Thursday, April 19, 2018

When and Why Glass IV Bottles Disappeared

Glass IV bottles were all fun and games until you dropped one.
Up until the early 1970s you could receive your IV dispensed from any container as long as it was a gleaming glass bottle. These time tested and trusted  vessels had been the workhorse of infusion therapy for decades and possessed a sense of inertia that suggested that they would be around almost forever.

Having been raised  with glass IV bottles, older  nurses had a special reverence  for them. It was easy to view the level of remaining fluid and  glass was inert to allay worries of interactions with the fluid contents. A strip of ordinary adhesive  tape could be easily applied to the side of the bottle with the time marked for the fluid levels. Pumps and controllers were nonexistent so we counted gtts/minute (gtts is a Latin abreviation for "gutta" meaning drops.) It  always amused me how health care folks  used  Latin to obfuscate the issue, but alas, that's a post  for another day.

KCl  and B&C vitamin supplements could be added to bottles without even using a needle, just plug that naked syringe into the air vent and inject away. I used to relish the visual treat of the deep yellow vitamin solution as it merged and mixed with the clear IV fluid in the bottle. Inject the colorful solution rapidly and a model of a spinning water spout could be replicated. I've heard the term "lightening in a bottle," but a miniature water spout was even more impressive.

 Nurses mixed all  IV fluids  on the patient care  floors, no need to involve the pharmacy with all those superfluous phone calls or redundant paper work. The air vent had another feature nurse's came to know and love. As the air bubble gurgled it's way through the fluid in the resonant glass botle to equalize  pressure, the soothing noise  was an auditory cue that all was right with the infusion. Infiltrated IV sites never produced the  gurgle. Glass IV bottles had a special place in every nurse's heart. We never gave a thought to their disappearance. What could possibly replace such a dependable and familiar piece of equipment?

The beginning of the end for glass IV bottles occurred in July of 1970. Outbreaks of hospital acquired sepsis by the bacteria  Entrobacter cloacae  were linked to Abbott Labs newly designed glass IV bottles with screw caps. The decades old bottle cap was pealed off to open the bottle similar to a pop tab on a can. Occasionally the metal would peal off unevenly resulting in a problem opening the bottle. A new screw on cap was designed to eliminate the opening problems. There were also problems with spiking the old design caps. Sometimes a tiny portion of the black stopper would break free and float freely in the IV solution. We were always told not to worry about it, but foreign bodies like little black flecks of stopper made every nurse nervous. Who in the world would want something like that coursing through their veins?

The newly designed threaded cap was easy to use and the problematic  black stopper was retired. We all liked the new design, but problems were waiting in the wings that would spell the end for glass bottles.

Viable bacteria gained access to the IV fluid while it cooled following the autoclave procedure which created a vacuum drawing bacteria in through the threaded interstices of the newly designed  screw- on cap. The end result was 412 known infections among hospitalized patients and 50 deaths. All of Abbott Lab's intravenous solutions in glass bottles  were withdrawn from the market in March, 1971.

On May 29, 1973 a Federal grand jury indicted 5 corporate officers from Abbott Laboratories. Investigation revealed the Abbott IV plant in Rocky Mount, N.C. was contaminated with a variety of pathogenic bacteria. The proliferation of bacteria was exacerbated by glass bottles of D5W falling from the assembly line and breaking ( a problem nurses knew all too well)  which provided the bacteria with an ample supply of growth media. This was one of the initial cases of health care officials facing criminal charges.

Hospitals were desperate for a supply of IV fluids and Baxter Labs had just introduced a novel product - IV fluids in a flexible rectangular configuration featuring a plastic container that collapsed as fluids infused. The flexible IV bags were tagged with the clever  name "Viaflex" and the revolution had begun. These bags could be stored in any position and touted a completely closed system-the bags collapsed as the fluid exited. No venting required. With the old bottle system it was risky to piggyback antibiotics into a primary line because drugs like Keflin came in 2 gm. bottles requiring a vent and connecting a vented secondary bottle to a vented primary line could allow for air embolism. Small plastic bags of piggyback medication eliminated the air embolism risk. Baxter acquired a pharmaceutical company and began selling premixed drugs in small 100cc plastic bags. The IV piggy back was off to a running start with the closed system mini-bags.  Soon many drugs administered by IM injection were being given IV and fancy new fangled notions of determining peak and trough levels of drugs evolved.

For a brief time period (1976-1980) Viaflex bags and glass IV bottles assumed  a tenuous coexistence. Vented IV sets were bicultural so to speak and could be used with either Viaflex IV bags or glass bottles. Using  nonvented  Viaflex IV tubing set up on a glass bottle was strictly taboo. Hapless practitioners that pulled this stunt found that without a means to relieve intrabottle pressure the drip chamber collapsed like a lung in a punctured pleural cavity. If the problem was not promptly corrected the negative pressure could begin to draw venous blood through the angiocath producing a tell tale red streak of blood in the IV tubing. Spooky indeed and guaranteed the nurse a prominent position on the wall of shame and vulnerable to endless gossip..."You would not believe what Suzy did with her IV last night...yada..yada," nurses only made this mistake once.

By 1980 the intravenous therapy world was ruled by Vialflex like flexible bags and glass bottles were gone for good. Abbott even began producing their own IV bag that had an unusual feature that nurses disliked. The port for adding medications was a blue bull's eye  target about 3 inches up from the bottom of the bag. When adding drugs to an IV, nurses were used to holding the port in one hand to steady it while injecting with the other hand. There was nothing to grasp on that blue bull's eye and nurses in a hurry were known to poke a hole through the opposite wall of the bag resulting in much cursing and  general unpleasantness.

This transition from glass to plastic  was difficult for seasoned old nurses who by  nature of their basic constitution were resistant to change. Glass bottles had prominent labels and were easy to identify; bags were produced with an over wrap that obscured the label. Drip chambers on glass bottles hung perfectly vertical; on bags the drip chamber was often hanging at an angle. Patient transfers with a bottle always required the careful use of a pole to maintain the positioning of the bottle. Nurses were appalled at the occasional  practice of tossing the IV bag on the patient's lap or chest during brief transfers.  Bottles would roll off and break if this crude trick was attempted. It was easier to thread a solid object like a bottle through an opening for an arm when changing patient gowns. Those IV bags were like getting a grip on a handful of Jello.  Finally, hanging those flimsy bags could be difficult. It was necessary to free up the folded vinyl hanger and thread the small opening over the hook on an IV pole.

I am truly impressed by the variety of realistic sounds produced by electronic devices like that camera shutter clicking noise on cell phones or that  "whoosh" noise when sending an email. The Oldfoolrn  medical equipment design institute has come up with another innovation. How about an electronic IV pump or controller that emits a skeumorphic noise replicating that gurgling noise as a bubble coursing through a vented  glass IV bottle. Lots of old nurses would  truly love hearing  that reassuring noise again.

Tuesday, April 10, 2018

Blood Bag Blues

It's been a very long day. The somber cacophony of suctions sucking, Bovies burning, Airshields ventilators chugging , instruments clanging, and surgeons bellowing has decrescendoed to a strange and rare moment of blissful silence. Those weary legs wobble like Jello as they acclimate to an absence of weight bearing stress. The impending fatigue unleashes a contemplative frame of mind so different from the acute attentiveness  required of a scrub nurse busily loading needle holders and delivering the exact required instrument at the exact right time. My mind sometimes fixated on the remaining flotsam and jetsam scattered about the tiled temple as I planned my clean up activities.

Drained of their miraculous magenta contents, empty blood bags are neatly stacked sit on the anesthetist's  gas machine awaiting their round trip journey back to the hospital blood bank. The few remaining droplets of blood form an intricate spider web design visible through the transparent container that always reminded me of stained glass. The drained bags are now a component of the detritus remaining as an artefact of the previous surgical adventure with their own tale to tell.

Artefacts and relics mean different things to different people when their intended function has ended. I thought many times how strange it sounded to keep blood in a  "bank," but then I began to figure it out. Some of my very best insights occur when fatigued and sleep deprived as that caffeinated jolt works it's magic.

Blood bank CEOs and commercial bankers have much in common. Blood banks rely on the innate goodness of volunteer donors  whose reward might be a glass of orange juice and a stale cookie. Bankers of money pay paltry sums of interest to the hapless savers and charge exorbitant fees to credit card users. Blood bank CEOs and bankers reap their massive  salaries and stock options on the backs of little people just trying to do the right thing. In nursing it always felt as if large sums of money flowed  right around me much the same as the  blood in a suction tubing. Nursing and donating blood is a waste of time if you are doing it for the money. It may sound strange, but I always felt a sense of pity for the greed consumed CEOs lounging in their administrative playgrounds. They probably never had the warm feeling that comes upon you when really helping someone at a critical time in their life.

Blood had almost magical qualities when transfusions went well and the source of blood loss could be corrected. Used blood bags always had redundancy in miniscule sticky labels with an identification number. There were always plenty of these little stickers left over even when all the documentation was complete. I tried to keep the good juju times a rolling with these little stickers by sticking them on the back of my name badge or wrapped around the earpiece of my trusty stethoscope. I don't really know if they helped, but when times were tough, I could cheer my spirits with a quick glance at the back of my name badge.

Sunday, April 1, 2018

A Remembrance of Nursing Pins Past

The land of the free and the home of the brave was once home to 4,000 diploma schools of nursing  each with their own unique nursing pin. These pins were typically designed by committee and the final version was often a hodge-podge collection of sometimes divergent elements. It was tough for a committee to come up with a consensus for a coherent design.  At my alma matter the pins were the responsibility of the Admissions and Promotions committee and it required weeks of heated discussion to decide if one letter on the pin should be changed to reflect the conversion of our hospital to a "medical center." After much heated debate it was decided to change the "H" which was for hospital to "MC." Nursing pins were sacred symbols and change did not come easily.

Implant something in an adolescent brain while it's developing and it sticks forever. We were brainwashed  conditioned  into believing our pin was the ultimate reward for 3 years of soul crushing labor while  subjected to near constant badgering and belittling by down right mean instructors like Miss Bruiser. That beloved pin had a transcendant element to it that required a compulsory level of reverence. It was the alpha and omega to any 3 year diploma student. The  radiant pin glowing against a pure white background was the first thing your eye settled on when a nurse appeared on the scene and it told the story of a nurse's experience. If only nursing pins could talk.

I spent many hours staring at the cover of RN magazine when their annual nursing pin edition was published. A cover adorned with 30+ pins in glowing color was a feast for any diploma grad's  eye. The most common pin design was a Maltese cross with the schools initials plastered one on top of another over the center. I just loved pins with a singular sculpted design like the  Ravenswood Hospital School of Nursing in Chicago. The pin featured a beautiful version of the Good Samaritan that seemingly glowed in the dark. Wow.. that was one heck of a pin.

Speaking of good samaritanns this unusual pin featuring a beaver really got my attention. Simple, straightforward design at it's best. Beaver's are like nurses; hard working and they have the ability to modify their environment for unexpected needs. Beavers are also continually growing just like me after too much hospital cafeteria food. I really cherish this pin and think it has much better aesthetics than mine which resembles a policeman's badge. While working in psych, I found that it was prudent to remove my pin lest I be confused with an undercover cop.

Another animal themed nursing pin with a serene looking moose in the foreground framed by the hospital's name. I wonder why the moose is gazing in the opposite direction from the beaver. I think it looks better from a nurse's view looking down to have the animal facing the nurse.   The cross in the background forms a lovely backdrop. It takes a moose 3 years to attain adulthood and 3 years for a diploma nurse to graduate; an interesting fact that ties it all together. A moose also has muscular shoulders and nurses acquire the same qualities  after a stint on the orthopedic ward. I admire these two pins because they are straightforward and very pleasing to the eye.

So many pins contain multiple symbolic features that are difficult to decipher. I was admiring the floral design on a friend's pin and was quickly informed they were no ordinary flowers. "That's the Papaverum somniferum plant that is the source for opium," I was told. Her pin was symbolic of the nurse's duty to relieve pain.

It really bothers me when I hear that present day nurses must pay money for their nursing pins. A nursing pin was no ordinary commodity that could be purchased with money. Blood, sweat and tears were how we paid for our pins. The symbolic meaning of a diploma nurse's pin stays with a person forever. I sneak little glances at my pin all the time just to remind myself of who I was am.

Sunday, March 25, 2018

Blowing Smoke to "Settle Your Nerves"

For some proven measures to ameliorate shaking hands and promote smoke free steady nerves please peruse my long forgotten post;  "A Fool's Foils for Fasciculating Fingers. Please pardon  my lame attempt at alliteration-sometimes my foolishness overwhelms me.

Sunday, March 18, 2018

Successful Swallowing Secrets

It's one of those rare occasions when it's time to sequester my foolishness to the back burner as I offer some time worn proven measures to help patients experiencing difficulty swallowing.  Long term endotracheal intubation,  TPN,   and neuro problems all invite dysphagia.

Position the patient upright and check for a gag reflex or at least some indication of an intact airway protective response. The famous ramrodding a patients posterior pharynx with a tongue depressor is not what I had in mind. The gagging and retching elicited by this cruel trick does not necessarily indicate a protective response against aspiration. A kinder, gentler  method of assessment involves asking the patient to say "Ahhh"  and observing if the uvula and posterior pharynx retract. I have also been told that an intact blink reflex indicates an intact gag reflex because the same nerves are involved. Cross over of neural impulses makes me hesitant to trust eye blinks as an indicator of airway protection.

Caution is the key so don't even think about injecting fluids into a patient's mouth with an Asepto or using drinking straws. The suction applied to a straw to permit atmospheric pressure to propel the liquid into the mouth can compromise airway protective reflexes. The act of applying suction can impede the transition to an airway protecting response.

Drinking from a glass replicates a familiar experience for the patient, but hyperextending the neck by tilting the head back to drink opens up the airway. The epiglottis is repositioned from closing the trachea-something to be avoided at all cost.

The secret to keeping the epiglottis positioned over the trachea when swallowing from a glass is to keep the chin level or even slightly tucked down. How do you raise the glass to drink without tilting your head back? All it takes is a few snips of your trusty bandage scissors to create an aspiration resistant drinking device.

Cut a nose clearance notch in the side of a paper cup and you can drink without tilting your head back maintaining the airway. Just drink from the side opposite the open notch and as the cup is tilted up to take a sip the opening accommodates the protuberating nose. The mandible remains level and the epiglottis remains intact covering the trachea.
Smaller notch for more petite noses. This 
aspiration resistant cup works perfectly for 
Oldfoolrn's like me.

Tuesday, March 13, 2018

Fevers - Antiquated Defervescent Interventions

Venerable, old nurses were taught that fevers were a destructive response that required immediate intervention to bring the body temperature back to that magic number of 98.6F or 37C. Since there were few real cures for much of anything back in the good old days, rigid authoritarian protocols, whether they worked or not, were established to control the chaotic world of febrile hospitalized patients.

Temperatures of all patients on the ward were routinely checked first thing in the morning with glass mercury  thermometers. We had one complete class session on the proper way of shaking thermometers down.  It's all in the wrist snap.  Fevers did not follow a rigid time  schedule and could spike rapidly just about any time of the day or night. It was easy to miss fevers with routine schedules because they could rise and fall with reckless abandon within a very brief time frame.

Protocol called for cultures for temperatures over 101F even if the cause was suspected to be neurologic and their was no sign of sepsis. Fevers climbing to that dreaded 102F threshold triggered a series of unpleasant and down right miserable interventions for suffering patients. Denial exists on both sides of the bedside rail and lots of compassionate nurses reported thermometer readings of 101.8 to put a halt or delay to some of the more miserable interventions to drop temperatures. Hyporeportinosis in it's finest glory.

This illustration shows the fight fire with fire fever treatment. That's a teapot propped up on the stand at the foot of the bed. The steam cools as it infiltrates the tented sheets and the nurse is applying ice packs to the patient's head. The thinking (if you could even call it that) behind the steam bath was that it opened pores and promoted a profuse diaphoretic response. From the patient's perspective, I suspect it felt like receiving a hot foot while having your head stuffed in a freezer. Miss Bruiser, my favorite nursing instructor had many tales about patients in steam baths; none of them pleasant. I don't think she ever had a temperature reported as 101.8.

Alcohol sponge baths were another weapon in the armamentarium to battle fevers. Equal parts of water and 70% isopropyl alcohol were combined in a bath basin. After placing axillary and groin icepacks the nurse swabbed the patient's entire body with the alcohol laced cooling solution. The shivering induced by the strategically place ice packs  was bad enough, but the fumes from the evaporative  cooling action of isopropyl alcohol was even worse. I'm certain the shivering and hacking cough produced enough muscular activity to counteract any of the cooling attempts. Some old nurses replicated the experience of greenhouse workers by borrowing misting bottles from housekeeping and spritzing the febrile patient with a toxic mist of alcohol and water.

Introducing ice water into just about any available orifice was another hoary nursing intervention favored by those practitioners with a masochistic vein. Nasogastric tubes were swiftly passed and flooded with boluses of ice water. Miss Bruiser would rest her oversized meat hook of a hand on the patient's epigastrum as the frigid water infused and arrogantly nod her head, "Ahh..he feels cooler already." It was always a mystery to me how she could feel past the barrier of the stomach wall, abdominal muscles, fat, and skin, but it was never prudent to question Miss Bruiser or her whacky methods.

Just about any ailment had a specific enema treatment and fevers were no exception. Febrile patients were subjected to backside buffoonery that entailed ice water enematizations. This approach from the rear did seem to reduce fevers, but I always suspected it was limited to the localized cooling of sphincter muscles when temperatures were measured with rectal temperatures. I always had the notion if Miss Bruiser could catch a glimpse of the patient's misery filled facial response to this frigid intrusion that she would temper or soften her approach to patients. Fat chance of this occurring, Miss Bruiser's field of view was limited to the icy enema tip and it's intended target.

Asking questions of old time nurses about the science behind their crude interventions could land an innocent student in a heap of trouble. Fever interventions were largely based on empirical notions and asking to see supporting data was seen as an indirect way of telling the person they really did not know what they were doing. Both parties full well knew there was no science to support their dubious activities and asking for the data when there was obviously none, was seen as rubbing salt in the wound.

Monday, March 5, 2018

Finger Cots - Minimum Coverage Saves Vintge Hospitals from Bankruptcy

"Here is your daily allotment of gloves. Use them judiciously and I better not here about one shift hogging them - remember they have to last 24 hours."
Finger cots substitute for gloves in budget minded hospitals

This was the warning issued by one of those stern nursing supervisors as she reluctantly surrendered a box of one size fits all gloves. A box of 24 latex (nobody was allergic to this substance in the good old days) gloves was supposed to suffice for three busy wards inhabited to the gills with patients vomiting, excreting, and  oozing every bodily fluid known to mankind. At least these fluids were organic, the Cidex based cleaning solutions we used on hospital equipment would make unprotected skin boil and bubble up like a dousing with boiling water. We always tried to handle cleaning solution soaked rags with forceps, but sometimes the volatile fumes were enough to accelerate skin lesions. Nasty stuff indeed and don't dare get caught wearing a precious glove on an ordinary cleaning mission.

Old school nurses eschewed gloves for reasons other than the negative impact such extravagant expenditures had on hospital budgets. Nursing was a hands on affair and this meant bare hands  with skin to skin contact. Gloves imposed an unnatural barrier and were viewed as an offense to the patient.

I was conditioned like Pavlov's dogs when I had gloves on. This was just not right and my shoulders hunched over with a strong sense of self consciousness. Even when using gloves appropriately, I was anticipating that cranky old nursing supervisor in the background  hollering and belittling me.

Finger cots came from the supplier in boxes and were clean (hopefully) but unsterile. Sterile finger cots like Montgomery straps and scultetus binders were produced in house by cantankerous, past their prime nurses who toiled diligently in central supply. Three finger cots were oriented in the same direction and placed in a glassine finished envelope which was then autoclaved. A piece of autoclave tape sealed the envelope and verified sterility by proudly displaying diagonal black stripes.

You could do lots of fun tasks with sterile finger cots such as dressing changes or Foley catheter insertions without bankrupting the hospital on  exorbitant expenditures like sterile gloves. Donning sterile finger cots took lots  more practice than  sterile gloving. After carefully opening the sterile packaged fingercots with your ever present bandage  scissors, place them business end down on a bedside stand. Judiciously apply a very small dab of tincture of benzoin to the tips of your thumb, index, and second finger with an applicator  and blow dry with a couple of puffs. Smokers (which compromised 95% of all nurses) with their comprised tidal volume might need three puffs.  Press your thumb into the very center of the rolled finger cot and let the tincture of benzoin work it's adhesive magic. With the finger cot firmly stuck to your thumb slowly and carefully unroll it with your free hand while touching only the inside surface of the finger cot. Rinse and repeat for your index and second finger.

Now that you're all  gloved cotted up it's time to rock 'n roll. To maintain sterility it is essential that you curl up your bare naked  third and fourth fingers. For the time being just pretend they don't exist (I used to make believe  they were burned off in a Bovie mishap.) You do not want them flopping about contaminating the sterile field or the catheter.  You can now use your finger cot festooned fingers to make like a forceps and guide that Foley home to pay dirt. When you're in (urine) haha, its time to peal off those finger cots and hook up the drainage bag.

Finger cots have limited surface area compared to gloves and can be predisposed to slipping off your digit at inopportune times.  The no finger cot left behind doctrine incorporates several measures to prevent in vivo loss of cot custody. The tincture of benzoin trick helps ameliorate wandering finger cot issues when sterile technique is used. For the more common everyday uses of finger cots  the keyword is restraint. Discretion is definitely the better part of valor when exploring any internal orifice with a finger cot. Never ever inset the finger cot into anything past it's cuff. If you poke that finger cot in deeper past the cuff all it takes is a sphincter contraction to strip it off faster than  a chimp can peal a banana.  It's a real challenge to gain purchase on a retained finger cot and the best course of action is probably benign neglect while hoping that it works itself out.
A tenaculum  grasping cervix and a cot on
the index finger. Note the 3 exposed fingers
providing traction on the tenaculum. Gloves optional.