Sunday, December 9, 2018

Is Surgery A Spectator Sport?

Observers in a sanctioned overhead viewing site 
advancing their surgical acumen. Serendipitous 
snoopers were another story.
Vintage hospitals went to great lengths to provide surgeon and/or nurse wannabes the opportunity to observe surgeries. European hospitals even referred to their operating rooms as "theaters."  I once worked with a charming British surgeon that affectionately  referred to  us "theater nurses." This soft spoken man actually  thanked  us personally after a case was finished even if our performance was not up to snuff.  A different breed of surgeon compared to his American colleagues.

Surgical spectators were all different and the most interesting  involved the serendipitous observer who happened to be in the right wrong place at the time of the surgical experience.  Don't get me started on those whippersnapperrns who freely use that confounded "experience" word to describe a planned operative  anatomical alteration, but I figure if you can't beat 'em, join 'em. Who says you can't teach an old dog new tricks?

The operating rooms where I toiled were on the very top floor of the hospital and offered a beautiful view of Lake Michigan which was 8 blocks due East. Large picture windows offered surgeons and nurses the opportunity to feast their  weary eyeballs on a  tranquil visual treat of sailboats and sparkling blue water far off in the distance. A welcome reprieve from eyeball stinging Bovie smoke and squnting to thread fine needles with 8-0 white silk while a surgeon hollered at you in the background for being too slow for his speedy needle plunges.

Everything was fine and dandy until the esteemed members of the hospital board decided to erect a high rise employee housing palace  next to the hospital. Nurses were agitated because these were luxury apartments and unaffordable for all but the most privleged office sitters. We were stuck in our 3rd floor walk ups where heat was a rarity even on the coldest winter nights.

Various members of Chicago's building trades toiled on the construction crews erecting this palace for the medical center moguls. They were a cast of colorful characters to say the least. Ironworkers in particular were a flamboyant, in your face sort of personality. I think it had something to do with their performing hazardous work at elevations where one false move meant falling many stories to a colorful  death.

As the building began to rise, we eagerly watched the progress while standing at the scrub sink which was probably less than 50 feet away from the ascending steel I-beams. You  could hear the ironworkers incessant babble before you could see them.   We joked with the surgeons that the ironworkers must be afficionados of expensive German automobiles just like them because they bantered constantly about "beamers" while guiding the gigantic steel beams into place.

The merriment came to an abrupt halt when the ironworkers ascended to the level of the operating room windows. This rag tag bunch of haggard workers acted as though they found a visual paradise. They glared and made contorted expressions as they avidly observed the goings on in the operating rooms. If they found the proceedings in one room not to their liking a short stroll along the steel beam provided a different procedure to observe. Legitimate surgical observers were limited to viewing the proceedings in just one room while the ironworkers enjoyed a virtual cafeteria of surgical sightseeing.

Their ringleader with his distinctive orange striped  hardhat led his merry men along a steel beam parallel to the OR windows until they found a procedure to their liking. The cysto room was the least popular after a worker nearly stumbled off a beam while observing a meatotomy. That procedure shivered my timbers too, so I could empathize with their revulsion.

The most popular room for these happenstance journeymen observers was the orthopedic room. A hammer is a hammer whether the one doing the hammering is a surgeon or an ironworker. The orthopedic surgeons were kept busy reducing and stabilizing bones just as the tradesmen were with steel beams. Both used lag screws and plates in their work. A brotherhood of sorts was established.

The surgeons took little notice of these nosey nitwits, but nurses thought the activities bordered on voyeurism and should be halted. Plan "A" was to scare them off. Sponge racks were crude, nasty looking devices ostensibly designed to facilitate counts, but really served to provide the surgeon of a visual reminder of blood loss. These morbid contraptions were wheeled, so positioning loaded sponge racks dripping with blood  in front of the windows worked to frighten off the men of steel. Some nurses took to displaying suction bottles full of blood on the window sills, but gradually the men of steel acclimated to our repulsive displays.

Alice, our beloved supervisor came up with the ultimate solution to the problem. Being an ultimate Killjoy, she used autoclave tape to suspend surgical drapes over the windows. some problems work themselves out with benign neglect. The observation opportunity ended with our move to the new operating rooms in the Stone Pavilion. Windowless operating rooms were very popular in the mid 1970s and put an abrupt halt to all the fun.

Thursday, November 29, 2018

Retention Sutrures

Old school surgeons had a tendency to overdo just about everything from meticulously double tying simple bleeders to throwing in heavy duty retention sutures for added insurance against impending complications. A patient with wound dehiscence or more bluntly a burst abdomen was like a graphic, negative advertisement of surgical ineptitude. Something  to be avoided at all cost.  The  illustration above shows a wound that is beginning to "dehis" on the right side, but the retention sutures are averting a catastrophic blow out.

There was little science in deciding when to deploy torturous retention sutures and empirical notions ruled the roost. The end result was almost every obese surgical patient suffered the excruciation of miserable retention sutures which were applied in wide suture bites through skin, abdominal fat pad, and firmly anchored in the muscular abdominal wall. The dimpling of the  delicate skin before it yielded to the vicious thrust of a gigantic cutting needle pulling heavy suture was a chilling sight. A surgeon strafing a delicate abdomen with retention sutures shivered my timbers like nothing else. Orthopedic surgery with all it's bone crunching sawing and drilling was small potatoes compared to the forcible  application of retention sutures.

These gargantuan  sutures were usually left in place for about 2 weeks of abdominal throbbing madness for the hapless patient. Removal  was the most painful part of the surgical experience. ( I just love that new fangled vernacular where just about everything in modern healthcare is an experience or journey.) How about that, I can write like a whippersnapper if I try really hard!

The suture extraction process was very painful as a result of tissue adherence during the healing process. Sutures were practically cemented in place.  The fact that the abdominal wall was richly innervated exacerbated the situation. Considerable traction was necessary to pull the unyielding suture free from it's tenacious cementation in the underlying tissue. The sordid suture removal   affair reminded me of pulling cold taffy accompanied by loud screams and anguished howls. The task was almost always relegated to the least senior resident. Thank heaven, nurses never removed retention sutures.

One aspect of retention sutures always reminded me of an executioner applying a hood to the condemned before the act final was completed. This action was ostensibly done to make it easier on the prisoner, but the only real beneficiary was the executioner who could not see condemned man's suffering. For patient "comfort" the retention sutures were cushioned with short lengths of latex tubing where they contacted the skin. These bolsters or bumpers as they were called were custom made by the scrub nurse trimming a length of tubing as the sutures were placed. Any "comfort" from these little gems existed solely in the mind of the surgeon.  Retention sutures fueled post-op pain like pouring gasoline on a fire whether bolsters were in place or not.

More recent knowledge suggests that alteration  in the integrity of connective tissue is responsible for wound dehiscence and not necessarily obesity. The retention suture for all obese patients was not appropriate. Hopefully laproscopic procedures and improved techniques have made retention sutures extinct.

Thursday, November 22, 2018

Giving Thanks

Maybe it's my advanced age or the Sinemet I'm taking  for uncontrolled spasms, but I have this recurring dream. I'm called in to scrub on a messy trauma case. When I show up in the tiled temple with overhead lights ablaze, everyone is glad to see me. Dr. Slambow greets me with that subtle grin and says, "Boy am I glad to see you,  we have a real doozy here. Open up a thoracotomy set with your usual general surgery  paraphernalia. I suspect we're going to need it." Trouble was always around the corner with this request because Dr. Slambow was a general surgeon and the administration determined that he did not have privileges for chest procedures. I always thought that my job was to do what's best for the poor soul lying there bleeding out on the cold table. Office sitters be damned.

About this time I wake up and realize it's all a dream. I'm just an oldster huddling under the covers with knees aching so bad that I would be lucky to crawl out of bed, much less stand at a Mayo stand for hours on end.

OR nursing was difficult to say the least, but I had people who really appreciated my efforts and made me feel important. Maybe a bit too important for my own good.  The difficulties made everything seem more worthwhile. At least I was trying to help someone and was grateful for the opportunity. I don't know what I would have done without it.

I'm grateful for a different sort of life now. I never thought I would outlive so many of my contemporaries who were more fit and much healthier than my foolish self. I was marveling at my longevity with my internist and he summed it up by saying, "Well you never know when your time is up." How true, and I'm  thankful for all these years whether I deserved them or not.

Thankfulness has opened up my soul to humility and the realization that it's not necessary to work in the OR to have a purpose-driven life. I'm grateful for a day unburdened by obligations with freedom from time constraints. The ability to reflect on all my foibles and foolishness. It's difficult for me to believe so many folks read my foolhardy reflections and memories. I am especially thankful that so many of you read my blogging foolishness. Gratitude brings about an all encompassing feeling of peace and satisfaction and I will always be thankful to those who indulge in my foolishness by perusing this blog.


Sunday, November 11, 2018

When The KARDEX Was King of Communication

Glen from Texas emailed me with a suggestion to write about my experiences with the nursing KARDEX which he advised is disappearing. I had no idea. How could something with so much utility just up and disappear?

Christians have their Bible, Jews have the Torah,  and nurses from a bygone era had their KARDEX. Named after a company that specialized in using index cards for data storage, KARDEXES  were the center piece of any nursing station. Patient charts come and go with whoever snatches them up, but the KARDEX is always front and center at any gathering of nurses. Change of shift report without this wonderful collection of data would be impossible.

The front and back of  a vintage KARDEX was a solid sheet of gunmetal grey steel with a piano hinge through the midsection. When you opened this hefty collection of vital information an audible, metallic  CLUNK would echo around the room. That harmonious sound reminded me of a church bell announcing that something important was about to happen. The flipping through the KARDEX index cards  made a gentle rustling sound like the wind blowing through a Midwest cornfield just before the combine moved in for harvest. What a contrast to the contemporary clicking, bleeping, and clacking of a computer keyboard. I loved this bit of KARDEX  acoustic candy because it was an auditory sign that my shift was over and more peaceful, restful times were ahead.

What information was included in the KARDEX?  Everything a nurse needed to know when providing patient care: demographics, treatments, medications, allergies, consults, code status,
 urine reductions, diet, surgery, I&Os, IVs, and  IM injection rotation sites (everyone received these painful ministrations and rotating the  sites distributed the pain over a larger area).  The patient's name and physician was written in ink, but everything else was written in pencil and unlike the medical record, subject to erasure. The Kardex was not a formal document and when the patient was discharged, the cards were ceremoniously tossed in the circular file. No HIPPA - No shredding.  Identity theft was unheard of.

From my blogging foolishness, I can attest to the fact that people say different things under the cloak of anonymity and the KARDEX was no different. I was a quiet and reserved scrub nurse and just look at the blowhard  I've become  with an anonymous blog.  Notations in the Kardex were not signed and nurses perfected a generic form of printing to avert handwriting analysis. This cloak of secrecy  promoted blunt and sometimes crude KARDEX entries.  KARDEX notations often liberated many a nurse's free spirit and foolishness was not too far away.

Nurses who came  before me often had to administer painful and unpleasant (to say the least) treatments and never took "no" for an answer. Rather than write that it was necessary to restrain or hold a patient to the bed for a treatment, code words were used. "Patient needs assistance maintaining proper position for enemas," sounds better than "restrain his arms to prevent fighting to dislodge  enema tube."  In pediatrics the youngsters often needed "help" to receive painful injections or treatments. Those old school nurses were a force to be reckoned with and their KARDEX entries sometimes bordered on fiction. I vowed to never cultivate a mean, sadistic nature present in these hard core care givers.

As I was thinking about the KARDEX, a stream of odd ball and memorable entries returned to my obtunded consciousness. Every student nurse remembers their very first patient. Mine happened to be a pleasant, young Hispanic man recovering from a heroin overdose. Prominently displayed on his index card was a very good suggestion: No heroin on discharge.

Downey VA could be a very dangerous place to work and assaults were an unfortunate occurrence. A night  nurse pulled from the medical side of the facility left an ominous warning taped to the front of the KARDEX: Unsafe to be in attendance here  at ant time. DO NOT ask me to cover this ward again. I heartily concurred but could not do much about my situation. Building 66 was my permanent assignment.

Folks addicted to drugs had a very difficult time in vintage hospitals and old school nurses seemed to delight in social engineering to make their stay as miserable as possible. The old "That'll learn ya" attitude on steroids. A frequent entry on a drug addicted patient's Kardex was: Known drug abuser-no pain meds of any kind.

Floor is slippery. Patient expectorating giant phlegm globs.  Enough said.

If patient is experiencing difficulty voiding, have him blow through a drinking straw. Along with running the sink, this trick really worked.

On the post-partum unit: Remind patient to pull inverted nipples out. if the delivery experience wasn't bad enough.

A patient, Dudley, that I cared for as a student nurse smelled of urine no matter how carefully I bathed him. A perusal of the KARDEX offered an unusual explanation of the pungent odor.  Remove patient's prosthetic leg  from the room on PM shift. He awakens at night and fills it with urine.

Have footwear at bedside for AM pulmonary function testing. We all knew what this entailed.  PFTs were conducted in the stairwell at the end of the hall. If a patient could ascend  2 flights of steps with a  resident encouraging him from behind, he was deemed an acceptable surgical risk. Just be careful not to slip on the giant pools of phlegm/mucous left behind on the steps.

Some patient families are prepared for just about any contingency. I remember well the family that brought a 3 piece suit to the hospital with a dying patient. The KARDEX notation:  Make sure the suit in the clean utility room goes with the undertaker when he comes for the body. Yikes!

KARDEXES were the hospital equivalent of a jungle telegraph and revealed information that you were afraid to ask about or never knew existed. I think rigid and permanent forms of medical record keeping, electronic or paper, can block nursing inventiveness that drive holistic care. The old KARDEX unleashed the nursing free spirit by delineating what really worked for the patient.

Sunday, October 28, 2018

Le Mesurier's Hammock - An Early Scoliosis Treatment

Kids have unique gifts and abilities; some are smart, others have artistic ability, and last but certainly not least, some  are preternaturally athletic. I could not lay claim to any of these wonderful  attributes, but I did posses the gift, if you could call it that, of unusual joint flexibility. I could take my heel and twist it at an acute angle and tuck it behind my head. My favorite move was performed from a seated position and involved taking my right foot and lifting it above my straightened left leg while pulling it toward my body. Why did I enjoy such foolishness? I guess the answer was similar to the reason climbers give when they ascend Mount Everest - "Because it's there."

My Mom, a long suffering nurse from the Greatest Generation  did not appreciate my skills as a junior contortionist. Just when I had finished twisting myself up like a pretzel, she would holler, "Stop that tomfoolery before I take you to the hospital and string you up in a Le Mesurier's  Hammock. Do you want curvature of the spine?"  Her admonishment did little to curtail my extremity entanglement and circumvolition  activities, but it did whet my curiousity about that hammock thing threat. "How bad can that be?"  Le Mesurier's Hammock conjured up restful, peaceful experience. My next order of business was an investigation into the how and whys of the hammock threat. This could prove interesting.

Like me, my Mom retained her old nursing school textbooks and class notes which were carefully archived  heaped in a basement corner. One day while perusing the hodge-podge collection of nursing texts a serious looking black bound tome called out to me.  Nursing of Children  was the no-nonsense title and the table of contents listed topics like Diseases of the Glands, Spasmophilia, Hordeolum of the Eye, and Early Correction and Fusion in the Treatment of Scoliosis.

During my quest for hammock enlightenment I happened upon a chapter  about bedsores. This little tidbit of medical horror instilled a sleep disorder that persisted well into adolescence. In a mood of wonderment and sheer terror my eyes popped at the images of patients with oozing gaping wounds on their lateral hips and shoulders sustained by simply lying in bed. How could this be?  I made a note to myself to awaken q2 hours to check myself for these loathsome lesions. A peaceful night's sleep was gone forever because visions of bedsores danced in my head. Some things never change, now it's a pain in the prostate that awakens me q2 hours for that lonely journey to the can.

Finally a chapter in the orthopedic section about a condition known as spinal scoliosis revealed the LeMesurier's Hammock treatment. This was another one of those medical misadventures treatments that involve harnessing the spinning earth's gravitational pull. Weighted speculums that are ram rodded in various orifices to gain exposure during surgery are a twisted, devious use of gravity  but the LeMesurier's hammock use of this force  was far more grotesque.

When one views the history of treatment of pathological spinal curvature it is apparent that crude and brutal measures rule the roost. Lemesurier's Hammock involved placing the patient in an orthopedic bed that had risers on each corner connected via an overhead frame matching the dimensions  of the bed. These steel framed monstrosities were frightening in their own right but add traction pulleys and assorted doodads for limb fixation and they resembled medieval racks that could dish out unthinkable tortures. YIKES and double YIKES.

A scoliosis patient in position just prior to application of the hammock.
The victim's scoliosis patient's ankles  wrists were liberally padded and heavy leather cuffs are applied and connected by traction cord to pulleys on the corners of the ortho bed. The extremities begin their audacious ascent until the patient is suspended so the apex of the spinal curve is straightened. After a couple of days hanging around over the net, a body cast is applied and a large window cut to expose the operative site. A surgical spinal fusion is the final step in this uplifting treatment.

Helpful tips from this vintage nursing text advise that the leather cuffs can be sourced from the psychiatric ward and the hammock portion can be constructed from ordinary fishnet. The reference to the psychiatric ward  probably foretold impending problems. Patients subjected to 4 point suspension over a surplus fishing net are likely to sustain psychotic ego fragmentation and the nursing staff subject to PTSD. Perhaps a package deal is in order with the whole the whole kit and caboodle; patient, nurses, and leather restraint cuffs  winding up back on the psych floor.

Nurses are stuck in the quicksand of existing knowledge and looking back it's shocking to realize the barbarity of period treatments like LeMesurier's Hammock. It's amazing what patient's will submit to when the treatment is ordered by paternalistic  physicians attired in immaculate white lab coats uttering trite expressions such as, "It's all for your own good." Old school nurses in there all white uniforms and caps were a commanding presence too. It would have been tough to say "no" to authority figures like that and probably wouldn't have stopped their ministrations if you did.

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.