Thursday, March 21, 2019

Nurses of The Greatest Generation

Miss Bruiser, a proud member of The Greatest Generation
My indoctrination , if you could call it that, to the world of nursing  came under the tutelage of a rough and tough assemblage of gallant geezers from the heart of The Greatest Generation. These nurses were forged in a cauldron of  devastating diseases, arrogant paternalistic physicians, and a life of abject poverty where it was a virtue to eschew any accumulation of material goods.

Battle scared nurses like these aroused paradoxical emotions among lowly student nurses. We held them up as the ultimate in role models, yet we wanted to be nothing like them in their surly approach to nursing care and life in general. Their level of dedication was without question, but their demeanor left much to be desired as they were a frightening assemblage of care givers.

These  nurses had sacrificed and paid the price on a daily basis. Trivial pastimes and activities for amusement were unheard of. Today's notion of self care for nurses would have ignited a hearty belly laugh from these nurses and a stern rebuke, "Spend more time with your patients and stop thinking about yourself. It's not about you!!" The notion that caring for others required caring for yourself was the ultimate in tomfoolery.

These nurses were masters at giving up personal comfort for what bordered on self  torture. Sacrificing ease for discomfort to benefit patients was second nature to this intense hard core group. Their footwear, Red Cross shoes, were metatarsal unfriendly to say the least. Remember that Pulitzer Prize photo of the nurse kissing the sailor at the conclusion of WWII?  Those were bunion busting Red Cross Shoes and a podiatrist's nightmare. Those heavy, white starched uniforms looked very official, but on those wards that were brick oven hot, cotton clothing acted like a sweatsuit. I don't know how they functioned with pools of sweat dripping from overheated extremities.

Vintage diploma nursing schools were ruled by a set of rigid authoritarian regulations. Marriage was prohibited any time during those tortuous 3 years and pregnancy meant an automatic expulsion. One of my fellow students had a fascinating tale about her mother's determination to graduate from nurse's training. Mary's Mom was a large-scale sized person so a few extra pounds on her was like an extra suitcase on a Boeing 747; not something noticeable. Near the end of the nursing program she became pregnant with Mary. She delivered the baby at nearby Ravenswood Hospital a couple of weeks prior to graduation and was present for the final awarding of her nursing pin with not a soul the wiser. Mary was in the graduation audience cradled in her grandmother's arms.

Nurses from this era had a sense of consecratedness to their profession where persistence was one of the primary themes. These folks had a never say die mindset and persistent nurses never quit when it gets rough, when they lose, or when it hurts. I've known older nurses to continue working despite disabling arthritis and physical disability that would hobble just about anyone else.

Older nurses were highly skeptical of anything new. I remember the outcry over the installation of  nurse call lights when wards were being divided to semi-private rooms. These nurses thought it was ridiculous for a patient to summon a nurse by pressing a button. The nurse should always be close to the bedside. Team nursing, disposable needles, anything made of plastic,  and  swadged, atraumatic sutures were other useless new fangled ideas. Why tinker with something that worked for decades.

It's a good thing that Press Ganey patient surveys were unheard of  in this era. Old nurses were in charge and always  knew what was best for their patients. Any health problem that could be construed as self-inflicted drew a particularly tough, unsympathetic rebuke. As a student caring for an alcoholic patient with draining wounds on his legs, I was enlightened by one of the older nurses, "That's all the filth and evil leaving his body," Rita knowingly advised. I was belittled when coming to the patient's defense. Clearly, these nurses were not ones to tolerate dissent.

Friday, March 15, 2019

Fun in The Sun at Diploma Nursing Schools

"After I sink this one, let's  visit the sun deck!"
Old time 3 year diploma nursing schools lacked the recreational amenities  of modern learning institutions, but they did provide some outlets for brow beaten,  harried students to unwind. The notion of fresh air and sunshine as a curative modality was a core value of the traditional Nightengale mindset; hospitals had solariums and almost every nursing school had a sundeck.

As sundecks were the common denominator at diploma nursing schools, most hospitals had at least one other diversional activity. Cook County School of Nursing had a magnificent indoor swimming pool. After a brief journey through dingy, rat infested catacombs an elegant facility complete with Romanesque columns emerged. The lavish pool was a  unique oasis oddly situated in the midst of a dingy, depressing, medically underserved environment of intractable social problems and abject poverty. A true diamond in the rough.

 Our hospital had a lowly pool table located adjacent to the sun deck entrance and students often picked up a cue and attacked the racked balls before sunning themselves. Nearby Ravenswood hospital had dual purpose sundeck that also served as a badminton court. Weiss Memorial Hospital had a combo shuffleboard court sundeck.

Most all sundecks in Chicago hospital nursing schools  were located on the roof of the nursing school as a concession to the cramped urban environment. The nurse's sundeck was on the roof and 4 stories off the ground at our beloved learning institution. (If you could even call it that.) The operating rooms on the seventh floor overlooked the nurse's residence sun deck and provided geezer surgeons an unobtrusive vector for ogling the scantily clad students. An amorous break from the rigors of the operating room was only three stories away and many took advantage of the opportunity.

A generous sized cedar wooden deck that occupied about a third of the roof top made up the formal deck. This structure was surrounded by a chain link fence that prominently commanded a sense of forbiddance. A few deck chairs and a large phony looking  plasticized   palm tree provided atmosphere. A tropical paradise amongst the Chicago concrete jungle seemed to be the idea.  Just toss a dime in the nearby beverage  vending machine for a can of Tab soda and stretch out on a beach chaise. Life was good.
Tropical Bliss Comes to a Chicago Nursing School
Sundeck activities, like everything else, were governed by the rules set forth in every student nurse's bible, the official student hand book. Here is what the powers at be had to say:
A sundeck is provided for the convenience and pleasure of the students. It is open from 8AM to sunset. School linens, pillows and blankets are not to be taken out on the sundeck. Radios are permitted on the sun porch if played softly. Suitable chairs, chaise lounges, and mats are provided and must be returned after each use. Some type of beach coat or covering must be worn to and from the sundeck.

Like Baptists, diploma nursing schools firmly believed in total immersion, not in water, but in the hospital milieu.  I think any oppressed minority cultivates  a latent rebellious streak and student nurses were no exception. The sundeck overlooked the faculty entrance to the hallowed halls of the lecture auditorium where bitter, hardened, old instructors put their students through their paces. After a severe ear beating on the clinical unit for a pillow oriented the wrong way  toward the door, one of the students, Rose, hatched a diabolical plot for revenge. An Asepto syringe and a bath basin created a sluice of water that cascaded over the sundeck just as the formidable Miss Bruiser made an appearance. She was an aficionado of flowing capes, but nevertheless received a generous soaking

Soon after Miss Bruiser's unfortunate encounter with the cascading fountain of water, a warning sign was posted; Any  student caught propelling any substance off the sun deck will be referred to the student disciplinary committee for possible expulsion. As young Rose loaded her Asepto for another aquatic volley she replied with a snicker, "They have to catch us first!"

Friday, March 8, 2019

Professional Courtesy - A Lost Custom

Forty years ago physicians would have never considered denuding fellow doctors and nurses of their limited financial resources to pay for health care. Any doctor would see any colleague without money changing hands. Physicians were apex predators in the hospital food chain and they always got what they wanted without question.

One of the ideas behind professional courtesy was to prevent doctors from treating their own family members. Physicians and surgeons tend to overthink and overdo things when caring for close relatives. Laproscopic minimally invasive surgery was in the distant future and overdoing procedures like radical mastectomies or laryngectomies was not a pretty picture. Professional courtesy spared fellow health workers from lots more than financial pain. It was a grand idea that was a tradition for many years.

I worked with the internationally known ENT surgeon, Maurice Cottle, who thought virtually anyone could benefit from a "Cottle Nose." The purported gas exchange improvement by breathing through remodeled nostrils was  claimed to improve everything from longevity to energy levels  Student nurses were among his favorite subjects  patients and many took him up for the free, albeit painful rhinoplasty which of course was done as a professional courtesy. I treasured my native proboscis and politely declined his frequent offers for cost free, fragile nasal bone crunching surgery. When scrubbed with him I made darn sure my mask was covering my nose completely so as to not give him any bright  ideas. There was something about hearing those loud snap, crackle, pop noises as he plied his trade on a wide awake, locally anesthetized patient that gave me goose bumps. This was not for me.

A triangular alliance of administrative busy bodies, health insurance companies, and governmental regulation put a halt to the long standing tradition of  professional courtesy. Physicians now had to kowtow to a host of  policy makers outside the medical world as managed care became the norm. Healthcare became technology proficient, but empathetically deficient. Balance sheets and quarterly reports were the metric that defined hospitals. Professional courtesy was gone for good as business minded bean counters controlled the medical landscape.

Some old time docs did not go quietly into the night when it came time to abandon professional courtesy. When an old school surgeon like Dr. Slambow received a medical bill for banding a series of uncomfortable internal hemorrhoids he went ballistic with the poor young lady from the billing office. I only heard one side of the memorable  phone conversation argument, but the snippets were permanently engraved in my long term memory including  phrases like: "I demand professional courtesy - I'll bend over and extricate that overpriced elastic ligature and  mail it back to you C.O.D.- if I ever see you on the OR table." I don't know if his medical bill was forgiven, but the hapless young lady from billing received an earful.

There have been many attempts to reform medical billing such as the ill fated Medicare DRG schedule where hospitals received fixed amounts for procedures. Maybe it's time to go one step further and take a lesson from attorneys with their contingency fees. Simply place all the funds paid to correct a health problem in a reserve fund. When a physician accomplishes the final cure, he gets the whole pot. This would incentivize finding a cure rather than finance a medical goose chase with pricey diagnostic studies that produced minimal result. Now that's something to think about.

Thursday, February 28, 2019

Student Nurses Misappropriate Birth Certificates to Imbibe

Vintage diploma nursing schools had rigid, authoritarian  rules for just about everything  that could be construed as fun. From restrictions on outside visitors, especially men, to strict study hours, all recreational outlets were meticulously managed with onerous regulation. The rules regarding alcoholic beverages were especially strict and came from the hallowed chambers of  The Hospital  Board of Trustees. This mysterious and often cited governing body was a force to be reckoned with because just one measly slip up of their regulations could get you expelled from the nursing program.

According to the esteemed board, alcohol was the ultimate in forbidden fruit, especially for stressed out and underaged nursing students. The notion that imbibing in the magical elixir of alcoholic drink was wrong, made it all the more appealing. Diploma nursing students were in the same boat as Eve in the Garden of Eden.

By the time nursing specialties: pediatrics, psych, and obstetrics, rolled around, nursing students were feeling the pressure of their chosen vocation. I was going to say chosen profession, but we were brain washed into submission and nobody really believed we were worthy of such a lofty title. I'm just a nurse was our mantra. Doctors were professional-nurses were not.

All nursing specialties were difficult and stressful. Cures for seriously ill children were few and far between. Leukemia of any variety was a death sentence. Our clinical psych experience was on the back ward of a state hospital and it was your lucky day if your patient wasn't homicidal. I don't know which was more trying on your soul,  psych or pediatrics. It was a toss-up.

Obstetrics was different, especially post partum where the exuberance of young mothers was uplifting. Our time in OB was rotated in monthly intervals through delivery room, nursery, and post partum. Everyone had their particular favorite, but delivery room duty was the highlight of just about any young student  nurse's  training. The miracle of birth was something that stayed with you and served as an antidote to all the pain and suffering in the rest of the hospital. Birth and death were the ultimate Yin/Yang experience.

The delivery room had another up side. Stashed right next to vials of silver nitrate which was used prophylactically in  babies' eyes to prevent blindness from contact with gonorrhea was a stack of blank birth certificates.

The unwritten rule was that each student nurse was entitled to one blank birth certificate at the conclusion of their delivery room rotation. Students treasured documents from their various specialty rotations and I still have a plundered birth certificate along with a sponge count record from the OR and a restraint and seclusion record from psych.

I first learned what could be done with a blank birth certificate from one of my fellow students who had been released from Cook County School of Nursing as being unsuited for the practice of nursing. That "unsuited" business was a catch all phrase that covered a multitude of sins and was a step up from academic failure because some of these students were able to transfer to another diploma nursing program after "maturing." Transfer students were a valuable resource when it came to surviving nursing school because they knew many of subtle ins and outs of getting through the madness of three years of torture.

Light fingered nursing students knew exactly what to do with a poached birth certificate. "All you have to do is fill in your own name with a birthdate of more than 21 years ago and the document becomes your ticket to freedom from the evil clutches of the sanctimonious "dry" hospital environs," explained one of these wise transfer students. Time to unleash the libations.

Barkeepers found the neighborhoods surrounding hospitals as fertile ground for their trade. There was no shortage of stressed out workers that had pay checks to support their bar tabs. These taverns often had clever names like "Recovery Room" or "Barborygmi." The bar of choice near our hospital was "Ratzos" and the barkeep would just wink and pour when presented with a birth certificate with freshly inked infant footprints. This little charade had been going on for a very long time and was one of the dirty little secrets of old school diploma schools. Cheers! as Sue  would say.

Thursday, February 14, 2019

How Hospitals Transitioned From Chairity Care to A Corporate Cash In Culture

The land of the free and the home of the brave is home to some  the most expensive health care in the known universe. What the heck happened? The last I remember,  the  rate for nursing, room, and dietary in a big inner city hospital was 68 bucks per day. The charge was known as the hospital NRD fee and it covered just about everything except for OR fees and pharmaceuticals which were dirt cheap.  A visit to the ER was 28 bucks if you had it and no patient was ever out of network or even asked about insurance.

 Hospital superintendents were paid slightly more than nurses and there were no big bonuses for anyone. We were all in the same boat and everyone knew and respected frugality. This is my anecdotal account of what happened during the transition to the current cash-in culture of today's healthcare. One caveat, these notions have been filtered through what's left of an ancient nervous system that remembers old school nurses who never expected to own much of anything and lots of MDs were content with an apartment.

It's easy to rattle of a list of culprits in the stratospheric rise of healthcare cost. Entrepreneurially motivated physicians and nurses wth the notion that I worked hard and deserve bountiful financial compensation for my work is a part of the story. Patient care in of itself was the old school compensation and material deprivation produced a sense of solidarity among nurses with everyone looking out for one another.

Old nurses like myself really had it easy compared to the all for one, and one for all whippersnapperns of today when it comes to salary. Our basic needs were met without worry and there were no school loans or financial demands. If we needed medical care any MD would gladly see us as a professional courtesy and if a hospitalization was required, our diploma school had a private "alumni room" for our exclusive use. It was the only room in the hospital with genuine Karastan carpeting. Nurses lived the good life without money changing hands. It's no wonder we affectionately referred to our hospital as "Mother."

Explosive growth of technology and electronic record keeping consumes lots of dollars. So do mindless Press Gainey surveys. Old school physicians would argue until they were blue in the face that patients are not qualified to make judgments about the quality of their care. I can see their point. Some of the very best surgeons I worked with were not very touchy-feely, and that's putting it nicely. Dr. Slambow would visit post-op patients with part of his breakfast and/or lunch spilled on his tie and shirt. I can see why folks would question the credibility of a surgeon wearing his breakfast and lunch, but he was one of the best when it came to minimizing post-op complications.

In the late 1970s my humble school of nursing was closed down for good after being in existence for almost 100 years. The building functioned as an oncology clinic for a couple of years and was then razed for the construction of a multi-level, monstrous parking garage. Fancy hospital parking facilities are given short shrift when considering how corporate interests made health care such an expensive commodity. This is where the rubber meets the road (or parking garage) in my woe filled tale. Parking garages are at the root of the problem.
Parking garages became the welcoming mat for hoards of greedy go-getters

Very few nurses owned cars when I was toiling at the bedside. We made do with the CTA, bicycles or good old fashioned shoe leather, those Clinic shoes were made for walking, It's interesting to note that our nursing school was way ahead of the curve when it came to alternative transportation. The first object to greet someone approaching the school was a massive bike rack, usually at least half full. There were no worries about locking your bike. Who would even think of stealing a nurse's bike?

Physicians and the fortunate few that owned autos found ample space on the street or small unregulated surface lots. Patients arrived at the hospital by taxi, bus, or walk-ins. There was no EMS, and trauma patients frequently arrived in the back of police cars or paddy wagons. Chicago police operated unique,  three wheeler Harley-Davidson motorcycles  which could be ridden just about anywhere. I vividly recall a drowning victim from Montrose Beach being hauled up to the ER secured to the back of a police officer's tricycle motorcycle. The officer even went so far as to suggest the road bumps jostled the water out of the victims airway. The patient survived with quite a story to tell. Maybe the cop had a point.

Hospital parking garages dramatically demonstrate the ridiculous profusion of administrative busy bodies, clerical, and unnecessary hucksters attempting to sell everything from pharmaceuticals to medical equipment. Visit just about any hospital parking facility on a Sunday morning to observe first hand how few workers are  really necessary to take care of patients and it's not because administrative big shots and pharmaceutical representatives are attending church. The Sunday morning deserted parking garage syndrome is even more acute at government agencies such as VA Hospitals.

Hospital parking garages are like a beacon to pharmaceutical hucksters. In the old days drug reps were a non-entity. No one needed to sell penicillin because it really did kill strep and everyone knew it. Much of drug pricing today is done with blatant extortion. A marketer of Zyprexa might claim that his drug will negate the necessity of long term hospitalization saving untold tens of thousands of dollars, hence,  his product is worth a ridiculous charge.

Epinephrine was dirt cheap. Everyone  knows what Mylan's Heather Bresch did with exorbitant charges for that "lifesaving" drug. I betcha if drug reps had to ride a bicycle to hospitals they would be few and far between.

Parking garages and the influx of money seeking hucksters changed how doctors and nurses thought about their patients. Money changing hands at every corner of the hospital amidst a bean counter culture changed who people were. Mega bucks doled out in bonuses to administrative big shots who never helped anyone except for themselves became the rule. It was so  much better when all I had was a Raleigh Super Course bike to ride to work and to heck with all those monstrous parking garages.

Sunday, February 10, 2019

What Blood Loss??

 What blood loss? That's all irrigation in the suction bottle. At least 2 liters.

A good scrub nurse always agrees with the surgeon even if the patient lost a unit or more  of blood. I felt just like Nancy when concurring with a surgeon understating the blood loss. I always felt there were 3 categories of blood loss estimates: ABL, anesthesia estimated blood loss -  EBL, estimated blood loss by the surgeon  and NBL negotiated blood loss after the surgeon vs. anesthetist argument concluded. Actual blood loss was one of the great mysteries.

I promise this is the last of my political foolishness. Blame it on my brain freeze.

Thursday, February 7, 2019

Euphmistically Speaking

I overheard a group of whippersnapperns discussing the advantages of rewording the term "terminal wean" to "compassionate extubation" when discontinuing mechanical ventilation and  allowing nature to take it's course in a critical care unit.  Over the years lots of terms were changed: Directoress of Nursing is now Chief Nursing Officer, Hospital Superintendent is now CEO, Janitors are Environmental Engineers, and Personnel became Human Resources.

All this got me to thinking, which is always a dangerous proposition. I'm  in the midst of a midwinter brain freeze when my thoughts are too incoherent for a typical post. Anyhow, here are some terms that could be reworded to be more politically correct or incorrect, depending on your perspective.

Suicide to euthanasia from unbearable emotional pain.

Bathroom privileges to free range bathrooming?  That sounds dumb, but anything is better than B.R.P.

Doctor's orders to physician's proposals.

Physical restraints to boundary maintenance aids.

Near miss to near hit

Drug addict is a label loaded with lots of pejorative connotations. I've never really had to deal with this issue because old school discharge criteria mandated that a patient be relatively pain free upon discharge. There were very few legal narcotics outside the controlled environment of the hospital. So..lets start referring to those poor souls addicted to drugs pharmaceutical aficionados

I'm saving the best for last. An oldie but a goddie; Emesis to feedback. The simplest ones are always best.