Happy New Year

May the absolute delight, joy, and sense of accomplishment we experienced at our capping ceremony be with all those toiling at the patient's bedside in the New Year.  I hope you receive rewards that far exceed any monetary consideration. As an aging scrub nurse, I would give up anything I own just to scrub with Dr. Oddo one more time. It would be an added bonus to receive one of his tongue lashings even if the precipitating event was not my fault.  At the end of a difficult case we were always the best of friends and I miss him often.     Happy New Year and may your memories be pleasant.

Santa Brings Dr. Oddo a Polavision Outfit

Edwin Land, CEO of Polaroid Corporation with his most technologically advanced product, the Polavision film movie camera and processor/viewer which looks like a small TV. circa1976

Dr. Oddo, Chicago's internationally known neurosurgeon and my favorite person to scrub with bounced into the operating room a couple of days after Christmas ecstatically announcing his latest Christmas present. It was a Polavision film movie camera with a viewer that processed the film immediately after it was shot. This enabled someone to view the movie shortly after it was shot. A filmed based substitute for digital recording.  It was his notion that the circulating nurse could document the key elements of some of his procedures to show off educate the neuro residents.

Shortly after  Polavision was introduced, Sony came out with the Betamax. Polavision was less expensive and more compact than the bulky Betamax. The Betamax held some key advantages, Polavision film ran for 3 minutes, the digital Betamax went for an hour. Betamax had sound while Polavision was silent. Initially, it looked like there would be decent competition between the two products. Dr. Oddo always liked to be on the cutting edge of technology, but over time digital killed film.  Polavison was a really advanced technology for the times and Polaroid spent a small fortune in R&D cost.

Polaroid then spent millions on advertising even enlisting famed photographer Ansel Adams to shoot movies with Polavision, Yoko Ono and John Lennon shot home movies of their son with Polavision. In the end not enough of the product was sold to cover development cost. Polavision was sold only a couple of years at a retail cost of about $700. The price might have been affordable to a neurosurgeon but that amount of money represented my monthly take home pay. I was not about to run out and buy one. This product was the beginning of a long downward spiral for Polaroid.

Polavision may have succeeded if it had been introduced decades earlier. It was introduced too close to the emergence of digital recording. Kodak came out with digital 8mm cameras later and the Polavision era had ended. Film for the Polavision system was even discontinued. Dr. Oddo cajoled us into filming some aspects of his surgeries for a couple of months and then lost interest with the arrival of a Betamax system. The hospital even hired an audiovisual aide to run the machine. That was the end of film.

The whole Polavision got me to thinking about technologies that were regarded as high tech, but now appear very crude. The first procedure that came to mind was the pneumoencephlogram which was invented by the famous neurosurgeon, Walter Dandy at Johns Hopkins. The patient underwent a spinal tap where CSF was withdrawn and air injected. The patient was the secured to a chair that moved 360 degress in a vertical and horizontal axis. Film X-rays were made as the chair was rotated and the air bubble moved around between skull and brain. This was a brutal diagnostic test bordering on torture and about the only thing it did well was diagnose menengiomas. Thank god for CT and MRI scans.

I think another contemporary diagnostic measure where the technology got ahead of the knowledge is with PSA testing. The sensitive test was very good at identifying prostate lesions that were best left alone and not so great at identifying appropriate candidates for surgery. Add the Davinci robotic surgery device to the mix and you really have to question if this is a triumph of technology. I am sure their are great anecdotal accounts of miraculous robotic surgeries, but are their any studies that support robotic surgery? I think this robotic surgery thing is another example of the marketing hype exceeding the benefit. I'm certain hospitals must recruit a good number of patients just to cover maintenance cost.

I wonder if electronic medical records are another Polavision in the making. The development cost had to be huge and the system cannot even communicate between different healthcare systems. When I visit my MD he has been converted into a data entry clerk. Heck even proud bedside nurses now have their heads buried in a computer screen and there is even an animal called a nurse infomaniac or is it infomatics. These people will be the Polavisions of the future. If you are not a physician or nurse directly caring for a patient it will someday be time to get off the bus. When the healthcare bubble pops those doing indirect care will be the first to go. The administrative cost in today's healthcare is obscene.

I better stop this nonsense before I get carried away. For people caring for patients, I hope the New Year rewards you with a true sense of personal fulfilment and peace. The only thing that makes me feel good about healthcare is the notion that I might have helped a few people over the years. Don't let the business of corporate healthcare rob you of that personal satisfaction of helping others during their most vulnerable time. When you get old that's all that really matters.

A Christmas Trauma Tale

In the early 1970's, Chicago's Lakeview neighborhood was home to a couple of
rival teen gangs, the Aristocrats and  Latin Kings. Luckily, for local residents, their gang culture viewed firearms as not cool or macho. Gang fights usually resulted in knife inflicted trauma of varying levels of acuity. If a gang member could walk away from a knife fight, they would often go home and attempt to sleep it off as one would do with a hangover. The end result was an emergency room visit the next day when the sleeping it off routine failed. I was always mystified by the thought process behind the "sleeping it off routine."

Stab wounds were a fairly common trauma at our hospital. These wounds could really be deceptive because once the blade of the knife was withdrawn, the skin retracted and something minor in appearance could hide serious injury. Single edged knives caused the least trauma because they would push bowel and organs  away from the blade as they were inserted. Double edged blades caused more trauma because they perforated rather than pushed structures out of the way.

When these young gang members were anesthetized and on the OR table they presented a sad picture. It was then that it sunk in. These were just children, little kids caught up in an urban nightmare. They looked so menacing on the street and so vulnerable lying on the table. I used to feel really bad for them.

I was on call, Christmas Day 1974 when the phone rang in the call room. We were getting a case. It was a 15 year old gang member, Sam that had been stabbed in the abdomen on Christmas Eve. He tried sleeping it off, but by Christmas morning the pain was so severe he reported to the ER. After a cursory exam in the ER, it was off to the OR to patch  up Sam's abdomen.

I would be working with Dr. Slambow one of my favorite surgeons. He liked to make scrub nurses feel important by asking them what kind of suture to use and really getting them engaged. He opened up Sam's abdomen and began exploring, everything was pretty much intact and without major organ or vascular damage. He meticulously sutured several stab wounds in the small bowel and then engaged the scrub nurse by asking me to return the section of small bowel to the abdomen. He even taught us how to follow along the small bowel to find the cecum. I was always amazed at how slippery and difficult it was to handle bowel.  The abdominal organs always felt so fragile like a glob of jello and pushing the bowel back into the wound always reminded me of when I worked as a grocery bagger as a teen. When I thought of the abdomen as a paper bag filled with gobs of Jello, it made me realize how fragile we all are. We did one final irrigation of Sam's abdomen and Dr. Slambow closed. It was an uneventful and straightforward case which ended well.

A few days after Sam's surgery Dr. Slambow approached me and suggested I visit Sam on the ward because he was such a pleasant youngster. I had never visited a post-op patient and was hesitant, but Dr. Slambow was insistent.

Sam was in a 4 bed ward and sitting up in bed when I approached. I explained who I was and he was profoundly grateful. He thanked me profusely for helping him and we began chatting. I mentioned to him that I was sometimes fearful walking the 1/2 block distance to the hospital from my apartment. There was an area under the elevated tracks that had an abandoned old station wagon which was overturned. It was heavily tagged with the Aristocrats circled  "A" symbol. Sam told me the station wagon was on of the Aristocrats favorite haunts, but that I had nothing to worry about.

Months went by and my thoughts of Sam had subsided. One Spring evening I was walking to the hospital at about 11:00PM. As I approached the junk car under the elevated tracks a shadowy figure poked his head out from behind the rear fender of the rusted hulk and offered a friendly salute. It was Sam guarding my way on the walk to the hospital late at night. Keeping me safe.

Christmas tales like this reflect something meaningful about the season. Two people helping each other with whatever resources they had available.  Merry Christmas and if you are working in a hospital this holiday season, I think you are doing something very special.

In Cold Blood - The GE Monitor Top Refrigerator

The monitor top - just look at it - scarcely bigger than a hat box - yet one of the most amazing - one of the most revolutionary triumphs of modern engineering.  (From a GE magazine ad)

We had one of these old classic refrigerators that met all the refrigeration needs of our suite of operating rooms. It was centrally located in an alcove in the middle of the hall just past the ENT room. I vividly remember the label on the front that proudly proclaimed "General Electric Refrigerating Machine."  The door made a solid click - clunk when the spring loaded latch engaged. When the compressor ran it purred like a kitten.

We kept surgical specimens in the bottom section of the monitor top. It did not have crisper doors like a modern refrigerator, just a wire shelf. The two shelves above the specimens held our lunches and the blood products for the scheduled cases. If  there was a big case in the afternoon that required blood, someone made a trip to the blood bank after lunch.

When I first started working in the operating room, it kind of creeped me out, eating my lunch after sorting through a bunch of blood bags. It seemed like something a vampire might enjoy. The older nurses did not give the comingling of blood and lunch a second thought, so I soon learned to ignore the uncomfortable feelings.

A second advantage of using a monitor top refrigerator for a blood storage unit is the availability of a blood warmer. You can say goodbye to those messy warm water baths. Just stack the blood bags on the condenser monitor top. It takes about 40 minutes to warm up to the right temperature.

One of the unique things about the combined blood storage and lunchbox refrigerator was that you never had to worry about someone stealing your lunch. I think that the time it took to sort through the blood bags to find your lunch reduced the temptation to steal. The presence of a diseased gall bladder lying on the bottom shelf of the refrigerator probably served to spoil the appetite of a would be thief.

I don't know where our old blood storage unit/lunch refrigerator is today, but I suspect it might still be in operation. They built these things to last. I doubt that with all the regulatory oversight, you could get away with using a GE monitor top refrigerator for blood storage. It's probably also frowned on to comingle a ham sandwich with banked blood.

Old school rules for patient care

Never ever give ice water to a cardiac patient. This triggers a vagal response resulting in life threatening arrhythmias.

Never allow a patient on Coumadin to use a standard razor. An electric shaver must be used to prevent exsanguination.

The open end of all pillow cases must face away from the entry door to the room. On wards, the open end of pillow cases must face away from the window.

A patient could not get out of bed (OOB) to use the bathroom without a BRP (Bathroom privilege order.) This one really bothered me. Since when is going to the bathroom a privilege?

If the patient vomited on a dietary tray, nursing service must clean it up. This rule was especially unfair since it was probably the food that triggered the emesis.

Our neuro OR had  big notice on the door: "NO TALKING OR LAUGHING  NEUROSURGERY IN PROGRESS."  I guess I will have to stroll down to the heart room before busting a gut.

Patients with abcesses or infections were in a special classification - Contaminated Case which had all sorts of special rules such as being scheduled at night after all other cases were done, everything that exited  the room except the patient double bagged, and scrubbing the tile walls upon conclusion of the case with some sort of toxic witches brew of disinfectant.

After finishing a case in the OR all instruments must be returned to Central Supply unratcheted. If you really wanted to get a rise out of the old geezers in Central Supply, return a knife handle with the blade attached. Witnessing an old battle hardened nurse moving toward you at the speed of light with a knife in her hand is very frightening.

The grounding plate for the Bovie must be placed exactly in the center of a patient's buttocks. This rule caused much animated discussion and and arguing about gluteal anatomy. The grounding plate was the size of a cookie sheet and the best strategy was to place it on the table prior to the patient's transfer from the Gurney. I always thought this must be a really bad pre-induction experience for the patient. Imagine being frightened by the strange environment complete with scary, sharp metal objects and then being plopped onto a cold metal plate all gooey with conducting gel. YIKES and OOW that's cold.

The circulating nurse must be at the patient's side during induction even if there is nothing for her to do.

Use only a glass syringe to administer that Paraldehyde and make sure the  number on the syringe barrel matches the number on the syringe because  old syringes were not interchangeable. Don't you just love that Paraldehyde-Paregoric-coffee ground emesis smell on the alcohol detox ward. It was a great deterrent  when the urge to imbibe struck. "I think I'd just like a Coke tonight. That  Paraldehyde smell is imbedded in my nostrils."

I am certain there are many more, but I seem to be having one of my brain freezes. Don't forget to hold that cold water when caring for a cardiac patient!

How do you cook a Thanksgiving turkey in an autoclave?

Wow! one of those high end double ovens autoclaves and check out the size of that roasting pan.

Sometimes a confluence of events come together  (How is that for some foolish double talk?)  and the end result is both unexpected and spectacular. We were on call Thanksgiving Day and just received a hot tip from the medical center  switchboard  operator. The hospital administration was giving out free turkeys as a good will offering to all on duty nurses. I suspect they had incorrectly estimated the low holiday census and were just trying to get rid of them.

Dr. Clobber, the on call anesthesia  resident ordered me to head on down to the hospital dietary department and collect on our free turkey. "Don't ever look a gift turkey in the beak," he replied with his typical smug, all-knowing  expression whenever he had an epiphany. "We're going to have turkey for dinner tonight!" Thanksgiving was usually a good holiday to be in the hospital for call as there was not as much surgical trauma  or  mayhem as say New Years Eve.  There were always 2 nurses and an anesthesia and surgical resident in the OR suite for call. If we were not busy, foolishness was frequently forthcoming if we were not busy.

Back in the day we did not have a lot of regulatory agencies breathing down our necks telling us do this or don't do that. I do not know how you whippersnapperns function with preceptors, infection controllers, nurse infomaniacs, and assorted clinical whiz kids breathing down your neck all the time. I could never be a nurse today. We had much more latitude with what we could get away with clinical practice back in the day. The point is, I doubt you could get away with foolishness like this today, so unless you have an old unused autoclave and some time away from regulatory snoopers, don't try it.

We had an old operating room that dated to the 1930's at the very end of the corridor. We never used it and it was more or less a museum (there was an actual observation deck) and it basically functioned as a store room. It did have a vintage functioning autoclave permanently built into the wall. This  steamy  hissing beast was one massive piece of equipment that was one of the more impressive products of the Industrial Revolution. The bankvault-like door was anchored by 8 massive spokes that reminded me of the configuration of a radial airplane engine with the giant wheel to open it, the propellor.

There were no electronics to control or monitor this hulking steam fired behemoth. You had to eyeball the pressure gauge to make sure it read "0" before cranking open the door with that massive wheel. There were no safety interlocks and if you wanted to be the first scrub nurse on the moon, just open that door up under full pressure. Look out Neal Armstrong here I come!

When I returned to the OR suite with my prized gobbler, Dr. Clobber  whipped out his ever present slide rule (no calculators) and asked me the weight of the turkey (about 9  kg.)  and some other data about the autoclave in the old OR room. We test fired the old autoclave and it fired right up with that impressive belch of steam. No bothersome preheating with this baby!  It worked like new. We just had to be careful to remember the correct autoclave door opening sequence. Our newer ones were all equipped with safety interlocks and modern safety devices like pressure relief valves.

After some frenzied slide rule calculations, Dr. Clobber said to fetch an instrument tray and place the turkey in the roaster instrument tray.  Next, proceed to the old  autoclave and run it for a 20 minute cycle. We tied the gobblers legs together with autoclave tape more or less out of force of habit.  We figured it would function as well as one of those pop-up gizmos. After the 20 minute cycle we popped the autoclave door open to the most delightful aroma of turkey I have ever experienced. Betty Crocker would have been impressed.  The turkey was moist and delightful and made for a most memorable on-call experience.

The only improvement to the cooking procedure would be to stuff  turkey's cavity with some ABD pads to prevent the bird from collapsing under all that pressure. It kind of resembled road kill after the autoclave pressure smashed the bird's thorax into it's spine. The squishing of the bird was only an aesthetic issue and it in no way impaired the delicious, tender meat that we all enjoyed. I don't know if  using actual bread stuffing would work with this cooking method, but we did not have any, so it's a moot point. I would be concerned  with the collapse of the bird, bread stuffing might get squirted out into the autoclave making a big mess.

They say imitation is the most sincere form of flattery and I was astounded during a recent outing to Kohls. There in the kitchen department was a Wolfgang Puck pressurized oven. They copied our autoclave cooking technique  cooking technique to a "T." Although much smaller in scale, the basic formula  looks to be the same.  Heat + pressure = delicious turkey.

In an upcoming post, I am going to investigate the feasibility of sterilizing a minor surgical instrument set-up in the Wolfgang Puck pressure oven. Just like our old autoclave, I suspect it could be a dual purpose machine. Just what the busy surgical center of the new millennium needs, sterilize instruments in the morning and cook your lunch between cases later on.

I am very thankful for all of you who indulge me in  these foolish ramblings. Happy Thanksgiving.  I know as I enjoy the holiday, I will reflect back on those old days when we autoclaved that turkey. It was an unexpected treat and really was delicious.

What makes a scrub nurse cough?

As a youngster I was troubled by a serious dental problem having  teeth twisted this way and that way. Two teeth were extracted to make more room, and then braces worked well to straighten things up. As a young adult, I still had orthodontic bands on my back molars to pull them back into position with small rubber bands. The bands were attached by small hooks on the buccal  (I learned that cool term for cheek from an oral surgery fellow)  aspect of the molar. The only time I removed the rubber bands was for eating.

I was scrubbed on a long case with my favorite neurosurgeon, Dr. Oddo, and was getting distracted by a full bladder. I really needed to pee. As visions of a beautiful white toilet danced in my head, I must have opened my mouth in a weird way and one of the orthodontic bands popped off.

Before I could even process what was happening, it ricocheted off a tonsil and sailed down my trachea. My concern with having to void was overshadowed by a string of violent coughs. Dr. Oddo asked with  concern, "Are you OK."  "Yes,"  I lied in a feeble restrained voice as I tried to  stifle the cough.  I managed to hold it together until the end of the case. I was coughing like a TB patient as I ran to the bathroom.

Dr. Oddo was there when I exited from the bathroom and showing genuine concern, wanted to know what was wrong. I explained to him what happened and he immediately consulted a nearby thoracic surgeon.  After a cursory look he suggested a quick bronchoscopy.  Any time a neurosurgeon is concerned about your health, you are probably in deep trouble.

Dr. Clobber, an anesthesia resident, I knew well from being on call with wanted to have a go at the rubber band with a laryngoscope and a Magill forceps. That sounded better than a bronch  and he had a bottle of Cetacaine on the ready to numb up my throat. I was skeptical  of this and asked him, "What if you blast that rubber band further down the trachea with the Cetacaine spray? "Good point, I never thought of that," he replied.

By this time a crowd with expertise in just about every surgical specialty had gathered. I was really more nervous about the gathering gang of surgeons than the stray rubber band. Somewhere from the back of the gaggle of surgeons came the voice of reason. "Have that fool suspend his upper torso over the table for some postural drainage."

I suspended myself upside down over the side of a table and after several minutes the rubber band slid out by gravity. I came away from this experience with  two lessons. The simple, staightforward,  approach to a problem is best and never wear orthodontic rubber bands in the OR, especially when you really have to pee.

Pharmacists and Flu Shots

Maybe I'm just not ready for this brave new world of retail healthcare, but it is disturbing to me when you stroll into a store and pay money directly to the person giving you a shot. The person administering the treatment should have some distance from the financial end of the transaction. My perspective of the entire situation is probably distorted from being trained at charity hospital. There was no money changing hands here.

Fifty years later, the Giant Eagle Pharmacy where I live is even offering a fuel perk or discounted gasoline with a flu shot. If  I could have charged piece rate fees for every IM administered, I would be a millionaire.

I wish my favorite nursing instructor, Miss Bruiser,  could have lived to see healthcare today. She would begin by giving the pharmacists a dressing down for administering IMs in the deltoid. I can just hear her screeching voice, "Listen up Linda (she could not remember all our names and called just about everyone Linda) the deltoid  is a terrible site. You are going to wind up injecting the subdeltoid bursa. What kind of antibody response will you get there?  The correct initial site to consider would be the dorsogluteal site and I do not want too see any of you attempting to give the injection without the site adequately exposed. This means pants all the way down with the patient completely supine and the needle inserted at an exact right angle to the counter table."

She would really emphasize that selecting the correct site trumped all other issues. "This is not about modesty, and if you are hesitant or shy about doing the right thing you can leave immediately because you are nothing more than a tin angel."  Whenever a student nurse looked for an easy way out or did something like taking an oral temperature instead of a rectal, they were a "tin angel." It was the ultimate insult. If anyone verbalized being uncomfortable or embarrassed they were a "tin angel." We quickly learned how to maintain a stoic demeanor even when Miss Bruiser insisted on "demonstrating" an invasive procedure on a fellow student nurse. It was tough to look stoic with a bright red blushing face, but we tried.

I think these pharmacists maybe onto something with limiting their IM injections to deltoids. This notion of choosing the most convenient or comfortable way of doing things should have occurred to me many years ago in my nursing heydays. One thing that bothered me as a scrub nurse was cautery smoke. I should have said, "Dr. today I would like you to utilize ligatures only on all bleeders.  My eyes are irritated by all that  Bovie  smoke and please don't even think about burning your way into that abdomen, here's a #10 blade." I probably would have been fired, but what's good for the goose should be good for the gander. If pharmacists can do it the easy way, scrub nurses should have the same option.

Miss Bruiser may have been a bit of a radical, but I can appreciate some of her points. Whenever there is a situation where everything is done the same without individual consideration, something is probably wrong. Giving all flu shots, even though the injected volume is small, in the arm is probably  not prudent. Oldsters and kids can have really miniscule deltoids. It might be wise to at least consider gluteal or vastus lateralis sites.

The other big thing in healthcare today is patient choice. Instead of asking which arm would you like this in, ask what site would you like this in?  If  Miss Bruiser were giving the flu shots she would be ordering all patients customers to assume a supine position with their pants to their knees. She was not a big advocate of patient choice and who wants to be publicly belittled and humiliated by being called a tin angel?

Nurse Graduation Day 1968

A true classic. It seems like yesterday! The person recording this must have thought it was a very important event. There were no cell phone video recorders or even cam corders. The person had to use a camera running genuine film through it and synching it to a magnetic sound strip.

I posted "Commencement" back in March specific to my graduation if anyone is interested. It was very similar to video. The closing scene with the lit Nightingale lamps and graduates reciting the pledge was a diploma school universal event. Our instructors always positioned themselves in front of the class during the recitation and at our school it was a tradition that students "accidentally" dripped hot wax from our candles on them. A passive-aggressive payback for 3 years of pure torture. We had our pins and diploma. What could they do except scream?

Bed Making 101

Making a proper bed was a complex issue with the potential for many serious pitfalls. The most senior and cranky instructors such as my favorite, Miss Bruiser, were put in charge of teaching probie student nurses the finer points of bed making. When there were few curative treatments for serious disease, little things like bed making assumed an exaggerated importance. Maybe you could not control a brittle diabetic, but Miss Bruiser could dominate and control a lowly student nurse.

The initial step was  to remove the existing linen with a minimum of movement to avoid airborne contamination. Never mind all those aerosolized pathogens being sprayed about the room by that portable suction machine, if you flap that linen around you are in for a bitter scolding by Miss Bruiser. Here is another vital tip: cover that pillow up by placing it under a sheet when you fluff it up or you will liberate more bacteria. Oh, and God forbid any of that dirty linen contact the floor or it might get contaminated.

If the patient was incontinental  (this is how Miss Bruiser pronounced incontinent) you had some judgments to make. If there was a small to moderate amount of stool, you could remove the stool from the patient, but don't make the mistake of wearing gloves. Gloves were very expensive and they distance and depersonalize the nurse in the eyes of the patient  as Miss Bruiser would explain during her bitter diatribe. If it was a massive Code Brown (I learned that term from you whippersnapperrns, very clever) then you must remove the patient from the effluent and wrap up the unholy mess of sheets and stool in a draw sheet and transport it to the dirty utility room.

We had a clever device located right next to the hopper in the dirty utility room called a sluice which separated the effluent from the linen. It was an inclined sheet of ribbed stainless steel which had a water source on the uphill end and a drain to the hopper on the downhill side. Very efficient, but the rinsing  ordeal process could overwhelm your senses. If a sheet was not properly sluiced, the offending ward would receive an unpleasant visit by a nursing supervisor. I don't know how they were able to trace the soiled sheet back to the offending ward, but it certainly did not take a blood hound to follow the odor of. stool infested sheets that had ripened in the heat of linen storage bags.


Don't forget to double flush that hopper after sluicing your sheets
 

After the soiled ( that's putting it nicely) linen was removed, the actual bed making process could begin. An unoccupied bed was relatively straightforward. The linen included 2 flat sheets, a heavy muslin drawsheet and a cotton blanket. The bottom sheet was stretched tightly and tucked under at the top with a drawsheet centered in the middle. The top sheet finished it off. All corners were supposed to be mitered at exactly 45 degrees. Miss Bruiser would test the sheets for tightness by dropping her scissors handle first onto the bed. If they bounced up at least an inch all was OK. If the bed did not meet specifications, it was time to start from the beginning.

The next category was the surgical bed for the hopefully returning post-op patient. The first order of business was to crank the bed to maximum height to approximate the level of the gurney. The next step was critical and a mistake could lead to big trouble. You must determine which side of the bed the patient would enter and carefully fan fold the top sheet in the opposite direction so that it could be easily pulled to cover the patient using just one hand. Last minute adjustments of the top sheet would invite a bitter scolding from Miss Bruiser.

The typical occupied bed scenario involved rolling the patient to and fro from side to side while sliding the dirty sheets out of the way and replacing them with clean sheets. The really challenging occupied bed was one made vertically or from top to bottom when the patient could not be turned side to side. No turning  was common with hip and eye surgery patients. In the early 1970s total hip replacements were called Charnley Low Friction Arthroplastys and the patient was to remain flat on their back for 7 days to prevent dislocating the prosthesis.

The difficult part of this from a patient's view, was the fact that he must be elevated up toward the ceiling under his own power by pulling on a trapeze while the sheets were being slid into and out of position. If he could not lift himself, several burley students had to act as a human Hoyer lift while the sheets were being changed. For a proper linen change the patient was lifted 6-8 inches off the bed.

Miss Bruiser was an early adopter of coordinated care and viewed an elevated patients backsdide as a rare opportunity for a dorsogluteal intramuscular injection. Just about all parenteral medications were given IM and we rotated sites from deltoid to vastus lateralis to ventrogluteal. With a patient restricted to a no turn regimen, linen changes offered rare access to the dorsogluteal site. I used to think this was a cruel way to treat a patient struggling to lift himself up off the bed, but I knew better than to question Miss Bruiser.

This student is reviewing Miss Bruiser's instruction on how to administer an IM injection in the dorsogluteal site while he is up in the air for a linen change. "Insert the needle straight up at a right angle to the  bed  and be sure to clear out of the way before he comes thundering down." At least the patient will have clean sheets to rest his throbbing backside on when all is done.

Bed making was really emphasized as one of the most important tasks a nurse could perform. I remember Miss Briuser telling us "the bed is where the patient lives while in the hospital." or "How would you like to lay in that bed ?" I think if I was supine on my back and Miss Bruiser and her students approached, I would resist having my bed linen changed to avoid that searing, throbbing pain of an antibiotic being rapidly injected in a vulnerable, exposed area.

High Fiber

"WOW!   That ultra high fiber diet has impressive results."



Editor's Note: I am nominating these brave healthcare professionals for the "Oldfoolrn Clinical Courage Award" for handling this monster without the use of gloves. My instructors would have been very proud of you because it is a known fact that the use of gloves to handle stool can easily bankrupt a hospital. Next on the money saving agenda will be  instruction and a  return demonstration of how to insert a Foley Catheter using 2 fingercots. Any volunteers?

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"I find the contents of this blog deplorable. The foolishness must cease or I will whack your knuckles with a sponge ring forceps. See how well you can type with erythematous and edematous knuckles, Old Fool RN.

Why does RN smack instrument in surgery?

Two people googled this question and were  referred to my blog. I might have made casual mention of slapping an instrument into a surgeon's hand, but never really answered it. I felt like the kid in a classroom when the teacher asks a familiar question.  I know!    I know!

One reason for the brisk slap of the instrument is to overcome what I call the trampoline effect. The surgeon has his hand extended in the open position when receiving an instrument. This action stretches his glove between the extended thumb and extended index finger creating an elastic mini- trampoline smack dab in the middle of his hand. If the instrument is not delivered in a firm manner it will bounce right out of the surgeon's hand and he might offer some unpleasant editorial comment.

Dr. Oddo, our international neurosurgeon, always had novice scrub nurses wear glasses with loupe magnifiers just to see what they were like. All I could say is kudos to  anyone with the patience to work with these things on their eyes. Your peripheral vision is blocked out and you cannot really see much of anything except that which directly in front of you. Anytime a scrub nurse works with a surgeon wearing loupes you know he is working by feel when receiving an instrument. It takes a slap and then a little push into the hand for the surgeon to easily grasp it. Don't be timid. The surgeon's vision for anything outside the operative field is nil.

Mentioning loupe magnifiers brings to mind a bit of foolishness unrelated to slapping instruments. Dr. Oddo used to tell his residents to wear loupe magnifier eyeglasses on all their cases just to get used to wearing them. When one of these eager beaver residents showed up in Dr. Slambow's  general surgery room wearing loupe magnifiers he would bellow, "We're not operating on an ant's ass in  here. Take those damn things off." General surgery cases did not really need the up close magnification and Dr. Slambow was not one to be trifled with.

When the tempo of a case picks up or something unexpected happens the instrument slapping can become a little more aggressive. I think it is a subconscious thing that goes along with the hyper vigilance when you have to move really fast and not think too much about what you are doing. It's a conditioned response.  I have never had a surgeon complain about me slapping an instrument too hard into his hand.

About the worst thing you can do when  instrument trafficking ( a slick term I learned from you bright young whippersnapperrns) is to "dangle" an instrument over the field. It's a novice mistake everyone makes. The surgeon has no idea where a dangled instrument is in space so it's of no use to anyone. To a novice, a dangled instrument does feel like a security blanket- you at least have an instrument at hand. It's really just in the way and you might miss handing off something that is needed in a hurry.

Some old school scrub nurses (to me), so it's second generation old school to you whippersnappers engaged in what I call malicious instrument slapping. If a resident was caught napping or was slow to respond they would take a sponge ring forceps and whack the knuckles with the handle end of this instrument. A sponge stick is one of the more lengthy instruments and with the leverage, capable of delivering a painful blow. Come to think of it a sponge stick is about the same length as a ruler. I wonder if this is the operating room sister equivalent to the parochial school knuckle slapping nuns. I never thought of this angle before, but it seems to make sense.  Do not attempt knuckle slapping with an attending surgeon, it would be a big mistake. I never had the guts to pull this trick on anyone, but based on anecdotal accounts, it was a favorite trick of old time scrub nurses.

OUCH!

Old scrub nurse mentors have told me, "Now that stunt deserves a good crack on the knuckles. Always have a sponge ring forceps ready to go on the residents side of your Mayo Stand." I never did this and I never talked back to any surgeon. These same old scrub nurses used to counsel me, " Don't let that surgeon scream at you like that when it's not your fault. It's bad for your soul." Maybe I should have heeded their advice.

When an instrument is passed correctly it's not really a hard smack. It's like a brisk flick into the hand followed by a very brief firm push. The surgeon then reflexively grasps it and is ready to go. It probably looks like a smack and might even sound like a smack, but I'm not sure that thinking of it as a pure smack is the best way to conceptualize it. You know a proper instrument smack when you feel it!

I suspect that with modern laparoscopic and minimally invasive procedures instrument slapping is becoming a lost art. How in the world do you slap a laparoscope?

Happy Halloween

Hospitals can be fertile ground for spooky, scary stuff. This abandon OR really does look kind of creepy. Just imagine the people that probably had their souls separated from their earthly bodies in this very room. Maybe there is some type of virulent bacteria or pathogen embedded in the ceramic tile grout. What about those ceiling ventilation openings? Most likely  they are still equipped with filthy air filters saturated with all kinds of bad pathogenic  things. It looks like a good place to hold your breath or wear one of those hazmat suits.

There are certainly other scary things associated with hospitals related to blood and gore, but these are too obvious. Subtle little events can creep up on you. As a young scrub nurse, one thing used to really freak me out. It never seemed to bother anyone else so I never vocalized my feelings of being creeped out. I guess I did not want to be thought of as an insecure scrub nurse.

Here is what gave me nightmares. We are nearing the end of a trauma case that was going along smoothly, a walk in the park.  We are getting ready to close and all I have left on my Mayo stand is a couple of needle drivers, scissors  and a pair of pick-ups. The surgeon announces, "I think I would like to get a stat X-Ray just to make sure we removed all of the fragments." In marches the X-ray technician with the portable machine. He wrestles the X-ray plate into position underneath the drapes  and announces "Everybody take cover I'm shooting an X-ray."  The circulating nurse and anesthetist run out of the room and the scrubbed members of the team hustle over into the corner behind a lead curtain.

A horrified glance over toward the OR table reveals a person lying there ALL ALONE, not a soul in sight, with a big wound. There is a stray sponge stick protruding from the wound like a mini flag pole and the hot lights are reflecting of that steel self-retaining retractor.  The mechanical ventilator left unattended by anesthesia is making that rhythmic, ominous whooshing noise. The unattended Yankauer suction gizmo is making a hissing noise like a venomous snake preparing to strike. This scene  used to give me that sick feeling right in the heart of my solar plexus.  It really spooked me.  YIKES!

I think several things here got to me. The stark realization that this was a real person, someone's mother or father, and not just another trauma case. The vulnerability of the person lying there all alone was stark. There should be a team of people in frenzied activity taking care of this person. The loneliness and helplessness was overwhelming. Luckily this lasted only the few seconds it took to get the X-ray and normal activity resumed. I literally ran back to my Mayo stand and was usually the first person to emerge from behind that lead curtain when the X ray was done.  That very brief spooky moment of the patient lying there on that table all alone is really burned into my memory. It still gives me the creeps!

Lacking much of an emotional IQ, I could never really figure why this always spooked me out, but it certainly did the trick. Maybe it was goal interference in that it separated me from what I thought I should do. A loss of control?  I don't know.

Halloweens of yesteryear were always fairly quiet uneventful when I was working. It was mainly just a holiday for the kids. With all the adults celebrating Halloween today, I suspect there is more mayhem necessitating medical attention. I hope all those people toiling in the trenches of todays healthcare systems have a peaceful and uneventful Halloween. I really do appreciate all of you who take the time to indulge in reading my foolishness.  HAPPY HALLOWEEN!

Downey VA Hospital in the News

I was really surprised by the number of people that read my post about "Downey VA Hospital a Lost Empire." I thought that Downey had probably disappeared for good and that there would be little interest. I was going through my collection of old nursing junk memorabilia and lo and behold I came across some yellowed newspaper clippings about assorted trials and tribulations at Downey. As you can see bad press about the VA is not just a recent phenomenon.

From the Suburban Trib May 12, 1975:
The FBI has begin an investigation into the operation of Downey Veterans Hospital. The Suburban Trib learned of the FBI investigation on the heels of an announcement that the General accounting Office was studying the administration of the hospital at Buckley and Green Bay Roads.

Sources will nor specify what FBI agents are studying, except to say the probe is in the initial stages.

F.E. Gathmann, acting Downey Director, said Tuesday that he was not aware of any FBI investigation other than into the murder last month of a 45 year old patient found stabbed at the hospital. A 17 year old Waukeegan IL youth was charged with the murder.

The hospital has recently been embroiled in controversy. John Reeves, a cook at the hospital and president of Local 2017 of  The American Federation of Government Employees, recently charged that former Downey director was transferred because he stepped o too many toes trying to convince the VA to fire incompetent employees.

Reeves has also charged that:
There has been mismanagement of funds at the hospital.
Drugs used in treatment programs are missing.
More attention is being paid to the needs of the Chicago Medical School  formerly  at 2020 Ogden Ave., Chicago than to patients.
Hospital employees have been threatened with reprisals for making public concerns about patient care.


I am not sure of the exact date of the next one, but I think it was from a local newspaper, the Independent Register. Perhaps a bit later than the previous article

Downey Veterans Hospital in North Chicago has launched an investigation into why 7 psychiatric patients took their own lives during the last 11 months.

Hospital administrators told the Independent Register the "suicide rate at Downey is no greater than at like institutions around the country, but what disturbs me is what we can do to spot the potential suicide and stop him before it is too late."

Administrators, who promised a report in two weeks, took action following Lake County Coroner Oscar Lind's charge of lax security at the hospital. Those who died were:

Robert King, 51 a patient who leaped from a 3rd floor window.
Thomas Azzano, 26 a patient who stepped in front of a Northwestern train in North Chicago.
Robert Horwitz, 40, a VA patient who stepped in front of of a train.
Michael O'Mera, 37, a resident patient who jumped in front of a train.
Allen Hamburg,37, a resident patient who committed suicide on the same spot he saw O'Mera die.
James Caba 57, who leaped to his death from atop the hospital water tower.
James Zvala,27, who committed suicide by a medication overdose.

Lind expressed his concern for increased security at the hospital and with the number of pills some of the patients had in their possession at the time of their deaths. "From our investigation...and results we believe this must be negligence," Lind said.


This is from a Chicago Tribune Column from October 29, 1976 by Jeff Lyon called: "The Law on Insanity-Time for its own Trial?"

There is a paradox here.
Wednesday night, security guard Sam Valenti,66 was killed in his cargo-gate guardhouse at O'Hare Airport. He was beaten and stomped so much that his face was caved in. His nose was nearly cut off with a pocket knife.

Police arrested a man outside the guardhouse. they said he was singing when they found him. He told them Valenti had refused to page an airport employee for him and explained his own gashes by saying  he had slipped on Valenti's blood and fell thorough a window.

The man was a former Chicago fireman and Golden Gloves boxing champion James O'Malley, 55. He was indicted for murder before in 1972.

On New Years Day that year, James O'Malley walked into a pizzeria and shot a stranger to death. Moments before he had pistol whipped another man who offered to help move his stalled car. shortly afterwards, O'Malley was found incompetent to stand trial. He would not understand the charges or cooperate with his attorney. He was remanded to the Illinois Department of Mental Health for treatment. Last year he was at last pronounced able to face trial.

During the trial psychiatric testimony was brought before Circuit Judge Romiti: O'Malley had been "schizophrenic," "delusional" at the time of the murder. He had been hearing voices. judge Romiti did what he had to do. He found O'Malley not guilty by reason of insanity. But he also found him in need of further treatment and sent him back to the DMH, apparently confident that mental health authorities would do what they had to do. And that simply, would be to keep n mind O'Malley's past violence and make sure he was well before he was released. That is where Judge Romiti was wrong.

O'Malley spent 22 days at Manteno State Hospital before he was sent to Downey Veterans Administration Hospital on April 21. Downey discharged him on May 26 ruling he could function in society. For nearly five months he did. Until the explosion in Sam Valenti's  guardhouse.

Valenti did not have much time to think much about the aw before being fatally beaten. The law says that if a man is unfit to stand trial, the courts retain jurisdiction. Once he comes to trial, after treatment, he is likely to be found innocent by reason of insanity. That means he is not guilty. It does not mean he is sane. but that's when the courts lose jurisdiction over him; psychiatrists not judges can decide when he returns to society.

The judge can scream as loud as he wants. If Downey VA says he goes out, he goes out.

I had n interesting chat with Marjorie Quant, Administrator at the Downey VA Hospital. Miss Quant said a treatment team of doctors, nurses, social workers, and the like deemed O'Malley ready to be set free. She said she could not reveal what  their reasons were, because of the Federal Privacy Act.

But she said, "I think we followed our normal procedure here. If  you're assuming there was an error here, that would not be correct." When they released O'Malley, did they take into account that he had committed a murder?  "I'm assuming something to that effect would have appeared in the medical history," she said.

Wouldn't that have made a difference? "What made a difference was his medical condition at the time...A patient is discharged only if it is determined he is well enough to live in society. If he is well enough to go home, he has the same rights as anyone else."

Judge Romiti declared Thursday that "you don't just put a bombshell back on the street." DA Bernard Carey called O'Malley's release "outrageous."  There are those who might even call releasing O'Malley from Downey something else. They might call it insane.

Atraumatic Suture Needles

This is a scan of a flashcard that I created for myself as a whippersnapperrn. It has held up well over the years, just a bit of yellowing and the tape is starting to deteriorate.  Whenever I wanted to learn something quickly, I made flash cards. Suture needle flashcards had the added incentive to master  names quickly because of the hazard of being stuck with one of the needles when grabbing the card out of your pocket. I know from personal experience that the  Straight Milliner intestinal needle really inflicts a painful and embarrassingly bloody wound. Traumatic needles indeed. Take my word for it, you do not want to see the flash card I made for the different scalpel blades!  It still has a split thickness sample of skin on the #11 blade from the back of my hand. I really learned those blade numbers in  lickety-split  fashion.

After learning the different suture needle names it was time to learn how to thread them. Surgeons could be a persnickety lot and it took considerable time to learn the correct length to cut the suture and position the needle in a  driver at the preferred angle. Suture always came in 48 inch lengths and I could cut it down to either 12 inch or 16 inch lengths in the blink of an eye. Needles and suture material were always packaged separately.

French needles were really easy to thread, just pull the thread through the open back of the needle. Presto! You did it. There is nothing more satisfying than to feel that suture material snap into a French needle for that quick hand-off to a waiting surgeon. It was definitely more fun than threading a needle with a standard eye.

Just when I when I completely mastered handling suture needles, a new product was introduced at our hospital, atraumatic needles. When I first heard this term (atraumatic needle) I thought it was some kind of practical joke. In my experience suture needles were not a major source of trauma in surgery. Trauma came from aggressive retraction where tissues were stretched out like  candy at a taffy pull. How about hacking away at tissue as if you were attempting to open one of those clear plastic clamshell containers? Hey, That's a gall bladder, not a high end HDMI cable! How about using a chisel or curette on an actual living tissue? Now that is trauma and has nothing to do with suture needles. Pulling an extra strand of suture material through tissue, no matter how friable, is really small potatoes compared with other events occurring in the OR.

Atraumatic needles had the end of the suture attached or swadged  directly to the needle. This eliminated the drag from the suture attachment site and extra strand of suture being pulled through  the tissue. A noble accomplishment, but not up to all the hype and ballyhoo that came with their introduction. If you really want to go for the Nobel Prize, think about inventing an atraumatic Balfour Retractor or an atraumatic rib spreader.  Atraumatic needles and  their accompanying  hype were akin to an elephant giving birth to a flea.

Look Ma, No Eyes!

Swage sounds like one of those made up words that pharmaceutical companies developed  to give their product some panache. It does sound more sophisticated than calling them suture needles without eyes or other visible means of  attachment.

There were two methods of swaging suture to a needle. Drill swaging involved boring a hole into the end of the needle, shoving the suture material into the hole and crimping the end of the needle. Channel swaging involved casting the needle with a valley-like depression at the end and positioning suture in the channel and crimping. Channel swaged needles were few and far between and I saved a couple of them. Dexon a new-fangled absorbable suture came channel swaged.

All this atraumatic  foolishness has inspired another great idea. I am off to the  Oldfoolrn  product development institute to work on an atraumatic pillow. Stay tuned!

Non Glare Surgical Instruments - A Solution to A Problem That Never Existed

"That glare from those surgical instruments is blinding. I'm glad my boyfriend, the football player, gave me that tip about wearing eye black. It works like a charm."  These are the first two characters I have heard complain about surgical instrument glare, but at least they found a solution to their problem without monkeying around with the way surgical instruments are finished which was a true abomination.

It was the Summer of 1970 we were getting a new bunch of surgical residents and a new shipment of surgical instruments. We were habituated to the brilliant shine of highly polished stainless steel instruments. They were so bright they almost glowed, just like the bumper on Daddy's "57 Chevy. We thought they looked nice, the instruments NOT the Chevy and just figured they would be the forever standard in the OR. The surgeons and nurses really did like the shine. It helped delineate the separation of the tissue with the tip of the instrument for the surgeon and looked nice to the nurse when they were set up on a Mayo stand. Why fool with something that everyone likes?

One of the 10 commandments of being a scrub nurse was to NEVER pass a dirty instrument. We always kept a moist 4X4 in our left hand to buff that Babcock up to a beautiful shine before slapping it into the surgeon's hand. The proof of the cleanliness of the instrument was evidenced by it's beautiful shine. I never had a surgeon complain about an instrument being too shiny or that it was a source of glare.

Surgeon complaints about instruments usually involved issues of misaligned points or tips of the instrument, poor or stiff  joint function, and ratchets that released too easily or stiffly. The offending instrument was often "repaired" on the spot by the disgruntled surgeon who destroyed it by bending the handles to a right angle of the functional part of the instrument. This officially retired the instrument and we ordered replacement surgical instruments every Spring.

There was something new and very different with our latest shipment of  surgical instruments. Needle holders or as you whippersnapperns call them needle drivers were a dull grey color with gold handles. We did not know what to make of these bizarre (to us) non-shiny instruments. Dr. Oddo our world famous neurosurgeon was consulted and he did not know what to make of them either and suggested calling the manufacturer. We figured they had missed the polishing part of the manufacturing process and were defective. They certainly looked nasty to our shineophillic eyes.

To our utter amazement we learned these instruments were made to look like this by design. They were "Non glare instruments" and the needle drivers were the camel's nose under the tent, because soon we had non glare hemostats and assorted other permutations of their ilk. We hated them. They looked dirty and no matter how much you rubbed them with a 4X4 would not come clean. Some old time scrub nurses asked, "Can you mix these grey instruments with our polished instruments?" The non glare instruments just did not look right after years of handling the beautiful polished stainless instruments. Comingling them with bright, normal instruments seemed like a sin. Would the yucky matte finish instruments lead the shiny ones astray? We did not know, but did not want to take any chances.

By the time I retired, non glare instruments had completely taken over and most of the young whippersnapperrns looked at me like I was crazy when my reptilian brain reminisced about all the missing shiny stuff. Bright instruments, Gleaming terrazzo floors, brilliant ceramic tiled walls all replaced by miserable matte dull finishes.



A beautiful shiny, proud Babcock






 



Non-glare. That is one nasty dirty looking Babcock!


 

                                                  .

Recipe for a Nurse-circa 1930



Hmm... What a tempting target for snarky comments. I guess I should respect the fact that it's from a different time.

More Foolish Photos

                                                             
           " The cooking instructions said 2 minutes on high, but this part is still cold.
              I guess I'll have to pop it back in the microwave for another minute."

                                "Stop screaming. These injector guns are completely painless."

 

"Wow! This has to be the mother of  all tapeworms."

 

 

 

 

"It's time to check morning temps. Let's see the blue tips are for rectals and the red tips oral or is it the other way around?

Medical Uses for Paper Clips

The ordinary paperclip has some novel applications for medical use. In the operating room we had access to an assortment of cutting, drilling, and scraping instruments. Sometimes a simple paper clip can do a more effective job than a surgical instrument. When a clumsy nurse got their finger pinched by a autoclave door clamp, a nasty hematoma developed under the nail. A wise old surgeon was quick with a fast, painless, cheap, and satisfying treatment method for both nurse and doctor.

 I really love some aspects of old time healthcare. If you had a problem and someone had a cure for it, it was done. No insurance company BS. No in network baloney. The problem was fixed.

The paper clip was straightened out and one end heated to red hot by a gas cooking stove in the break room. The red hot end of the paper clip was positioned directly over the hematoma and with light pressure, a drainage hole burned through the nail. This produces a very characteristic odor (like singed hair) because nails are made out of keratin the same protein found in hair. Works like a charm. I suspect the treatment today would involve specialty surgeons, lasers, electric drills, and cost hundreds  of dollars.

WOW.. Talk about a hot foot. The operator here is using a hemostat to hold the paper clip. This is really not necessary. The blowtorch seems like overkill too. When I saw this being done the paperclip was straightened and the very tip of it heated. I think you would have better control with the hand held technique. If you carefully heat just the tip of the paperclip you can hand hold the other end.  The idea is to release pressure as soon as the nail bed is penetrated or the patient will scream in pain. Nail beds are full of nerves.

Dr. Oddo, our internationally famous neurosurgeon, claimed that in 3rd world countries paper clips were used in place of Raney Clips on skin flaps. I guess this would probably be functional and a good example of using what is readily available. A neuro resident once gave Dr. Oddo one of those skeptical, eyerolling type of looks when he was relating the paper clip in lieu of Raney Clip story. Dr Oddo  promptly replied. "The proof is in the pudding. Nurse Fool I want a medicine cup filled with paper clips on your Mayo stand for our next crani."  Dr. Oddo  had a definite penchant for medicine glasses and there was always a line up of glassware on my mayo stand. One glass always held Methylene blue (please see my blue finger bigot post if interested), another held patty sponges in an epinephrine based sauce, and now another one with paper clips. All those glasses lined up made the scrub nurse feel like a bartender at the Biltmore.

 During the surgery, Dr. Oddo deftly applied the paperclips to  the skin flap. I bet this was not the first time he had done this, as he was very adept with handling the paperclips. We were all impressed, but I had a couple of fully loaded Raney Clip appliers ready to go in case one of the paper clips let go. Luckily, it was a brief  short case and all went well. Brief case sounded to businessman like for my taste, but you know what they say about oldfools!


On wet plate X-rays of trauma patients suffering gunshot wounds, radiology residents would mark the exit and entrance wounds with paper clips to serve as reference points for the surgeons  in the OR. The paper clip could even be bent to indicate the suspected direction of the bullet's travel. Paper clips were a crude but effective tool for X-ray marking. Whenever anyone noticed an X-ray with paper clip reference marks it suggested expeditious handling because you knew it belonged to someone with a serious trauma that needed emergency treatment in the OR. We always ran from point A to Point B when moving these films about the hospital.

Surgeons and residents always huddled around the X-ray viewer box before starting the trauma surgery. They were an unusually up tight, anal retentive group, but I could always get them to laugh and relax by calmly asking, "What kind of weapon shoots paper clips?" Surgeons never got tired of this joke and it worked every time especially with a new rotation of residents.

Another use of the lowly paper clip in neuro is for sensory testing of  2 point discrimination. There is a fancy device known as an aesthesiometer  that I have never heard of, but learned about when I googled 2 point discrimination.  An ordinary paper clip works just as well when straightened out and then bent in half. It is easy to bend the paper clip to vary the distance between the points when touching the patients skin.

I bet I am just scratching the surface with these paper clip uses. Does anyone have experience with other paper clip functions in nursing or medicine?

An Exciting New Product - The Nurse's Helmcapet

For decades, nurses were easily differentiated from other hospital personnel by their stylish white caps. They really bestowed a certain sense of authority to the wearer. Who was going to argue with a tough old nurse in a white cap wielding an 18 gauge needle and asking "Which side would you like it on?"  Nurses caps had a lot  more cred (see I can even talk like one of you whippersnapperns) than those plastic laminated badges with the big letters "RN."

Nurses' caps also served as a non- monetary reward system for nursing students. Every 3 year diploma nurse vividly remembers their capping and banding ceremonies. It really was a big deal and the cap became a badge of honor.

The cap's demise was fueled by a perceived lack of function and nurses probably got tired of caring for them. The closure of 3 year diploma schools was probably the cap's death knell. There has never been a worthy replacement of the nurses' cap. This is about to change.

Now, from the Oldfoolrn  product development institute, I am proud to present the Nurse's Helmcapet. I have spared no offense expense to develop this game changing product.  Originally, my staff wanted to call it simply a helmet cap, but I don't think that sounds nursey or proper.

This cap is very functional and will protect the nurse from swinging trapezes, hanging IV bottles bags (they still hurt) and even patient assaults. It also keeps the nurse's hair up off the shoulder which every diploma graduate knows is a mortal sin worthy a boatload of demerits. Long hair was thought to be an infection hazard that caused as many septic issues as the great plague.The beauty of this innovative new product lies in the marriage of form and function.

It quickly, once the laugher subsides,  identifies the person as a nurse. The plain white prototype model shown below is suitable for a beginning student. For senior student nurses and RNs a traditional black band is added around the lower circumference of the helmcapet with 3/4 inch wide black electrical tape. Now we call it the senior taping ceremony instead of old-fashioned banding. A true melding of tradition with modern practicality.

 

This is  prototype helmcapet

 

 

 

 

A production specialist at The OldfoolRN institute carefully inspects The Nurses' Helmcapet. The beautiful and equally functional Helmcapets are awaiting the finishing touch, applying the black band of electrical tape around the base. Note the close scrutiny of the supervisor (right background.)





Watch for another new product launch by the oldfoolrn product development institute. It's called the PenWaScis, a Swiss army knife sort of tool useful to all nurses.  It is a combination pen, watch, and scissors. You can't imagine the utility of this handy dandy  device in such a small package. Just ignore the patient when he asks, "Why are you cutting my dressing off with your watch?" 

 

 

 

 

Foolish Photos II

"Just flip this switch right here and we will be able to listen to Guiding Light"

 

"Don't worry Mr. Dunkfeather these new robotic circumcision machines never make a mistake."

Oh boy, I have been in this situation many times, being on the hot seat in front the Director of Nursing. It's never a pleasant experience. Here are some possible heinous offenses that would get you called in.

"Nice job polishing your clinic shoes, but you forgot to Clorox the laces. Lets shape up"

"At this institution we wear our caps parallel to our faces NOT on the top of  the head!" This was a common source of complaints from administration. Note how the director is wearing her cap. It doesn't look parallel to me.

"You are wearing black bobbie pins with your white cap. That is improper, they MUST be white."

"You were seen with a white powder substance in your purse. Are you a crack addict?" My response, No it's Polident powder for my dentures. Would you care to sample some?"

Ouch! That Really Smarts

Here are some mishaps that old school nurses faced causing  them to scream OUCH! We were never permitted to swear or raise our voices so a meek little ouch was about the only outburst allowed when being pinched, stabbed, or burned.

Pages  that went into the chart were imprinted by a handy little device known as an Addressograph machine. Each patient had a small plastic card with raised letters and ID numbers. The patient's card was positioned in the machine and the plate with the card pivoted into a rubber roller transferring the information to the paper. This was actually kind of neat. The machine made a reassuring click and whirring noise as it operated which I found rather relaxing. The OUCH resulted when someone, usually in a hurry, bent over close to the machine while it was operating and got a clump of hair twisted around the roller. The Addressograph machine would rip out a patch of hair faster than Moe of the Three Stooges. This was another reasons for nurses to wear caps - to keep hair form being ripped out by that nasty machine. It really did smart and all that giggling from your co-workers did little to soothe the pain.

"Portable" EKG machines used be the size of a grocery cart and when utilized to record the events at a code, required frequent replacement of the rolled paper. The tracing was made on heat sensitive paper with a very hot stylus. Is this technology still in use or has someone figured out how to do this without the burning hot stylus? Anyhow, when rushing to replace the roll of recording paper it was common to get your index finger and/or thumb roasted by contacting the blistering hot stylus. OUCH!

Metal chart holders were spring loaded to keep the pages pinched in place. This worked out great until Miss Butterfingers ( I am speaking from personal experience) neglected to move their finger out of the clamp zone when positioning a report in the chart and closed the spring loaded chart on a finger. OUCH. Now you know how a mouse feels when that trap snaps shuts.

This one really does hurt and can cause injury so don't try to replicate it. Those weighted speculums can get really slippery and have been known to slide right out of your hand in the OR. Just make sure it does not land on your foot. That really smarts and can cause serious damage. I have been thinking of inventing a non-slip version of this instrument, but lack the incentive. I made my fortune from being a scrub nurse, so maybe a nurse entrepreneur somewhere could cash in on this idea.

I hate needle electrodes with a passion. I really think they are inhumane and inflict unnecessary trauma on patients who are already compromised. Once when inserting an electrode, Miss Bruiser, my favorite instructor kept telling me to "slide the needle in more." They were inserted very shallow and almost parallel to the skin. When I inserted the needle as instructed it went straight through the patient's skin into my thumb. I tried to pretend all was well, but Miss Bruiser saw it all and really chewed me out with adjectives like "clumsy, awkward, and inept." I was in pain and totally humiliated. OUCH and OOPS.

Old time traction beds were an OUCH waiting to happen. There were a number of painful scenarios.The trapeze was typically at the same level as the nurse's head when she was providing care. Patients would be pulling at the trapeze while attempting to position themselves then suddenly release the bar causing it to bonk the nurse squarely in the head. If the nurse suddenly raised her head, it was easy to crash into one of the horizontal cross members above. Traction weights could be dropped on a nurse's toes.

Old school nurses never could get used to those new-fangled IV holders that hung from ceiling mounts. Give me a good old pole any day. We were constantly banging our skulls on these overhead hazards. I even witnessed an event that I affectionately call the "skyhook decapitation."  Unbeknownst to her, a nurse got her cap tangled up in the curley- Q hook of the overhead  IV rack and suddenly walked away. Her cap secured by multiple bobby pins was forcibly ripped from her head with a considerable amount of hair. Combine one of these overhead IV  poles with an Adressograph  and you have a formidable hair pulling machine. My scalp hurts just thinking about it.

I really know little about computers. All I know is that I type this and nice people down in that little box read it. Recently, I discovered that many people actually read my foolishness in the middle of the night or bright and early in the morning. I really do not feel worthy of your readership, especially at this hour ( the only writing experience I have is writing operative reports or nursing notes that were not read)  Thanks for giving an old fool something to do and I hope you have an uneventful night! I learned long ago never to wish night nurses a "quiet night."  All hell usually breaks loose after even thinking about that "Q" word.  Wishing for an uneventful night usually does work. At least it doesn't jinx you like that nasty "Q" word.