Sunday, June 24, 2018

Teaching Student Nurses - That'll Learn Ya

"The next time Miss Bruiser gives me the
business, I'm gonna let her have it."
Crime and Punishment was more than a great Russian work of literature. To a lowly diploma school nursing student it was an integral component of the educational  training process. Mishaps, oversights and downright mistakes were all dealt with by mean spirited instructors out to teach a lesson that usually incorporated humiliation and the infliction of discomfort if not outright pain.

A bulletin board in the lobby of our nursing school was referred to as the wailing wall or the wall of shame. It publicly proclaimed the scores on NLN proficiency exams with the less than stellar results underlined in red and accompanied by cryptic notations to see Miss Bruiser for further review or report to so and so for remediation. The "reviews" were not pleasant and "remedial" usually meant painful and/or humiliating of the highest order.

My scores in obstetric nursing were not up to snuff and as a shy, 19 year old male I was ordered to teach a post partum mother's class. "Fool," Miss Bruiser intoned in her most somber voice, "I've got something special in mind just for you. You  are going to teach new mothers how to care for their infants." It was as if Bozo the Clown had been put in charge of a manned spaceflight to Mars.  I had to demonstrate with a baby doll how to bathe and care for a new born infant. My "students" were all experienced multigravadas that did more laughing and chuckling at my ham fisted, clumsy attempts than an audience at the Comedy Club. I think it was probably the most embarrassing episode in my entire life and I have a special knack for putting myself in embarrassing situations.

My procedure pal Janess was very busy with passing meds and was late turning one of her patients. Miss Bruiser caught her in the act of being 20 minutes behind the turn schedule and had that look in her eye that shivered our timbers to the core. We knew something was up the next day when a bed from the nursing practice lab had been wheeled front and center in the nursing school  auditorium. Before the day's lectures began, Miss Bruiser ordered Janess to hop into the bed and with her usual brusque mannerisms proceeded to "position" Janess with the entire class as a captive audience. When all the bending and twisting of extremities was completed, Janess found herself in a side lying knee-chest position with her head canted at such an acute angle that  her mandible was parallel to her clavicle. "You will remain in that position for the duration of today's lectures," barked Miss Bruiser as she ram-rodded  the siderail up with enough force to elevate the entire bed. The entire class witnessed Janess's contortionist like  punishment  that went on for nearly 4 hours. When she was released from the surly bonds of the bed she could barely walk and all she ever wanted out of life was to be a nurse.

Thankfully, the operating rooms were out of bounds for Miss Bruiser, but Alice, my favorite nursing supervisor was a perfect stand in with a bag of punishments  honed over decades of service. She had a real obsession with finger nail length and would approach nurses at the scrub sink with her millimeter ruler at the ready. One millimeter was the specified nail length and any deviations were treated with a subungal curettage with the business end of a mosquito hemostat. I learned the hard way that the subungal space is highly innervated when Alice began carving away on me while I was a novice OR nurse. I learned how to shave  my nails to half a millimeter length  for an extra margin of safety.

Alice had a thing about tucked in scrub shirts because she claimed leaving them out provided an escape for sub-axillary micrcocci which she affectionately termed "pit fallout" not to be confused with perineal fallout. She  also claimed that lose dangling scrub tops were at risk for inadvertently contacting a sterile field. Alice's cure for untucked scrub tops was an aggressive manual tuck in followed by a practiced upward yank of the scrub pants. I believe the street name for such a maneuver is a "wedgie" and it was something to be avoided at all cost.  I always carefully tucked in my scrub top to avoid this pitfall..

Getting caught wearing gloves for anything but a sterile procedure was a serious deviation from accepted hospital practice. The punishment for wearing gloves was usually a cleaning assignment that involved hospital beds encrusted with a variety of dried on excrements and don't even think about donning gloves.

In the old days things were done in a different way. Nurses scraping by on a subsistent wage faced a wild, chaotic hospital work environment where there were few cures for some very dark illnesses. In this entropy rich culture rigid rules and their subsequent enforcement provided a twisted sense of security to hardened old nurses. Of course, things are different today...I hope.

Thursday, June 14, 2018

Time Out - I Contaminated my Gown

President Trump now seems to be buddies with his old North Korean nemesis and  most likely has surrendered his "dotard" title. So.... I've been thinking about changing my handle from OldfoolRN to OlddotardRN because there  is just so much about modern operating rooms that fall beyond my level of comprehension.

What happened to the sacred tiled temples that were once ORs?  Modern ORs have sacrificed  their penthouse location to practically anywhere in the hospital and worse yet resemble a waiting room at the Greyhound station. Valued work areas have been converted to electronic warehouses with enough computerized  doo dads to land a 747 in a whiteout.

The above illustration is the latest  iteration in a long line of befuddling situations. When I initially laid eyes on this young, scrubbed  whippersnappern I had that weird feeling that totally smacked my gob, (see, I can talk like a youngster if I try real hard.) She just contaminated her right hand by elevating it well out of the accepted zone of sterility. Everyone knows that the sterile part of a gown is restricted to below the armpits and above the waist tie-NO EXCEPTIONS.  If Alice, my favorite OR supervisor were on the scene she would be swinging her sponge stick like a baseball bat at this poor nurse's knuckles. Breaks in sterile technique earned the most severe knuckle bashing and I can almost see  Alice winding up like Mickey Mantle at the plate.

I educated myself about the situation and learned this nurse is calling for a "time out," which probably means she recognized the error in her ways and wants a sleeve and a new glove from the circulator. Asking for a sleeve to cover the contaminated section of a gown was a humbling experience because it required the assistance from a sterile member of the surgical team.  A surgeon helping a scrub nurse provided ample fodder for endless jokes. Dr. Slambow, my general surgeon hero usually made the nurse step away from her Mayo stand and assist with the surgery while he assumed scrub nurse duties to demonstrate the correct way of doing things.

There are a couple of other issues with the way this nurse is conducting her duties, but I think I'll let my esteemed readers point them out.

Sunday, June 3, 2018

Illness Stories for Profit

The local healthcare giants have discovered a new advertising strategy that must be lining their corporate coffers with gold. I was sitting in a crowded waiting room awaiting my next "experience" to begin a new health "journey" when the giant flat screen  flickered to life with an engaging story of  a profound, deep illness tale and subsequent recovery thanks to the miracle workers at the corporate hospital giant. I don't have one of those magical flat screens  in my little hovel; my 150#  Baby Huey tube TV brings in more nonsense than I can stand and all I use to get a signal is an ancient rabbit's ear antenna.

These corporate generated gems follow a predictable script and typically involve a respected member of the community such as a minister or retired kindergarten teacher sustaining a life threatening illness or injury but with treatment at "Big Bucks Hospital," is now back as a functioning member of society. Here is a sample.

Reverend Bagley was singing a hymn to the congregation with his lovely wife of 53 years accompanying him on the recently restored pipe organ. He suddenly clutched his chest and fell over backwards impacting his head on the altar rail. BBH  cardiothoracic surgeons performed a triple coronary artery bypass and repaired a septal defect that was found incidentally. Neurosurgeons promptly averted a life-threatening subdural by performing an occipital craniotomy. Now the good Reverend is back to singing in church with his grateful wife at his side. Remember -  choose your healthcare as if your life depended on it.

Old time nurses like to tell stories too but I don't think they would serve BBH's marketing needs. These stories are usually of complications (surgical are  the most profound,) that change someone's life forever. The purpose of these grim tales is to alert others of the mechanism of action so the event never happens again. Here is a sampler.

Officer Friendly was helping a stranded elderly lady change the tire on her old Ford and felt a sudden surge of disabling dizziness. He was transported to BBH where an MRI of the brain revealed a rather large juxta cortical area of increased signal uptake that could be neoplastic, encephalopathic , or vascular. A brain biopsy was recommended but the stereotactic head frame was ferrous and could be only used with CT. The lesion failed to visualize under normal CT protocols so two large bore IVs were established and contrast media was infused as rapidly as possible in a futile attempt to visualize the lesion. The fluid overload prompted a hypertensive crisis that ruptured the intracranial lesion which on autopsy was found to be a fragile arteriovenous malformation.

Somehow, I recall the later tale much more vividly than the feel good corporate fairy tale stories. Must be my age.

Thursday, May 24, 2018

I'm Going to Give You something to Think About! YEOWW

I stumbled upon this old image and it made my knees feel weak and my knuckles throb. It's a spitting image of my old time OR supervisor, Alice, who could wield a sponge stick with all the force of a burly cop swinging a billy club. This photo shows her assessing the severity of the infraction which will determine the location of the fulcrum to swing her weapon sponge stick from when it impacts the knuckles of her hapless victim. Swinging the sponge stick from the distal tip would inflict the most pain.

It looks like she is about to wail away with the fulcrum in mid position near the instrument's hinge. This was for relatively minor offenses  like passing an instrument to a resident rather than the attending surgeon, even though the resident was in the proper position to deal with the problem. Rules were rules-always provide the attending surgeon first.

The most brutal knuckle cracks were for any offense, real or imagined. that broke aseptic technique. Alice was an equal opportunity knuckle basher and residents were fodder for her cruel ministrations as well as nurses. She caught a young resident with his nostrils protruding over his mask and he received a double punishment, Cracked knuckles and a set of dental rolls plugging his nose. I think there might be an old post about that Aliceism somewhere amidst my foolishness.


Saturday, May 19, 2018

What Was the Most Useless Old School Diagnostic Test?

 The first notion that popped into my foolish mind was the "spit test" for digitalis toxicity. The patient was asked to produce about 5 cc  of pure saliva which was tested for potassium levels. The notion being that a high level of potassium excreted in the saliva was indicative of toxicity. Everyone had a different threshold to spill potassium in their saliva and hypokalemic patients could be digitalis toxic and have a "normal" potassium level on their test. This procedure was relatively benign in that it seldom led to further testing and had it's lighter side involving nurses providing graphic descriptions to befuddled patients about the difference between saliva and sputum.

The Histamine stimulation test for determination of gastric acid output was one of the chief  villains when it came to useless or even downright harmful diagnostic tests. The test was widespread in that just about anyone experiencing epigastric pain was a candidate and it frequently got the patient placed on the medical hamster wheel of cascading invasive tests all of which led to virtually ineffective treatment.

The underlying principle of peptic ulcer  treatment was the Schwartz dictum (no acid-no-ulcer.) This was accomplished by the Sippee diet which consisted of hourly swigs of 1/2 and 1/2 which was kept iced in a bath basin at he bedside. Copious consumption of antacids was also encouraged. This treatment did not provide a long term cure, but for some provided symptomatic short term relief. Peptic ulcer treatment improved dramatically when Australian researchers showed the root cause of the disease was bacterial. This insight was the gateway to effective treatment for peptic ulcers.

The test was sheer misery for patients. Step "A" involved inserting a naso-gastric tube regardless of the difficulty passing it. Miss Bruiser, my favorite nursing instructor, "assisted" novice nursing students perform this procedure by forcing the hapless patient to  take sips of water from a glass as she forced  the liquid past their  lips all the while barking, "SWALLOW..SWALLOW."  She often explained to the student nurse that inserting an NG tube was just like fishing; just wait until you get a  bite  swallow and ram rod that slippery cylindrical hose home to the patients eagerly awaiting stomach.  "The patient will have to swallow eventually, just like the fish have to bite."  Meanwhile the patient was coughing and spraying the forced water right back in the direction of Miss Bruiser's face. Karma in action.

After the position of the NG tube was verified by auscultation; I always wrote that exact line in my nurse's notes because Miss Bruiser gave brownie points to students that used esoteric medical terminology.  Most of my fellow students simply noted that the position of the tube was checked. Next on the agenda for this procedure was an uncomfortable painful injection of histamine that burned like a blow torch and resulted in a sore arm for at least 5 days.  This stimulated acid production in the stomach just as pouring gasoline on a fire exacerbates the blaze. Headache, dizziness, flushed face, and profuse sweating were frequent side effects of the injection.

The last component of the test is where the rubber meets the road. At 30 minute intervals X3  a gigantic piston syringe is coupled to the NG tube and as much gastric acid as the law allows is sucked  aspirated and placed in a carefully marked specimen cup. Patients often complained that it felt their stomach was being pulled out through their nose. My stomach used to churn and ache just witnessing such an ordeal and it was a cause  for rejoicing when those slippery specimen cups were on their way to the lab for analysis..

When learning about the cause of peptic ulcers the "ulcer personality" was stressed and was described as a person experiencing resentment, anxiety, and anger. I never believed these traits were the cause of ulcers. I always suspected the ineffective medical interventions of the day and the sheer misery quotient of the diagnostic testing caused much of the ill will and bad feelings on behalf of the patients. It's amazing how long  such an inappropriate treatment can remain in place and become accepted practice. Of course such foolishness would never happen in the healthcare environment of today!

Saturday, May 12, 2018

Skin to Skin Post Mortem Care

Skin to skin contact meant something entirely different to me than the currently popular post partum mother / infant tactile bonding technique. When I first heard the term, I asked myself  How in the world did someone discover one of my personal secrets?  I  felt compelled to lift the patient from the death bed or OR table with my bare arms contacting their skin. It was part of my way of saying goodbye.  There was a trick to this that involved spreading the morgue shroud open on a nearby Gurney with the distance dependent on the patient's weight. A 50 kg. patient could have the waiting litter across the room while a 100 kg "heavy hitter"  better be close to the bed. I tunneled my right arm under the patient's shoulders for a mid axillary target and my left arm went under the knees. A helper carefully supported the head while I carried the patient to the cart. There was something special about being there in actual contact with the patient skin to skin as they say. I always said a silent prayer for a peaceful journey to a peaceful place as I gently lowered them to the awaiting shroud.

Every old nurse had something unique and special to impart during post mortem care. Jane who was a dental hygienist before becoming a nurse always offered meticulous mouth care to the departed patient. When she was done the waste container was always filled with lemon glycerine swabs and an empty peroxide bottle. Bonnie hated to leave any tell tale sign of invasive medical procedures. The first thing she went for from the supply closet was adhesive tape remover and cartons of 4X4s. Every little bit of residual adhesive tape was lovingly removed. We did not have those fancy task specific devices to stabilize endotracheal tubes and all that tape about the lips and around the neck made an unsightly mess that Bonnie always made disappear. Lois hated those flimsy shoelace-like ankle and wrist ties and always substituted soft strips of wide Kerlix. After her gentle ties were in place she often kissed the patients hand. I hope I have a nurse like Lois when it's time for me to enter that shroud. I'm certain the journey to the other side will be pleasant with a send off like that.

Thursday, May 3, 2018

Glass IV Bottles - Breaking Bad

Breaking a  glass IV bottle was the stuff nightmares were made of. There were three elements to
consider with shattering  old time glass IV bottles. The glass bottle, a liter of fluid (D5W took the prize for making the biggest mess due to it's inherent stickiness,) and an air gap. The air in the bottle served to amplify the crash of the glass breaking so as to sound almost like a rifle shot. Hearing that booming "CRACK" followed by a piercing scream alerted the entire floor of the mishap and summoned a legion of gawkers for the messy clean up. It was an unwritten rule that the clean up was the sole responsibility of the unfortunate breaker of the bottle - don't even thing about calling for a janitor, oops, I mean housekeeping person. An empty Cardboard IV case was placed on the floor close to the broken glass which was gingerly pushed  into the enclosure with a portion of the box top. The procedure always reminded me of catching a piranha  with your bare hands, a slippery mess with a laceration or bite close at hand.

Glass IV bottles were at risk for breakage because their girth made them difficult to grasp. When CDs were designed one of the goals to make them easy to handle. Designers of glass IV bottles were not concerned with ergonomics and the diameter of the glass  container expanded to fit the volume of the fluid. Thank heaven there were no 2 liter  IV bottles.

Another common mechanism of bottle breaking was undershooting the hanging notch on the IV pole. That thin wire hanger was difficult to see especially under bad lighting conditions and many an old nurse thought the bottle was about to nest safely on the pole only to have it come crashing down. A good luck/bad luck conundrum occurred when the rapidly descending bottle came crashing down on the nurse's foot. The bottle, cushioned by the nurse's toes remained intact but hobbled the hapless nurse. Maybe nurses should have worn steel toe shoes like heavy construction workers.

Miss Bruiser, my all time favorite nursing instructor had a favorite tactic for dealing with bottle breaking students. After haranguing and berating the student during the clean up she insisted the clumsy student carry a glass IV bottle with them for 24 hours. A unique combination of public humiliation and learning how to perform daily activities with an ever present glass IV bottle was an excellent deterrent.

Finally the rolly polly crash and break was another way to reduce the glass bottles to glistening shards.  Everyone was acutely aware that there was only one safe position for a glass IV bottle and that was vertical. Inadvertently setting a glass bottle on it's side resulted in it rolling away and crashing at some distance from the nurse. Nurses frequently turned the bottle to this vulnerable position to apply a timing strip or write a note on the bottle label. This unfortunate event almost always occurred at times of great stress when there was an unforeseen complication or unexpected event. An acute hypoglycemic crisis required an immediate IV and if that gigantic ampule of D50 rolled and shattered it was like having a bull in an IHOP restaurant with all those syrup bottles; sticky, gooey syrupy stuff everywhere.

Despite the potential for breaking, nurses hated to see those glass IV bottles morph into those silly looking flexible plastic bags. If the complaints and derisive comments about heavy duty enema cans being replaced by flimsy bags was bad, the ill will directed toward IV bags was even worse. Veteran nurses used to joke  ( I hope it was in jest)  about using those newfangled flexible plastic IV bags for enemas because that was about all they were suited for.