Sunday, May 31, 2015

What was the tuition for a 3 year diploma nursing program in 1970?

A young fool works on a detail to the OB outpatient prenatal unit. If we agreed to detail assignments during our 3rd year, tuition for that semester was waived. That young foolette in the background was often my partner on OR details. We both loved surgery and that is how we got started in our first jobs. We used to rehearse together for difficult or new OR cases and she always got to play the surgeon! Once a scrub nurse, always a scrub nurse!

I found an old tattered Financial Information statement from the  diploma school's registrar's office. Here are the expenses form 1970. The registrar collected the tuition. If you could not pay it and were on good terms with the school, it was no big deal. Doctors routinely paid student  nurses tuition if  necessary.

We were socialized into the dogma that we were just nurses, but it was nice to have people who made you feel important. Dr. Webster, who was on the hospital board of trustees paid for part of my tuition. When he saw me on the clinical unit he would always stop to encourage me, even if he was rounding with a bunch of other bigshots.

Pre-entrance fee - $3.00 application processing fee. May be paid with US postage stamps enclosed with application.
Tuition Cost
First Year
Second Year
Third Year
Total                         $2,100.00
This price included everything: books, uniforms, housing, laundry, and meals.  We always affectionately referred to the school as "Mother" because all of our needs were met.
This was also the suggested list price of the tuition. If we agreed to be available for "details" during our final year, our tuition for that year was waived. Basically, we were sent to wherever help was needed in the hospital. It was a very good learning experience. If there was a nasty trauma coming in we all got sent to the ER to "help." Most of the time, though, we were paralyzed by fear and just gawked.
The tuition cost was really all inclusive. There was no foolishness  about paying for nursing pins upon graduation. I guess the school figured we had put in the clinical hours to earn it by our working.
There was no way this could be financially sustainable. The cost of salaries for instructors and utilities had to be many times the cost of our meager tuition. As soon as business types began running hospitals, diploma nursing schools were finished.
The historical significance or community image did not really factor into the decision when it became time to shutter the diploma schools.

Monday, May 18, 2015

What is the worst thing you have seen as a nurse?

Every old nurse has a graveyard of sorts in the back of their mind and a  memory bank of really unpleasant (that's putting it nicely) experiences. Here are a couple of really unpleasant examples.

To deal with frigid Chicago winters, homeless people used to wrap their bodies in layers of newspapers. The colder the temperature, the more layers of  The Chicago Tribune. There was a technique to this, in order to be effective the paper was wrapped in layers of up to 30 pages thick. This served to insulate, but as a handy dandy shield against rain or snow there were Chicago Park District litter barrels. They were about 6 feet tall and had a dome on the top. The opening where trash was inserted was covered by a spring loaded door which served as a window of sorts. A makeshift  shelter could be made by tipping one of these containers horizontal and bracing it on the sides with rocks so it would not blow around in the wind.

One bitter Chicago night a huge mass of newspaper the diameter of a telephone pole came in stuffed inside one of the park district barrels . The police (there was no EMS back in the day) told us there might be a person in the center of this mass and they could not ascertain if they were dead or alive, then, cryptically added "Have fun."   Not a good sign. We quickly ascertained that there was indeed a person somewhere in the middle of this. We quickly removed the trashcan with the help of hot blankets (it had been frozen in place) and were immediately greeted with the most nostril searing pungent eye watering scent I have ever encountered. A combination of urine ammonia smell, stool, and who knows what else. So much for the notion that freezing quenches odors. Next on the agenda was to remove the newspaper. One of the docs suggested using a cast cutter and this worked for a few of the layers but the vibration only served to aerosolize the paper and the odor became disabling to the extent that seasoned nurses were taking breaks to run out into the hall for fresh air to prevent fainting. Someone suggested putting a trace of tincture of benzoin on the outside layer of our masks which did blunt some of the smell.

We got enough of the newspaper off to determine the patient was dead. At this point the docs left and told the nurses to do post mortem care and transport to the morgue. We debated about leaving the newspaper intact and transporting the whole mass to the morgue. One of the orderlies had been a paperboy and even volunteered to make the "delivery."

In the end better judgment prevailed and we removed the remaining paper. It was beginning to thaw and it was like peeling the skin from an onion. The odor worsened with each layer removed. The last layer of newsprint had permanently transferred the ink to the ladies skin. Her body heat had apparently initiated freeze-thaw cycles causing the ink transfer to bare skin on her arms and legs. Funnies on the legs and Sports on the arms.  It was one of the most sickening, sad sights I have ever witnessed. Reading the paper was never the same after this. Housekeeping sanitized the trash barrel and we repurposed it complete with the "KEEP CHICAGO CLEAN" sign on the side.

When the post mortem report came back, the conclusion was that she had frozen her kidneys after drinking-she had a toxic blood alcohol level. She had only been dead for about 12 hours before the police transported her.

The next poor soul was a young man that had cultivated the unfortunate habit of injecting drugs into the veins of his penis. I was on call in the OR and I should have known something was amiss when the telephone  operator told me to come in but "no hurry."  Usually it was a big rush when I got the call.

When I got dressed and reported to the OR  I was happy to see one of my favorite surgeons, nothing ruffled his feathers. He looked perplexed and muttered something about not being sure where to start. Finally he told me not to bother with our usual set-up of back table and mayo stand. We would start with the patient in lithotomy and he wanted just the small gyne table set up at a right angle to the patient with the  general surgery tray.

They brought the patient in, he was in obvious distress and when we moved him to the table he loudly  accused us of engaging in sexual activity with our relatives. This was one bad boy that I could not wait to be anesthetized. We broke down the table and put him up in Lithotomy position.

His penis was so necrotic that it was black. Inserting a Foley was pure guess work and took several attempts. The most repugnant site was his soccer ball size scrotum. It glistened like an ascetic abdomen and was purple in color. His perineum was totally obscured. The surgeon said "I guess we have to start somewhere" and the made a stab wound with a #11 blade in the scrotum. Projectile purulent goo with assorted small bits of necrotic tissue flew over my shoulder and landed on the suture cabinet behind me. It looked like a mixture of strawberry preserves and tapioca pudding. The pelvic floor was covered in grape - like pustules and it was very difficult to identify anything that resembled his anus. The surgeon hypothesized that once the penile veins were sclerosed, he began injecting the drugs into his perineum.

Incising and draining them produced a  smell that  was unlike anything any of us had encountered. It made our eyes burn and nostrils throb. The circulator thought that spraying some Elastoplast ( an adhesive for dressings that had a very string odor) would mask the smell. It worked minimally. The surgeon ordered a case of neomycin irrigant and we also put in a request for Airwick. There was nothing that could really quench the smell. The surgeon did an orchiectomy and excised most of the scrotum and then said we really needed to go in form above because the abscess had tracked into the peritoneum. He also determined that the patients rectum could not be saved and a colostomy had to be done.

We redraped and I went back to my favorite backtable-mayostand set up. The surgeon had to remove a lot of necrotic bowel. When he was done you could look down through the abdominal incision on top and see the OR floor through the big hole in his perineum. Chilling.

When this case was done we gave each other Zepharin showers and finished with a Phisohex bath .I could not get the smell out of my nose. The surgeon said very little after the case other than "That will take care of my sex life for awhile."  The operative report gave little indication of the ech factor in this case. I remember phrases like "copious irrigation" and "meticulously excised" but no mention of the stench. Remarkable restraint.

I asked the surgeon sometime later whatever happened to our foul friend and he replied, "He survived to inject drugs into his colostomy stoma." I assume or at least hope he was being facetious.

I took away from these situations a sense that even on rough days my life was really good. I never had to sleep wrapped up in newspaper. It is also really sad to see how much some people suffer
You really have to love nursing unconditionally as you would a child to deal with really bad situations. Nobody is going to do this for the money.

If any of you whippersnappers have been in similar situations, I would love to hear about them.

Sunday, May 10, 2015

How were blood pressure cuffs secured before Velcro?

Recently this question was posed on a forum. There were no answers. I recall the days before Velcro BP cuffs vividly.
 By my recollection Velcro BP cuffs appeared on the scene around 1970 or so. There were actually
alternatives to Velcro, but none really worked as well .  A Velcro substitute was the "triangular bandage." It could be rolled into a rope like device or folded and tied in any number of ways to secure things. In a pinch they could be fashioned into a BP cuff.  They were muslin and packaged in a blue box with the Red Cross symbol.

BP cuffs had 2 discrete components. The black rubber material bladder with inflation and monitoring tubes which could be easily removed from the securing device. The best type of securing device was a long 3 foot length of soft conforming blue silky material. It looked like a snake that had been run over by a truck and indeed had a tail. To take a pressure, the bladder of the cuff was centered over the brachial artery and the long snake-like thing wrapped 3 or 4 times around the arm and the tail tucked in to secure it. When you inflated the cuff it was similar to having a boa constrictor wrapped around your arm. It worked well.. The main disadvantage was the time it took to apply-much slower than Velcro.

The next method involved a flat metal perforated strap about 3/4 inch in width and the same length as the cuff. It was positioned at a right angle to the long section of the cuff which had raised metal rivets similar to a snap. The perforations on the metal strap snapped into the rivets to secure it. This type was just as fast as Velcro but sacrificed the infinite adjustability of Velcro. The rivets were about 1/2 in. apart and if an arm was between sizes, the cuff would be too loose or tight.

In pediatrics there were several fixed size cuffs available which again sacrificed the adjustability of Velcro. This also posed the nuisance factor of having available multiple sizes of cuffs which always seeme to get misplaced.

When Velcro cuffs made their debut they had detractors. Nurses thought they made too much noise when removed and would startle patients. Remember this is when street signs warned motorists that they were in a  quiet zone because of a hospital and SHHH! signs were plastered everywhere. Nurses also thought Velcro would not wear well.

I bet you whippersnapperns have never had the experience of applying a BP cuff around a patient's neck and inflating it. I know some of you may have been tempted, but hopefully, better judgment prevailed.

There was a bonafide  neuro test called the Queckenstedt Sign that called for this unusual nursing action. The patient was positioned laterally, the doc did the LP noting opening pressure and the the nurse carefully inflated the BP cuff that was positioned around the patients neck. Then the Doc did another pressure test. It was prudent to cease the cuff inflation before occluding the airway.

A normal Queckenstedt Sign showed an increase in intracranial pressure when the cuff pressure was applied to the neck. Compression of jugular veins caused vascular engorgement which caused increased ICP. A positive Queckenstedt occurred when there was no pressure increase with compression. It suggested spinal stenosis.  Thankfully current imaging technology has done away with this crude test.

Today is really special because it is Mother's Day and it's Nurses Week.  Mother's and nurses are both very special. Best wishes.