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 were 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.

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 well...at 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. 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.

Wednesday, July 10, 2019

Quora

I've been having a difficult time organizing my thoughts for a post and my right hand has been acting up so that's limited my blogging activities. Lots of really nice people peruse my foolishness even when I fail to post so that's dampened my motivation.

I find myself doing better answering or making up answers to questions is easier than blogging so my latest addiction has been to the Quora web site. I was answering questions as Oldfoolrn, but received an email admonishment from the administrator (probably one of those despicable office sitters) that real names must be used, so I call myself Bob Balfour.  Bob seems like a friendly enough name and some how Balfour surgical retractors are engraved somewhere in the hindquarters of what's left of my nervous system so that's my pseudonym. Just visit the site and type Bob Balfour in the search box to view my lame answers.

I've had a couple of ideas for a post but can't make a selection. Here is what's been percolating somewhere in my mind; Zomax-A pain reliever that became a pain, Patient restraints-how to restrain without restraining, and finally, belly buttons, the black hole of the human body. Any advice about which topic I should explore would be appreciated.

Sunday, June 16, 2019

Head Nurse, Crazy Annie, Implements the Finder's Rule

Long time bedside nurses are just plain different, a breed of their own forged in a cauldron of unspeakable pain, suffering and just plain old garden variety misery. A mystical force motivates these caregivers to give all of themselves in the care of others. Mention self care to one of these hard core nurses and you are apt to get a snoot full of Camel cigarette smoke propelled by the robust laughter. If you were taking care of yourself, you were neglecting patients.

Crazy Annie was one of the most memorable old  nurses I had the experience to work with. Her facial expression reminded me of the Whistler's Mother painting; an aloof stare just waiting for an opportunity to unleash a verbal bomb.  She was a big lady with the arms of a power lifter from transferring patients. One of her innate beliefs was the notion that Hoyer lifts were impersonal and dehumanize the patient. I suggested that back breaking lifts were inhumane for nurses and received  an ear beating that I remember  all too well. Annie did not tolerate fools.

With retirement looming Annie became  even more vociferous with her various edicts about patient care. She believed that nurses should be on their feet the entire shift. "You can't take care of a patient if you are warming a chair," was her admonishment to anyone sitting around the nurse's station. She hollered at me for "holding up the building" when I was so exhausted that I was leaning against the wall in the dirty utility room after an especially grueling session with a balky hopper.

An assistant director of nursing outfitted in her finest attire made the mistake of rounding on Crazy Annie's floor. She was an unwelcome outlier to Annie. Bedside nurses were a tight knit group where people were unimpressed by degrees or rank, but how dedicated they were to caring for the sick. Annie  had a not so latent dislike for nursing administrators and derisively referred to them as "office sitters." I think that's where I picked up the use of the pejorative reference to those nurses who choose to avoid patient care. It might be insubordinate to think so negatively  about those in charge, but it would not be a mistake.

I hope the nurse administrator had room for gloves in her Vuitton Purse.





A fancy dressed, nurse busy body, from administration came strutting up to Crazy Annie with an urgent message. "The patient in room 606 bed 2  is covered in feces."  I smelled trouble in the air as Annie's eyebrows began their little dance as her mind percolated. Annie then started tapping her toe and had that look about her that always made me nervous. She squared herself to the offending nurse office sitter and sternly announced, "I'm instituting the finder's rule on this unit. Whoever finds the mess cleans the mess. Now get to it."

The Gucci nurse was paralyzed as Annie volunteered me as a helper by exclaiming, "Nurse Fool will help you turn the patient to make it easier for you. You look like the type that wears gloves for the unsavory tasks. The Central Supply Cart is in the clean utility room."

I hustled on down to room 606 with the Gucci nurse in tow. Upon arrival, the unsavory nature of the scene began to unfold. It was one of those my cup runeth over type of code brown's to use the whippersnappern  vernacular. A gurgling, gooey, smelly  mess of the highest order. The befuddled office sitter pressed her hands to her cheeks in deep thought. Just as I thought she was about to pitch in and help, she backpedaled like a circus unicyclist into the nearby stairwell.

As I went about the task of making the patient clean and comfortable, I could hear Crazy Annie proudly proclaiming, "I bet we don't see hide nor hair of her for a good long time!" A temporary victory in the land where all wellness is fleeting and office sitters have the final word.

Friday, June 7, 2019

A Shout Out To My Russian Readers

I've been delighted by a sudden increase in pageviews from readers in Russia. It boggles what's left of my foolish mind to realize that I can reach folks so far away from the basement of my humble little hovel. Maybe it's therapeutic to put my reclusiveness on the back burner and extend my foolishness to others.

I had the wonderful experience of working with a Russian educated surgeon - one of the perks of working at a big city academic hospital. I admired how she used her newly acquired English language skills. None of that subject, verb, predicate rigamarole that was drilled into us during high school English class. Direct, no nonsense commands were the order of the day. One of my favorites was, "Fix him to the bed," which meant limit the patient's mobility with a restraining device. "Scissors," became "scissor" because there was only one scissors used at a time. Russian English really made sense and got the point across.

Dr. Ospov, had a couple of unique surgical customs. She loved using long handled needle drivers and forceps. Muscle memory is a powerful force and once acclimated to a long surgical instrument, it's tough to change. Long instruments always amplified any fine tremor present in my lunch hooks fingers so I regarded them with caution. If you want to see an angry surgeon, just try to slip a smaller length needle driver into the mix. Don't fool with muscle memory.

I'm not certain that its a wide spread custom in Russia to eschew prophylactic surgical drains, but Dr. Ospov hated them. Her tight closure of tissues eliminated dead space and  minimized the need for drains. She also liked to throw in a couple of half hitches at the end of suture lines to help maintain the integrity of the closure which seemed like a good idea to me.

I vividly recall one scene that illustrates her no nonsense, get it done approach. We were called to a ward because a patient toppled out of his wheelchair sustaining a nasty occipital skull laceration. When we arrived on the ward, the patient was sprawled out on the floor next to a festive looking Christmas tree. As I prepared to transfer the patient back to the ward for suturing, Dr. Ospov barked, "Grab me a suture set and get down here to help me." The patient was positioned on the floor with his Bye Bye decubiti pad comfortably under his wounded head. I knelt down next to the good doctor as she deftly threw a half dozen sutures in the wound. It was quite a scene with the red blood and green Christmas tree in the background. She really knew how to get things done without a fuss.