Tuesday, March 31, 2015

April Fools

I have been the victim of a few April Fools pranks that played out in a clinical situation. To non-nurses I am sure they seem inappropriate, but they are definitely stress relievers. Foolishness does not work well if it ascends the nursing hierarchy, you can get into a heap of trouble. To be safe the foolishness must be between a couple of staff nurses that know each other well.

I may have fired the first shot in this episode of foolishness. One of my friends, Bonnie, was doing post mortem care for a patient that died as a result of bleeding problems secondary to his long term alcohol consumption.  I helped position the patient on the shroud and left Bonnie to discontinue his lines and finish preparing the  body. Soon Bonnie cried out to me "help, I need help." I was slow to respond, asking myself;  how much trouble can you get into preparing a body for the morgue? When I approached there was a huge circular blood spot running off the shroud and Bonnie was standing there with her finger aggressively applying pressure to his antecubital fossa. She said upon removal of his central line the bleeding would not stop. I told her with a snicker "any doctor or nurse knows all bleeding eventually stops."  Then I told her she would just have to pretend that she was that little Dutch girl with her finger in the dike and we would transport the body with her plugging the flow.

Bonnie was not amused and promised payback at a later time and occasion of her choosing. I tried to mollify her by stopping this post mortem exsanguination with a trusty piece of Gelfoam and a pressure dressing. It worked like a charm and I even helped her transport the body to the morgue in hopes of limiting damages to dampen down her threats of revenge.

Things went along just fine and I had forgotten the incident. It was April Fools day and I was caring for a patient that had abused amphetamines over a long period of time and had the unfortunate experience of popping two intracranial aneurysms. I have never cared for a patient this unstable and it was a true juggling act titrating her meds to maintain some semblance of reasonable vital signs. I usually forgo lunch when I have a patient that is not stable.  Bonnie finally convinced me to at least stop and go down for a bagel which I reluctantly did.

Bonnie had stationed a lookout in the hall who notified her when my return was forthcoming.  She then put her plan into action. She gathered several cohorts around the bed and then set the monitors to calibrate function so that the EKG and arterial line tracings were a straight line. The minute I saw this scene I felt  instant terror filled panic. She then, at the peak of my meltdown, yelled "April Fools." I really should have been wearing an adult diaper to contain the damages. It was one of those occasions that can take your breath away.

When the dust settled we agreed to a truce.

I know this probably seems politically incorrect and whippersnapperns have better sense, but it did serve to dissipate some of the stress.

I hope everyone has  great April Fools day.

Wednesday, March 25, 2015

Quotes From the Graduates

Graduating nurses were asked to submit a quote that was published along with their photo in the yearbook. The quote was supposed to reflect values acquired along your journey to become a nurse or a capsule view of the  nurses's  personality. Here are some quotes from the graduates.

Generous of heart with a calm disposition.

Always laughing, never sad, sometimes naughty, never bad.

She's known by her smile and friendly eyes.

Quiet and earnest with a smile of warmth and goodness.

A good sport in life's game.

The days that make us happy make us wise.

An agreeable person is one who agrees with me.

The secret of a happy life is not to do what you like, but to like what you do.

Life is short-Live it up while you can.

I thank heaven for the ability to talk.

Reason and judgment are the qualities of a good nurse.

Determination makes dreams come true.

To be athletic and still feminine is quite a feat.

As long as you're going to be thinking anyway, think big.

That last quote is a ringer. It's from Donald Trump. I think it may be more consistent with today's values in a world of nurse entrepreneurs, nurse  industrialists, infomatics nurses, and assorted others of their ilk. Nursing for some,  is no longer a humble profession centered at the patients bedside. It was impossible to think big when surrounded by a ward of seriously ill patients. You were too busy working with very limited resources to bring comfort to those in your care. I  really love and admire the young whippersnappern's doing direct patient care today. They have a much more difficult task in an exponentially more complex environment than I could have dreamed of. They are the nursing heros of today.

Sunday, March 22, 2015

Caped Crusaders

OK all you whippersnappern's gather around the oldfoolrn's  Hoveround to hear a tale about Nightingale inspired capes that I once wore to a bloodletting procedure.

All that is one big lie. Nursing capes were before my time. They were phased out at our school in the early 1960's. We did have a large display of capes in our school library and we even had one available to try on. I thought that this garment really had a lot of utility. It was navy blue wool with a smooth as silk red lining and very warm. If you were in a hurry, you could run and it would stay in place. It could be worn a number of different ways-pulled all the way around for maximum warmth, open in the front or draped over a shoulder.  I can easily see why it was the garment of choice for Florence Nightingale.

Graduating classes just a few years ahead of me had their senior portraits taken with their capes. A very nice look with the dark cape contrasting with the white uniform and cap. A classic Cherry Ames nursing look. By the way, "Cherry" was a nickname, her real name was Charity. My favorite was Cherry Ames - Senior Nurse which was an inspirational classic.

Capes also gave the nurse a sense of presence. A couple of our instructors wore capes to impress upon us the seriousness of being a nurse. It did really make an impression. You cannot get away with much foolishness when someone wears a cape.

There were some really beautiful designs. There was usually the school's insignia or pin embroidered on the collar. Bellvue  Hospital had the school pin design on their capes. It consisted of a crane representing vigilance surrounded by a wreath of poppy plants (opium's source) signifying comfort. A ring encircled this for continuity. A very impressive garment.

I know that nursing caps will never make a comeback because they lack function. I think capes could be resurrected for use by todays whippersnappern's. I think they would serve to dress up the ubiquitous scrubs that everyone wears today. Capes  really do keep you warm and toasty.

Tuesday, March 17, 2015


There was a definite lack of  academic tradition for our graduation.   The 22 graduating survivors (we started with 78) had just completed 3 years of training not education. The gowns and mortarboards of  academia were replaced by our nursing whites, caps, and clinic shoes. We looked like we were ready to hit the wards.

For the trip to the graduation site, an actual cathedral, we boarded our school's own group transportation device, a WWII era yellow school bus that was donated to the school and had seen better days. The rear fender wells had long ago rusted away leaving gaping holes in the floor that were open to the road below. We received one of our first  lessons in trauma nursing, when one of our instructors  pressed into service as a bus driver struck a rabbit while rolling down the road at considerable speed. The impact propelled  vital organs of the rabbit into the cab via the holes in the floor.  We quickly identified small bowel, but were unable to reach a consensus about the tissue that landed on the back of one of the seats. Some thought it was the liver while others guessed kidney.  It was a tossup.

Every time we got on the bus that old diploma school limerick was sung. The only 2 lines I can recall are:  Came here to get my pin / All I do is live in sin. It was a very memorable song and I wish I could recall more.

Our class flower was a white rose, but when we got to the cathedral a blue carnation was pinned to our uniform. I guess they must have been on sale.

We fired up our Nightingale lamps and processed to the front of the darkened cathedral.  My emotional intelligence is on the low end of the scale, but it was very memorable and a touching moment.

I do have an actual copy of our graduation program and the next listed event is the Inovation (sic). I don't know how a typo like this got past the proofreader, but our hospital was always trying to save money. I think they really meant Invocation and it was delivered by a Catholic priest, Fr. Kyle.

After the Invocation all the bigshots got to address the graduates. This included the Hospital Director(no CEO's), the President of the Hospital Board and finally the Medical Chief of Staff. No nurses were on the list of esteemed speakers.

Next on the agenda was a choral selection from the Freshman and Junior students. Maybe they were more insightful than given credit. The song was " Bridge Over Troubled Waters." We were about to jump into the deep end of the pool and become real nurses.

Next on the agenda was the presentation of special awards. This went to whoever was the best at kissing up to certain instructors. The most coveted award was the Dr. Strangeglove  Obstetrical  Nurse award. It always went to the nurse with the most superficial bubbly personality. Jubilant nurses who could cheerfully implement a labor  & delivery protocol that called for 3H enemas (High, Hot, and a Helluva lot) immediately administered upon admission to  supposedly facilitate contractions. I could not imagine a more invasive procedure employed at the most inappropriate of times.  I still recall the mother's blood curdling  screams during this procedure and the ensuing mess it created.  This type of nurse could also goo-goo and fuss over every new born regardless of how vociferous the crying. I didn't stand a chance for this award!.

Our class motto: "A journey of a thousand miles begins with a single step" was blabbered about by the Director of Nursing-This was the first time an actual nurse was given the podium. We all knew who was really running the show.

Time for another choral selection. This time it was "The Impossible Dream."  Our choir director was an elderly man who happened to be a single BK amputee. He also had limited use of an arm. What he lacked in mobility, he made up with bizarre facial contortions. Very memorable.

Finally we processed up to where all the bigshots were solemnly assembled and the Nursing Director physically applied our school pin to our uniform - the moment we had all been waiting for. The Chief of Staff handed us our diplomas. We were GN's at last.

In the interest of ecumenism, a protestant minister delivered the benediction and the ceremony was over.

Immediately after graduation we were notified that none of us would be allowed to take State Boards in Illinois because someone had stolen portions of the test.  Illinois was not permitted to administer boards for 2 years. We had to travel to Des Moines, Iowa, take boards there and apply for reciprocity to practice back in Illinois. Nursing was always like this. Someone higher up the food chain makes a mistake and the nurse working on the ward gets eaten.

All 22 of us passed boards and immediately went to work in the hospital. It never occurred to us to work elsewhere.

Friday, March 13, 2015

Health Care Slogans vs. Traditional Values

Recently, I observed one of my colleagues wearing a tee shirt emblazoned with a clever expression: "Inside every old fool is a young fool asking; What the heck happened?"   Todays health care systems slogans confound me and frequently bring this question to mind.

Hospitals did not advertise with taglines, their institutional values were clearly defined on our nursing pins. What follows is an actual hospital slogan contrasted with the values etched on a nursing pin. I will try to exercise restraint and not pontificate. They really do speak for themselves.

Convenient - Connected   vs.  Charity -  Hygiene

Believe in WE  vs.  A Deo Salus  (Health comes from God)

Hello Life! vs. Vota Vit Mea (my life is devoted)

Depend on Us for Life  vs . deo Juvante  (with God's help)

Engineering the Future of Healthcare vs.  Embracing the past while we sculpt the future

Professional..Reputable..Connected   vs.  Service-Research-Education

The healthcare system of opportunity vs. Non Sibi Sed Aliis  (Not for themselves, but for others)

Wisdom for Your Life vs. Dedicated to the Service of Mankind

Well Beyond Healthcare vs. Take care of him and I will repay you

Life Changing Medicine vs. Salus Generis Human (For the health of man)

Some of the slogans defied finding pins that expressed contrasting values. Nevertheless, I found them noteworthy.

 "Cheat Death" is an actual hospital slogan  that really perplexes me. Oldfoolrn's don't cheat. If we did our expulsion from nursing school was a sure bet. Furthermore we never could use the "D"word.
When patients expired, we transported them to the morgue in double tiered gurneys (the body was on the lower tier and the top looked like an ordinary cart.)  Nobody was the wiser as we passed trough the hall. Denial was the key word when dealing with death. Patients did not really die-they were "transferred to the morgue."

"5 star care"  This slogan brings to mind the question "Who says so?" This type of rating should only apply to movies.

"Pushing Beyond" Where is beyond and what are they pushing

These slogans were created for marketing purposes only, an attempt to exploit a patient's illness for business purposes. The values on nursing pins were the essence of what the hospital cared about. They were not advertised, but everyone had a sense of what they were.  Times sure have changed. What the heck happened?

Tuesday, March 10, 2015

Not so Big Pharma

I don't know how whippersnapperRN's  keep abreast of the constant barrage of  drugs. Just listening to all those direct to consumer ads on TV is headspinning.  The pharmaceutical industry truly has some remarkable offerings, but this progress has come with  problems I could have never imagined.

We had a very limited number of drug classifications and they really did work for their application. Drugs like: penicillin, digoxin, gelfoam, and Lasix did not need drug reps to sell them-they sold themselves.

Gelfoam was one of the most extensively used pharmacologic products.  This animal gelatin hemostatic substance came in a powder, sheets (about 4X5 in), and even in zig-zag strips for packing. It was a conditioned response-anywhere there was bleeding, think gelfoam. We even tried to force a slurry of the powder down NG tubes for GI bleeding. It was a remarkable hemostatic agent and I vividly recall that comforting rectangular Upjohn logo on the container.

The only limitation was that Gelfoam did not work well with arterial bleeding. It was like attempting to patch a firehose with chewing gum. The pressure would dislodge the gelfoam.

For pain control, Demerol was used for 3-4 days post-op. The patient was usually kept in the hospital until pain free. Upon discharge, they went home with some APC's (aspirin, phenactin, and caffeine)  tabs We used to call them All, Purpose Cures.  There was no drug seeking issues with this analgesia regimen and nobody ever claimed to misplace or lose APCs.

Antibiotic wise there was penicillin for gram+ infections and sulfa or gentamycin for gram- infections. When there was a question as to sensitivity, Keflin always seemed to work. The microbiology course I took made no mention whatsoever of viral illness. The concept of drug resistance was unknown and the limited number of antibiotics available did seem to be effective.

Digoxin was used extensively for compromised cardiac issues as well as nitroglycerine SL for angina. We also used a nitroglycerine paste that was applied to the chest wall. There were no beta blockers or calcium channel blockers. As a pressor agent, ephedrine capsules were used. Maybe it was a blessing that we lacked IV pressor agents. There would be no way to accurately dose without IV pumps or controllers.

Diabetics had the choice of beef or pork insulin. When antibodies to beef were developed, switch to pork. This came in two confusing strengths U40 and U80.

Huge categories of drugs we take for granted today were lacking. Things like statins, SSRIs, atypical antipsychotics, beta blockers, anti-neoplastic drugs, and oral hypoglycemics all missing

No unit dose. All drugs were dispensed from stock on the ward. This led to some whacky drug dosage calculation test questions such as you have a stock bottle of a 1:50 solution. How would you dilute this to a 1:250 with only 10 cc of diluent

Patients today have much greater expectations and I think the pharmaceutical companies promote this by overhyping their products. Nurses today have it so much more difficult today than I ever did.  I never had to face anyone demanding more opiates because they lost their prescription

Sunday, March 8, 2015

Mrs. Otero

One of the joys of bedside nursing is being able to work with some really good people. Their good deeds and actions get burned into your brain as an antidote to all the unpleasantness associated with nursing. Being in the presence of an effective bedside nurse is an emotional experience. Nurses like one of my youthful idols, Mrs. Otero, can actually initiate changes in neurotransmitters inducing positive mood changes in both patients and fellow nurses. Truly incredible.

Mrs. Otero always looked the same. A reassuring look that was part smile and part business which gave the impression any situation could be gracefully handled with a favorable outcome. She had one of those long white dresses that extended below her knees. Prominently on her head was what I call an aviator style nursing cap. The cap's edges were folded at a right angle to her head forming little winglets that paralleled the floor. With the speed she moved about, I bet her winged cap actually generated some lift. Her pin which looked like a miniature sheriff's badge was pinned to her collar. A very calm collected lady that didn't take kindly to fools (just kidding on that one.) She actually  took being nonjudgmental to a new level. She treated everyone with the same level of kindness and compassion.

She decided to become a nurse at age 8 after her older brother was wounded in conflict as a soldier and  never deviated from this plan. Nursing school in her native country, Mexico, was 5 years. The initial 3 years resembled our diploma education and the last 2 years was spent as free labor to repay the nursing school.  She immigrated to this country in her 40's and had been working here about 5 years when I met her.

She thought that call lights used to signal  for a nurse were an indication of an unanticipated need and these modern devices were unnecessary. Always giving 10/10 ths she would speed from room to room. For her, the nursing process went: Assess-Reassure -Comfort. speed off to the next patient.

Truly self-sacrificing, she tended to overlook her own well being. She used vacation days to have a hemorrohoidectomy done. I was lucky enough to care for her post-op and she told me she did not want to abuse her sick leave and this was too minor of a thing to call in sick for. I shudder to think what illness she would have deemed worthy of using sick leave.

Positive affirmations were always on the tip of her tongue. As a student nurse, I was helping her with an agitated and restless patient. She leaned over to secure a line on his arm and suddenly the patient unloaded with the grossest glob of pleggmy mucous that I have ever seen anyone spit. It landed squarely in the middle of her face.  As she was wiping this gooey glaze off her face, she calmly told the patient, "Don't worry honey, you'll be feeling better soon"... Unbelievable.. and whenever someone tried to aggravate me, this episode always came to mind. It always settled me down and brought a calming perspective to the situation.

One has to have what it takes to be a nurse like this. Usually a calling, sometimes fueled by a traumatic event,  a burning desire to help, and a willingness to work very hard. This is a rare find. Today I read about so many whippersnapperRNs that do activities such as nurse recruiter (take your self to the bedside, how do you expect to recruit someone to a job you cannot do.) Pharmaceutical sales nurse (if the drugs really are effective you don't have to sell them) What the heck is nursing infomatics? (sounds like a good excuse to get away from the bedside.) The list of these bedside nursing refugees is endless and in a way, pathetically sad. I would not trade 10 nurses of this ilk for one of Mrs. Otero.  Florence Nightingale did not waste time sitting in an office - the bedside will always be the essence of nursing.

You can probably make more money in one of these non-bedside endeavors, but you are missing the heart and soul of nursing. When you retire you might have a 401K, but it's not money that has brought me peace or happiness later in life.  Mrs. Otero and others like her have tattooed contentment and well being along many neural pathways in an aging CNS. It's a  comfort and well-being that is priceless.

Thursday, March 5, 2015

Requirements of an Operating Room Nurse - Circa 1968

This old mimeograph did not survive as well as the cap folding mimeo, it's faded in places, but still amusing interesting. I came into possession of little gems like this during morning report. We all gathered at 6:55AM each morning in an unused "observation room" in the operating room. The room did not have enough elevation and all that was visible from this vantage point was the backs of  the surgeons. Very poor planning, but the nurses had their very own "report room."

If there were student nurses rotating through the OR we received their hand outs too. I don't have a clue as to where documents, if you could call it that, were produced. It was unlike an email where there was an indication of where the directive originated. We always folded them up, stuffed them in our pockets to throw out when we got home. It's a miracle this product of a cranky old member of nursing abomination administration survived. I must have felt it had some special merit.

Maybe I was thinking that I could use that "Requirements for a nurse" paper as a defense in case I got in trouble (a constant fear)  or was disciplined for some heinous wrong- doing like having my fingernails 1mm too long. I reasoned that I could defend myself by saying that I never violated rule #3 by laughing in the hall outside the neuro room during a craniotomy. Luckily I never had to invoke the no laughing defense.

What strikes me most is the rigid authoritarian tone of this directive. It follows that old adage to control minor things when you cannot do anything about the big things. There is nothing here about the really important issues like infection control or reassuring patients. Big important things are bypassed.

Nurses had to wear pink scrub dresses. We were not allowed to wear the green scrub pants and shirts. This attire was reserved specifically for surgeons. On occasion the surgeons supply of scrub suits would be depleted. One day a surgeon showed up to scrub in one of our dresses. He didn't consider this unusual,  he was just using what was available. I wished that nurses could be this flexible and  more patient centered. Asepsis and technique was far more important than kind of slip you wore.

Circulating nurses had to check the furniture and equipment in each room every day before he first case. There was more "furniture" than equipment in the room. No electronics, except for an occasional "portable" EKG monitor that looked like a 2 foot section of sewer pipe with a mini Christmas tree light on the screen. We had 2 of these contraptions for 8 ORs.

The only equipment necessary for anesthesia was a precordial stethoscope, a hockey puck sized weighted scope that sat on the patients chest and a BP cuff. A stopcock enabled switching between the two. The only other devices that qualified as machines would be the suction and Bovie. It's amazing to me that things usually went very well with few problems.

Sometimes I think that I would love to scrub for just 1 more case, but then look down at my arthritic bovie burned finger and realize how crazy that notion is. It really is fun to remember the experiences. Time really does blot out the bad experiences and preserve the good. Aging can be good experience.

Monday, March 2, 2015

Fool's Foils for Fasciculating Fingers

This problem was never addressed in nursing school and I have also never seen it in a textbook. It was never even discussed among nurses until I began working in the operating room.  We were like a family, albeit dysfunctional, but there was a sense of being more open with our problems. No, the problem isn't drugs or sexuality. It's hand tremors.

This is for you that have  been in a situation where someone is yelling, Get that blood going STAT.  You just got a beautiful dark red blood return in that flash camber of that #18 Angiocath.  Now it's time to start threading it into one of the last remaining veins and YIKES!  My fingers won't stop shaking.

If you're in nursing abomination administration, or any other non-bedside care area of nursing this is not for you. This is for nurses in the trenches, under stress, and that care about their patients to the point of being self-sacrificing. It's definitely disconcerting when you have to perform a task and your hands shake. Exacerbating factors include being tired, stressed, or harangued. Things you encounter everyday. Here are some tips that helped me with this problem.

When you're threading that angiocath, hold it between your thumb and index finger while your other 3 fingers are in contact and braced by the patients arm. Most everyone intuitively does it like this but it does help if you think about being stabilized by being in contact with the patient. This also helps if the patient jumps or moves.

Limit caffeine, this is hard but does work. Avoid alcohol.

Keep your arms adducted and braced against your body when possible. Limit the distance you reach out. For me, the further I reached away from my body, the worse the shaking.

Keep your hands warm. This is another good reason for handwashing. Being cold really exacerbates the problem of involuntary tremors.

In the OR practice handling the instruments. Be able to open and close clamps and needle carriers without  having your fingers in the holes.  Practice extending your index finger straight up to the pivot hinge on the scissor to guide and stabilize it. When loading a needle holder don't worry about getting it positioned in the jaws right away. Swing the needle over to contact the needle holder and slide it up the side to the jaws, finally adjust the angle of the needle in the jaws. You can do this very quickly without loss of speed.

If you have to do something one-handed like cut a suture for the surgeon don't over reach. Get in as close to you can and stabilize that free hand on something like a mayo stand or retractor. Think of that steady support as your anchor. This really helped me.

Verbalize  your shakiness if appropriate. Our chief of surgery would when the occasion warranted it yell out "My hands are getting tired and shaking"  His hands always stabilized after acknowledging the problem. This won't work in the ER with patients around, but you can say this to yourself and it does work.

When capping a needle, angle the cap upward, brace the base of your thumbs together and deliberately bring the needle down onto the cap, then slide the needle into the cap. That way you won't have to worry about exactly lining up the needle with the cap.

Put a calm relaxing spin on whatever is in your physical environment. I used to imagine those hot, bright OR lights were beaming down from heaven. I learned this trick from an old time surgeon and discovered you can put a good spin on just about anything. Whenever the s--- hits the fan, there are usually bright lights somewhere, so this can work in other places too.

If you're wearing gloves imagine them stabilizing your hands and fingers. I think they may actually do this, but that probably borders on being delusional.

I did google this issue for a contemporary take on hand tremors. About the only thing suggested was Beta blockers. This probably does work, but in critical areas of nursing you need all the sympathetic tone your nervous system can muster. Bad things usually happen very quickly and you don't need anything slowing your response.

Try not to develop spasmophobia where you overthink or worry about your hands shaking. You are in very good company if you have this problem. Florence Nightingale's hands probably shook  when she made her rounds in that Crimean battlefield hospital.

This problem is a manifestation of how much you care for your patients and that you are doing real nursing at a patient's bedside. Nursing bigshots, administrators, and indusrtrialists never had to worry about their hands shaking or even getting anything  under their manicured nails.  The bedside nurse is where the rubber meets the road.  You are the person getting things done.