that blasted phone arouses the lowly scrub nurse from a peaceful midwinter slumber. The frantic voice on the other end of the blower announces, "Hey fool...up and at 'em, there is a hot trauma in the ER headed your way, it's time to hit it!"

I scrambled into our trauma room and hastily set up my Mayo and had my back table loaded for bear with enough pieces of sharpened stainless steel for the grandest surgical event known to mankind, Lansing, Michigan! I meticulously scrubbed up at my lucky porcelain scrub sink and my heart was in overdrive, just like a thoroughbred in the starting gate roaring to go.

Most often, this was the beginning of a long, late night slog involving a gazillion needle holders loaded with aching fingers to patch up shredded hollow viscus organs or lacerated livers. My personal, least favorite patch up job was with damaged kidneys, not only were they tough to access in their retroperitoneal hiding spot but required a significant quantity of little fat balls harvested by the hapless scrub nurse to seal and close severed poles. I once asked Dr. Shambaugh to suture a fist sized fat ball to the exposed glomeruli and be done with it and was promptly rebuked, "It doesn't work that way fool!"

Occasionally, an anesthesia resident would poke his head in the swinging OR door and proclaim with overtones of gloom and doom, "The surgery is cancelled, pack up and go back to sleep, Fool, and don't forget the bottom bunk is mine." Cancellations were a big letdown for me and in the back of my head, I knew someone had just crossed over to the other side without even getting a second chance in the OR. Trauma surgery cancellectomies had all the ingredients for a sad...sad story.

So instead of dwelling on death and depression, I would invent alternative realities to the grim happenings. One of my favorite self-told fables was that the poor soul got lucky and managed to sleep it off. What the heck, it was 4:30 AM and everyone else was sound asleep. Everyone is well aware of the regenerative power of a good snooze, well maybe not for massive blunt trauma or big time gunshot wounds, but the notion of  a trauma victim sleeping it off was as comforting as petting a lap dog.

Surgeons and scrub nurses are procedure oriented and live to do things to folks. The sad truth is that most surgical SNAFUS are errors of commission which contrast qualitatively with errors of our non surgical cohorts errors of omission. Maybe this cancellation saved some poor soul from a surgical mishap or foreign body misadventure. HOORAY...that cancellation was a good thing and saved someone from misery and suffering. 

The other mental slight of hand with cancelled emergency surgeries was the notion of a transfer. The fantasy went like this: although we were the only trauma center on the North side of Chicago, the patient was simply moved to another unit or hospital. A much more soothing slight of mindfulness than envisioning a poor soul resting on a hard slab in the morgue cooler.

Although we are living in the twenty-first century, our emotional responses emanate from a stone age brain. Telling yourself uplifting fables isn't all bad, especially if they allay that sense of paralysis inflicted by a troubled limbic nervous system.

Friday, November 4, 2022

Healthcare Paradoxes

  Wake up! It's time for your sleeping pill.

Go Lytely...This stuff is like a Mount Vesuvius eruption purge in a bottle! Not exactly lightly about anything.

Lifesaving surgery...Red Duke, the famous Texas trauma surgeon, debunked this one many moons ago. "When God punches your ticket, he does so with profound authority, without regard to human intervention." 

Soft code...When the notion that CPR was good for all surfaced, the concept of a muted code emerged: walk, don't run, pediatric compressions for 300 pounders, etc. There really is no such animal as a soft code.

Bathroom privileges... This is a biologic need. Do we have room air privileges for patients to breathe?

Therapeutic milieu... I learned the fallacy of this one early on at Downey VA hospital. A nurse office sitter was orienting me to my psych unit announcing that this was their "therapeutic milieu" as she opened the locked door to the ward. A pool ball sizzled by my head like it had been launched from a mortar and 2 patients were bayonetting each other over in a corner with a cue, while a third was struggling to remove an impaled rack from his head. Therapeutic???  I don't think so.

Normal saline...How normal is an IV solution when it can cause metabolic acidosis and renal function changes?

ILL health...Health is health and there is nothing ill about it.

Pressure ulcer... Nope, if pressure caused ulcers, divers would be one giant bedsore. It's the shear forces that cause decubitus ulcers.

Confined to a wheelchair...As an occasional wheelchair user, this one really grinds my gears. Wheelchairs provide mobility and freedom!

Saturday, October 29, 2022

Fun With Artificial Intelligence Image Generators


Since my native intelligence has been flumoxed by brain numbing complications from my knee replacement surgery, I've turned to artificial intelligence image generators for some foolish amusement. I typed in Old fool RN on "Stable Diffuusion," an open source image generator and my prompts produced this appropriate image. Maybe I should replace that rather dated blog profile photo of me standing under the overhead lights in the OR. Hmmm...I love how that under the overheads lingo sounds. It doesn't take much to amuse a fool.

If you have an opportunity check out Stable Diffusion. It's easier than a camera or paint brushes to construct images. Hopefully artists and photographers won't be data based out of an occupation, but who knows?

Sunday, October 23, 2022

Institutional Misogynism: The Women of Downey VA Hospital

At the height of the Viet Nam War, Buddhist Monks doused themselves with gasoline and immolated themselves near U.S. facilities to protest America's involvement in the conflict. Two Army nurses rushed to the aid of a monk who set himself ablaze near a remote Army field hospital. A Viet Cong sniper fired on one nurse, killing her instantly. The second nurse, for obscure reasons, was ignored by the sniper and survived. Screaming hysterically and subsequently lapsing into a mute state, the sole survivor eventually found her way to a long-term ward at Downey VA Hospital, a warehouse for the mentally ill. The slain nurse was hailed as a heroine and awarded several posthumous medals and an honorary promotion to Major. A street at Fort Sheridan Army Base was named after her.

(A snippet of Downey V.A. Hospital folklore)

I  worked as a nurse at Downey V.A. Hospital for several months before I was aware there were women veterans confined amidst the 1600+ men. One evening I received a frantic phone call from a nurse in Building 135 asking if I could come to their ward and start an IV on a patient who was seizing. My recent medical background was an anomaly among Downey nurses. Most nurses employed there had worked on the back wards for decades, allowing their med-surg skills to atrophy. Eager to be accepted in this strange new land, I let it be known if there was an emergent medical problem, I was available to do what I could.

I furiously jammed my bit key into the worn slot on the heavy solid steel door on ward 3A, Building 135 and the portal opened briefly and ominously clicked shut. I was shocked to see an emaciated young lady seizing away on the dayroom floor. I should have suspected that any women patients at Downey VA were sequestered in gender segregated silos. At the time, womens' roles in the military were restricted by gender. It was a male dominated world with tentacles that extended to the V.A. psych wards.

I learned there were two locked female wards at Downey in Building 135 and they were the only ones available in the entire health system. Everyone here was seriously mentally ill and a danger to themselves or others. This arrangement concentrated the most acute patients in one facility while separating them from family and community resources. 

The wards at Downey VA were touted for their therapeutic  milieu, but it's a real strain to deduce what could be gained by such profound isolation. There was an on-ward dining room where meals were served to avoid comingling with the young bucks in the communal chow hall. Washers and dryers were also available to reinforce that matronly obligation of wash day duties. The place was a tour de force of isolation  and womanly perspicacity.

Surfacing from my IV start and a hastily administered bolus of Valium, it was readily apparent that the wards in building 135 were much newer than my native Building 66 which was constructed in the 1920s. These contemporary quarters were straight out of the aseptic construction of medical surgical units. The gleaming terrazo floors and ceramic tile walls were more appropriate to an operating room than a place of comfortable lodging and recovery.

I had the notion that psychiatric units ought to be constructed in the architecture of theaters; not operating rooms. There was no shortage of high drama at Downey V.A.  In lieu of a stage, the television assumed the focal point  with the viewers numbly looking on like a brace of zombies. The TV came on at seven AM and droned on until bedtime.

I heard rumors that pregnant women gave birth on the unit and indeed there was an exam room eqipped with a table that sprouted stirrups from it's distal end. Hopefully mothers were carefully screened to delineate complicated deliveries, but you can never assume when it comes to VA care. The facility was loathe to having patients treated in community hospitals and had medical surgical units on site so the men did not have to venture off base for care. Pregnant patients flayed by desperate life circumstances giving birth on a psychiatric unit made me wonder what chance the infant had for a normal life.

As I eyeballed and wondered what a lone mattress was doing  on the dayroom floor, an attendant enlightened me. "We do takedowns differently here. I know you guys over in Building 66 like to countdown and have everyone grab an extremity to apply full leather restraints, but here we just force the unruly patient into a corner using the mattress as a shield and hold them there until they calm down. Visions of a mattress held vertically and used to pin down a patient reminded me of the Chicago Police in their riot gear and shields at the 1968 Democratic Convention riots.

Walking back to the hallowed halls of building 66 I thought of a cat driven high in a tree by a pack of dogs. Safe at last, but completely isolated like the women in Building 135. Maybe it's time to call the fire department.