Saturday, October 5, 2019

Old School Automobile Lap Belts Engndered Bucket Handles and Fruit Loops

Cars from the 1960s were rolling deathtraps. Two  tone paint jobs, wide whitewall tires, and chrome bumpers looked snazzy, but in a motor vehicle accident (incident or crash in today's lingo) the passengers were propelled into rigid spear like steering columns or protruding cowl like hoods over the speedometer which, to say the least, were evisceration proficient. Any poor soul lucky enough to escape compression injury via steering column impalement or gutting by the speedometer was hurled head first through the windshield and wound up with spidery split open lacerations on their forehead and all too often, hopeless neurotrauma.

Initial efforts to restrain vehicle occupants and  transfer some of the destructive forces to crumpling sheet metal consisted of lap belts.  Curiously, lap belts were always referred to as "safety belts," instead of the current seat belt terminology. These girth gripping girdles prevented some of the unfixable neuro trauma at the expense of the abdominal organs which ,at least, were potentially fixable with timely surgical intervention. Typical abdominal trauma from car wrecks  involved banged up and bleeding hollow viscus organs, blood oozing spleens, and contused and bruised livers. Retro peritoneal renal injuries were less common. Maybe all that fat surrounding the kidneys protected them from some of  the trauma.

Typical stigmata of lap belt trauma consisted of a 2 inch wide ecchymotic banding across the lower breadbasket. This ominous finding almost always meant internal injuries and called for the immediate diagnostic peritoneal lavage. After cannulating the peritoneal cavity about half a liter of normal saline was infused. After  about 10 minutes the saline was allowed to drain back out by gravity. Any blood in the drainage meant a quick trip to the anxiously awaiting personnel in the OR.

Innovative lap belts caused a surge in a new kind of deceleration injury, bowel/mesenteric separations which were a good trade off for the neurotrauma sustained from crashing head first through the windshield. Most abdominal trauma was fixable if caught in time, while neuro trauma usually meant a grim prognosis.

The bowel is fixed at the flexures,the ligament of Treitz, and last but certainly not least, the rectum.  With the colon and small bowel moving forward at 60mph ( or whatever speed) the sudden traumatic stop of an accident pulls like a John Deere tractor on the intestine adjacent to these tack down areas dividng bowel from it's lifeline, the messentery. Without mesenteric connection, the section of isolated  bowel withers up and dies like a man in the desert without water.

Mesentery supplies vascular, nervous, and lymphatic connections to the bowel. It also holds our  intestines up out of our pelvis where there are enough problematic structures without dropping another player into the mix. Mesentery is one of the most underrated abdominal players.

Suspense reigned as the surgeon cautiously entered a traumatized abdomen and when the problem was finally delineated and deemed curable, a feeling of jubilation and relief was experienced by the team. Hearing Dr. Slambow, my general surgeon hero, deliver his diagnosis was always a musical treat. As the Airshields ventilator chugged out bass beats in the background there was proprietorial pride in his harmonius voice as he practically sung out "bucket handle," four notes, key of "C," ascending. The hootenanny proceeded as the intestinal resections marched along with needle drivers clicking away like castanets and heavy instruments adding dissonance clunking away in the lap tray on the back table. The finale was always the best part as we stepped down form the podium with a meticulously patched up patient that was sure to recover.

 How did this injury acquire it's strange moniker? The section of large bowel stripped from mesentery did indeed look like the handle of  a bucket so the name fit. Small bowel separations were more subtle and were named after the little cloth hanging loops on the back of men's shirts of the day. Even though they did not resemble the popular breakfast cereal, everyone knew what an intestinal fruit loop injury looked like.
A bucket handle injury of the transverse colon and 3 fruit loops down below 
where small bowel parted ways with mesentery. That lower separation
is beginning to show the effects of devascularization.
(Photo courtesy Dr. Michael McGonigal)
When the call room phone incessantly rang  at 2AM and the harried voice on the other end intoned "Motor vehicle accident ETA 10 minutes," my feeling was similar to one of those daredevils going over Niagara Falls in a barrel. Lots of mental anguish leading up to the case because the final landing outcome  was unknown. Bucket handles and fruit loops usually led to a successful plunge over the falls.

Saturday, September 28, 2019

The Surgical Abdomen

While fresh, young  surgeons pour over detailed cross-sectional CT scans or overpriced, extravagant ultrasounds, old surgeons relied on the wisdom gained from a physical exam and meticulous history taking to delineate abdominal pathology. "Hot Bellys," in the vernacular of the day could be a real hornets nest to deal appropriately with, and the wily veterans had there own brand of diagnostic techniques which were crude, but effective.

Decisive clinical diagnosis was elusive, but a strange hodge-podge of clinical maneuvers (if you could call them that) were enlightening to the battle tested old surgeon. Observations were also key element  of the work up.  A "sweated brow" or "a hypovigilant countenance" suggested a septic process. Jaundice suggested some sort of hepatic dysfunction and a strange blue periumbilicular coloration signaled an internal bleed.

The exam of the acute abdomen consisted of, euphemistically, what would be termed palpitation, percussion, and auscultation, but was really poking, pushing, lifting, listening, and twisting limbs around with gusto, much like a pretzel.

The psoas test was performed by forcefully flexing the thigh while rotating the foot outward. The test was contraindicated with concaminant orthopedic injuries. A positive response elicited a vociferous verbal response from the hapless victim  patient and suggested a lower abdominal process.

A shake test was of great value when the patient had difficulty identifying the area of maximal belly pain. While in a supine position the patient's hips were slightly elevated off the bed while a vigorous to and fro shake was delivered. Dr. Slambo, my favorite general surgeon, had an interesting method of augmenting the shake delivery that only applied to ambulatory patients weighing less than 75 kg.

With the physician and patient standing back to back with arms interlocked together at the elbows a gentle elevation is initiated by the good doctor leaning forward. The optimal height was with the patient's feet about 6 inches off the floor. The abdomen is bowed such that the viscera are near  the surface while a side to side shimmy/shake elucidates the problematic quadrant. The technical name of this procedure (according to Dr. Slambow)  was the elevated, gyrating, gambol gambit and it was far better than one of those new fangled CT scans when it came to elucidating the exact focus of abdominal distress..

Dr. Slambow also knew how to augment just about any type of palpation technique with a miraculous gooey, slippery substance known as ordinary Surgilube. He began with a full tube, superior to the umbilical concavity and began squeezing until there was a generous pool of  goop.  He then began exploring the aching quadrant with his hand gliding across the abdomen like a shoe that stepped on a banana peal. The quantity of Surgilube used during the procedure also provided valuable insights when planning the surgical intervention. More than 1/2 a tube of the gelatinous goo signaled problematic obesity that called  for extra long instruments and a platform for Dr. Slambow to stand on while he looked down into the wound.

Fist percussion commonly known as a blow to the upper bread basket was performed along the anterior thoracic wall by placing one hand on the skin and beating it with a fist. Exquisite pain evidenced by vociferous howls indicated cholecystitis or hepatic issues.

Murphy's inspiratory sign can be demonstrated in acute cholecystitis  by asking the patient to take a deep breath while pressure is judiciously applied below the right rib cage. As the liver descends, the inflamed gall bladder is brought into contact with the abdominal wall causing immediate cessation of the inspiration.

I really liked scrubbing on acute abdomens because the offending problem was identifiable and fixable. There was no better feeling than seeing a seriously ill person stroll out of the hospital with a new appreciation of life. Viewing that so vulnerable  prepped abdomen supine on the table awaiting the surgeon's ministrations always put me in a contemplative mood with the realization that despite all our political and religious differences  we are all just meatsacks enjoying an undeserved period of wellness so no matter what or who, With this thought lurking in the back of my foolish mind, I tried to be nice to everyone and treat patients as though they were my mother, father, or child.

Wednesday, September 4, 2019

Hospital Signage

Yesterday's sign was a model of stark simplicity

Today a ridiculous hodge podge of word jugglery. What a mess!

Wednesday, August 21, 2019

Cyclopropane Anesthesia - A Blast From the Past

Inhalation anesthesia was dominated by ether until cyclopropane made it's debut in the late 1930s. This new agent was potent and did not induce the unpleasant nausea and vomiting associated with ether. Those operating room scenes from Ben Casey or Dr. Kildare where the patient is asked to count to 10 after the anesthesia mask hit their face were classic cyclopropane inductions. Most were sound asleep by the count of 3. Cyclopropane was like magic pixie dust in an orange steel cylinder;  inhale it and almost instant anesthesia, back on room air, and presto... near immediate emergence. There was only one problem, cyclopropane was explosive and had the potential to turn just about any cysto room into a wiener roast.

Every old time operating room suite  had a cyclo room that was heavily modified to avert cyclopropane detonation. I always liked the way cyclo room sounded when pronounced, it had an eerie Alfred Hitchcock feel to it because it sound so much like "psycho room." Indeed these were different sort of rooms where strange rituals and  happenings prevailed.

Cyclo rooms persisted until the early 1970s. Any new OR suite constructed post 1970 lacked an explosion proof room. The first line of defense against exposions was the elimination of statuc electricity discharge by grounding everything to a terrazzo floor which was interlaced  with conductive copper dividers. A gleaming terrazzo floor lined with glowing copper dividers was a beautiful sight.

Everything in the room was supposed to be grounded to the conductive floor. Operating room personnel wore shoes that were modified by a metallic plug smack dab in the middle of the sole and shoe covers had a conductive strip running from toe to sole. First order of business upon entering a cyclo room was testing shoe conductivity by stepping on a small bathroom scale like device. A green signal meant all was well and it was OK to proceed. The shoe testing requirement also served to exclude rubbernecking snoopers and busy body administrators. Only the personnel that really needed to be there were present. An anesthetist, 2 nurses, and a surgeon with an assistant could handle just about anything that came along.

Equipment in the OR was grounded to the floor by tiny metal chains that jingled  when the furniture was moved about. Old operating rooms were always furnished, never equipped. The anesthesia cart which was always a repurposed Sears Craftsman rolling tool chest  had double chains. Why take chances?

The other approach to explosion proofing the room was a bomb squad containment mentality. Potential sources of explosion were shrouded in a heavy steel housing. Operay overhead surgical lights had a particularly robust containment chamber that I thought resembled Russia's Sputnik satellite. I'm not so sure I would like to be laying on the table with that ominous black orb hovering  overhead. It looked spooky to me.

The electrical switch for the Operay was covered in a heavy leather boot that looked like the covering on a Mack truck gearshift. Every time I turned the overheads on, I imagined the carefree life of an open road trucker as opposed to facing up to the stressful work ahead. Oh least I did not have to worry about unannounced visits from my favorite nemesis, Alice, the all knowing supervisor, always steered clear of the cyclo room.

Working in the cyclo room was always the best part of my day, and then later on, the best part of my night. On call, high risk emergency trauma surgery was the perfect venue for cyclopropane because it actually elevated blood pressure to improve perfusion. A good question was; If cyclopropane is so frequently selected for the high risk trauma patient, wouldn't it be good for the healthier patient? The limiting factor was the risk of catastrophic explosion.

I loved the peace and quiet in the cyclo room. There were no Bovies  buzzing or power tools whirring, just the quiet swish as the anesthetist went about  breathing for the patient. The brisk snip sound of straight Mayo scissors cutting ligature after ligature was almost hypnotic.  Occasionally while in the midst of a messy trauma surgery you could actually hear a vessel bleeding.

 Cyclo also had a very pleasant, gasoline like smell that always reminded me of one of my favorite high school courses, auto shop. No matter how carful the anesthetist was with holding the mask, a tiny bit of cyclo always seemed to pervade the room.

Attending anesthetists often told the residents that cyclo was to be   handled with the finesse of a violinist, not with the banging of a kettle drum. Anesthetists were also advised to keep in physical contact with the patient at all times to keep the electrical potential balanced.

Whenever I see a modern operating room furnished with enough electronics to land a 747 in a whiteout and multiple OR personnel milling about it shivers my timbers to the core. To heck about worrying about the finesse of a violinist, these rooms are the equivalent of a symphony orchestra complete with a grand piano. Cyclopropane R.I.P.

Tuesday, July 30, 2019

Bed Scale Blues

It's easier to push a stalled '57 Chevy than a bed scale!
I made the mistake of reading some of my old posts and some of them resemble a distant ping from a satellite knocked out of orbit. Tales from a far away planet where bedside care was the only currency that mattered and what little money there was flowed away from nurse's pockets. It sounds paradoxical, but the more interface I have with "modern" healthcare, the more I miss the old days.

Oh well, Nero's circus must go on so here's my take on vintage behemoths that were part Hoyer lift, part ironing board, and finally part piano mover's dolly with enough free weights to open a gym. Bed scales were the hospital version of battleships, difficult to change direction when in motion, fraught with danger and best left alone.

The illustration above shows an intrepid  young nurse in transit for her mission; to weigh a bedridden patient. The ironing board part of the scale is hinged so it's vertical when in storage or moving  struggling down the hall. It's visible on the right side of the scale just inside the counterweights. After an arduous journey to the bedside, the ironing board like platform was tilted to a horizontal position. The patient is pulled, pushed, or glided onto the awaiting platform. You know, that old count to three and grunt routine.

The platform is elevated like a not so magic carpet by way of a hydraulic Hoyer lift like pump. Now for the fun part -  where the rubber meets the road. The patient is suspended inches above the bed while the nurse turns her attention to balancing the counterweights. A potential  hazard included becoming distracted by the precarious position of the patient and dropping a 20# weight on your foot. Clinic nursing  shoes did not have a safety toe so that's really going to leave a dandy bruise, if you are lucky. The not so fortunate will see the ortho clinic with compound fractures of the metatarsal bones.

One of the great nursing debates involved the question of including peripherals (How about that? I managed to hijack a term from the computer industry.) like Foley bags or surgical drains in the bedside  weight. The free spirit nurse simply tossed the Foley bag or drain apparatus into the mix and included it in the final weight. Dangling Foleys and drains were always at risk for unintended extrication during the transfer or elevation process so I usually left them be and subtracted a pound for the tare at the conclusion of the procedure.

One of my most colorful nursing instructors, Miss Bruiser had a favorite saying, "Work smarter; not harder." Every nurse hated bed scales with a passion and looked for a smarter procedure when it came to patient's weights. In nursing research there are methods for assuring interrater reliability so that results are consistent. Nurses weighing bedridden patients took a lesson from carnival weight guessing hucksters and followed suit. Before the bed scale weight was determined, the nurse took a guess at the patient's weight. When her guestimate came within 5 lbs. or so she became a certified patient weight confabulator. Leave that massive bedside scale in the clean utility room and bring in the certified nurse weigh approximator. These nurse's were also trained experts at clairvoyant counting patient's  respirations.

Sunday, July 21, 2019

What happened to Mop Swinging Nurses?

"That spot you missed will cost you 10 demerits"
Nurses from my generation knew their way around a janitor's closet as well as whippersnapperns know how to monkey with a Pixis. Mopping floors was an integral part of any diploma school nursing education curriculum. Just when you thought nothing could top scrubbing mucous/emesis stalactites from bed frames, mopping madness was introduced.

The swabbing the deck curriculum began with an orientation to perhaps the most important and critical cog in the hospital hygiene world which was the lowly slop sink. These marvels of plumbing technology consisted of a square, slightly elevated receptacle just inches off the floor. They were marble back in the day, but toward the end of my nursing days they were (gasp) fiberglass which definitely  lacked presence and looked cheap. Slop sinks close to the floor were a real boon to a nurse's back because the massive 30 liter buckets could be filled and emptied with minimal lifting. Filling buckets was lots more fun than emptying the bacterial/blood/stew medley that frequently accumulated after a mopping session.

Home base for the RN mop crew was a trolley consisting  of two 30 liter buckets on a mobile platform.  Bucket # 1 was filled with 19 liters of hot water and a foul smelling witches brew of ammonia compounds and an overpowering  detergent that really meant business. The ratio of solution was 10:1 and this factoid was always a question on just about any test. Bucket #2 was equipped with a wringer and Miss Bruiser, my favorite instructor, claimed that aggressive mop wringing was good for the bust line. I don't know about that, but my signature move was twirling the high modulous cotton/rayon mop head as it settled into the wringer which really got the juices flowing (the mop's, not mine) when the wringer mechanism was actuated.

Alice, my favorite operating room supervisor was equally  adept at mop swinging as sponge stick loading. My mopping abilities were honed to perfection by lessons from Alice. She  said to always pull the mop toward you while moving backwards. I modified her technique to a sideways  stance after backing into a kick basin and nearly breaking my neck in a free fall to the floor. After that episode I often referred to them a trip basins.

I actually enjoyed mopping operating room floors. The rhythmic swinging of the mop had a meditative component to it and I loved seeing the immediate results of my labors. After dealing with verbally assaultive surgeons and aching fingers from loading needle drivers, mopping was  a refreshing oasis complete with the soothing sloshing of water. A gift.

In the sunset years of my work in the OR, young nurses were surprised at my love of mopping and suggested there might be a better use for my skills. I was far too compliant to question mopping duties and too foolish  to refuse, after all, I was doing it for the patients. Old nurses would do just about anything for their patients.

Today on my frequent visits to hospitals as a patient, it's as though I'm entering the Twilight Zone. I don't know which is worse, carpeted floors or the total absence of moppers of any permutation. Modern hospital have descended to a hellscape of ubiquitous beeping and bleeping electronic doo-dads with nurses caring for computers on wheels. I would much rather be wheeling around something of substance like a fully loaded mop trolley.

Saturday, July 13, 2019

Clandestine Patient Restraint Techniques

Nurses providing ambulation assistance 
for an afternoon nap.
Restraining patients is probably one of the most unsavory elements of nursing practice and old school practitioners were masters of obfuscation when it came to forcible restriction of movement. Even office sitting nurses of the academic/administrative complex eschewed patient restraints. Everyone did their very best to find ways around outright restraint of those under their care.

Memos from on high regarding patient restraints were filled with officialese and gobbledygook in an attempt to camouflage what was really  going on. I found a VA restraint and seclusion Professional Services  Memorandum that illustrates this point: VA Form 10-2683, Report of restraint and seclusion.  "The doctor's orders (SF508) will be initialed by the GS9-11 ward nurse. The nurse will copy the prescription (form 10-2913) on the nursing notes (SF510) indicating the type of restraint and 24 hour report of patient's condition (VA form 2915). The nurse in charge of the ward during each tour of duty will maintain a record of each application of restraint on VA form 10-2683. After the last day of the month, the nurse will sign this form and forward it to the Registrar Division - 114A."  Some head nurses referred to the monthly reports as the "Funny Papers" because restraints were not always used according to Hoyle with the frequency of use almost always understated.

Downey VA Hospital, the long term psychiatric hospital I worked at in the early 1970s made extensive use of full restraints that consisted of heavy leather cuffs secured by robust belts. My ways of caring for these patients were unique and foolish, but averted some  of the unpleasantness associated with 4 point restraints. I began a patient enlightenment program that involved patients recognizing when they were beginning to escalate and request restraints before anyone was injured. A veteran of the Viet Nam war summed things up quite  nicely, "Restraints are just like an Asian civil war-much easier to get in than get out." I couldn't have said it better myself.

This illustration clearly shows the time tested maneuver aptly called "let me hold your hand...DOWN. Whether inserting nasogastric tubes or assisting with  excruciating procedures like the removal of Jackson-Pratt surgical drains, every old nurse had experience with this one. Initially, good intentions entailed holding the patient's hand for support, but soon evolved  into a vice grip not unlike the panic induced squeeze on the overhead bar of the Ravenswood EL train as it rounded an acute bend. Hold that patient's hand like a trapeze  artist grips the bar while the good doctor gives that J-P drain one final yank.

Distraction is another useful tool in the nurse's position inhibition  armamentarium   (please note, I did not use that dreaded "R" word.) This trick procedure does not work well with painful ministrations about the head and neck, but is very effective for procedures below waist  level like bedside urethral dilitations or removal of orthopedic external fixation devices. The nurse elevates the bed so that the patients eyes are close to the height of the nurse's ocular orbs. The patient's  head is immobilized between the hands as the nurse locks eyes with the hapless patient. Extreme eye contact seems to slow things down  and put a damper on some of the unpleasantness.

Children are especially vulnerable and the isolated snippets  in my mind of pediatric restraint have long sense departed. Whew! Am I ever happy for that. There is a harrowing  pediatric restraint device known as the  Pigg-O-Stat. Google it if you dare. This thing looks like a blender with the lid off and the youngster is dropped into it for X-ray procedures. It's no wonder so many people have claustrophobia later in life. They were probably popped into a Pigg-O-stat as a mere youngster.

 One of the more humane child restraint devices is a take-off on the old Trojan Horse idea. The restraint device is a toy rocking horse that lures it's young patients by whimsical looks, not brute force. While the child plays horsey, an X-ray plate is slid into position and the exposure made before anyone is the wiser. An elegant restraint solution! I wish they all could be so easy.