Saturday, June 27, 2015

Robots Blowing Smoke in the Hospital

Smoking cigarettes in a hospital was widely accepted in the late 1960's and into the 70's. I don't recall any restrictions on in hospital smoking until the late 1980's when it began to be restricted to break areas. Nurses made special accommodations to facilitate smoking for their patients. If there was oxygen being used in a room where someone wanted to smoke, we moved the smoking patient to another room. Friendly, little old ladies who volunteered, pushed "gift" carts laden with cigarettes, candy, and magazines. The clickity-clack of the gift cart wheels going over expansion joints in the flooring was ironically identical to the noise made by the crash cart.

Cigarettes were also readily available from vending machines in the main hospital lobby for about 50 cents a pack. These machines always seemed to do a brisk business.

                                           Care for a cigarette after that nebulizer treatment?

At the time, there was little attention directed toward preventive care and cigarettes were available to mitigate hospital induced stress. It did not really occur to people that cigarettes could induce disease or complicate just about every aspect of recovery.

For nurses,smoking was a good way to insure that you would be freed of nursing tasks for a few minutes. It was hard to irrigate a catheter with a cigarette in your hand. This may be hard to believe, but on a few rare occasions, I have seen ashtrays in use on med carts. It was very disconcerting to be leafing through the medication records and have a pile of ashes come cascading onto your white uniform.

Cigarette butts on the ward turned up in the oddest locations.  Setting up an orthopedic bed for traction was always a challenge because nurses patients used to stuff cigarette butts into the receptacles for the various cross members and supports. We used to have to dig them out with a scissors and attempt to identify the culprit from the brand of cigarette. A confrontation usually went like this: "Cathy, I had to dig 3 BelAir cigarette butts out of that bed frame before I could insert the traction supports." While dragging on an incriminating BelAir cigarette, Cathy would always reply: "I never smoke BelAirs."

Sometimes men would just drop their cigarette butts into a urinal because it was easily accessible on the bedrail. The old joke would be to attach a hand made sign stating: "Please don't drop cigarettes into your urinal. They get soggy and don't light."

When we were doing our psych rotation in nursing school, our instructors advised us that we should at least learn how to smoke so as to better relate to patients. Everyone, patients and staff smoked in psych. State hospitals supplied "indigent" cigarettes free of charge to anyone wanting them and Bugler roll your own smokes were always available when the rationed indigent cigarettes ran out.

If  you could not use your upper extremities there was always the handy dandy robot smoker available. Yes, in the days before robotic surgery we had robot smokers. It was the nurses job to load and light the robot. The cigarette was inserted into a round snug fitting receptacle on the base of the robot and a 2 1/2 foot length of tubing stretched from the bedside stand to the bed ridden patient. Patients liked the visual experience of watching the cigarette burn down, so it always had to be in view of the patient. These devices could be reused by multiple patients by simply changing the tubing.

                                                   "Nurse, my robot needs a light!"
I actually cared for a paraplegic, Cecil, who insisted on dual robot smokers which always reminded me of smoke bellowing from a cars dual exhaust. He claimed that the robot smoker was not very efficient and that it took 2 of them to equal a normally  inhaled cigarette. We lined up two of the robot smokers in tandem (side by side) on his bedside stand, simultaneously lit them, and inserted the 2 black mouthpieces and he was ready to go. I always wondered what would happen if we used  a different cigarette brand in each robot.

The nurse in this illustration should have been using a robot. We were never allowed to light a bedridden patients cigarette unless it was in a robot. The rationale being that if the patient was incapable of lighting it independently, he could not safely smoke it.

Today, I always find it depressing  to see the patients dressed only in their gowns outside smoking and marvel at how much times have changed. It's real progress that healthcare no longer promotes such a lethal practice as cigarette smoking.

Monday, June 15, 2015

What's the Prognosis Doc?

Predicting outcomes has never been easy. Here are some foolish prognostic indicators.


The surgery is performed late at night or on a weekend, even more grim if on a major holiday.

There is a long delay (45 minutes or >) between anesthesia start time and surgery start time

The circulator has to leave the room to flash sterilize an esoteric instrument during the middle of a case. Bonus negative points if it's a vascular instrument and the surgeon says to heck with the autoclaving, "Just pour some alcohol on it and hand it over."

The surgery is done with the table and/or surgeon in a novel and unusual position.

Overhead lights are adjusted 3 or more times on the same site during the same surgery.

A surgical drape becomes unsecured and drops to the floor in the middle of a case. When things are going bad and this happens it's like a Bovie  burn to your soul. You suddenly come to realize that it's not a tumor or aneurysm lying there, but someone who is a father or mother. I remember vividly an incident like this that happened over 40 years ago and it still brings tears to my eyes.

Both  kick basins in use simultaneously on the same case. I think this is how the term "Kick the bucket," may have evolved.

Surgeons shoe size is 6 sizes or > than the patients. Size 13 surgeon operating on a size 5 1/2 patient is not a good idea.

Patient has a tattoo covering the operative site. Yes, we had tattoos back in the day, and the surgeons spent more time worrying about approximating the edges of the wound so the tattoo lined up than any other aspect of the surgery.

The patient is a very nice guy/gal and is employed in a helping vocation like teaching, social work, or nursing. Why is it that the most pleasant people have the worst metastatic lesions and other intractable, inoperable problems?

The surgery occurs over the lunch hour with anesthesia and scrub nurses rotating in and out for lunch break. I always thought there should be a law preventing this practice, but it was common.

Two surgical specialties operating together on the same case. I was once scrubbed on the general surgery (abdominal) side of a bad trauma. The neuro guys operating simultaneously above declared that it was time to call it quits, declaring the patient dead  and my Doc said "Let's keep going,  more 3-0 on a curved, we're on a roll."  We could not get him to stop!

Arriving in the OR suite with an endotracheal tube already in place.

I can't really come up with any indicators of a good prognosis. For some reason with aging the bad things really stick in your mind. Patients with long standing problems that receive their care via frequent ER visits usually do very well. Another observation would be that drunk drivers can survive a wreck that would doom a sober person. In fact intoxicated traumas frequently do better than their sober counterparts.

Thursday, June 11, 2015

A Foolish Young Nurse Learns From an Enlightened Patient

We received the call from radiology that they had completed a cerebral angiogram and  needed a nurse from the neuro unit for the transfer. It was my turn for an admission and I knew to bring an AMBU bag because the patient was going to need a ventilator when we got back to the unit as she had already been intubated.

I quickly scanned the history. A 46 year old lady named Vicki  was shoveling snow and had collapsed and lost consciousness. Upon arrival in the ER, a neuro problem was suspected and confirmed by a CT scan. The angio showed 2 intracranial aneurysms had popped.

She looked so tiny and delicate lying there surrounded by the X-ray equipment. Doing a quick neuro check, I was taken aback by her soft green eyes and her heart shaped face which was framed by her jet black hair. There was definitely someone home behind those eyes, so I started talking to her explaining that we would be going to the neuro ICU and I would be caring for her.

Along the journey to the unit, I was able to detect some inspiratory effort and was really just assisting her breathing with the Ambu bag. On the unit, the critical care resident thought she could be extubated and I was communicating with her via eye blinks. After suctioning her we pulled the endo tube and her first response was "Thank-you."  As my shift came to a close, she became more alert and I told her confidently that I would see her tomorrow. I thought it was really important to say this to someone really sick, as it inspired hope.

The next time I cared for her she was alert and very animated, telling me about her work as an assistant anthropology professor at the university. She also profusely thanked me for all that I had done and that she remembered me explaining things and talking to her in angio. I could not for the life of me figure out why she was thanking me, in my 20 something mind, I had done none nothing to help her, she still had two aneurysms that needed clipped.

Patients like this activate the super nurse syndrome in young nurses and you want to bring all your personal resources to rescue this person. The fancy big building full of equipment, the tiled temples of the operating room reinforce that this life must be rescued at all cost.

This lady had a true inner peace about her and said that her whole life and study of anthropology was training for this moment and that the best things were yet to come. I really expected her to do well post-op after they clipped her aneurysms. We had started her on  the usual pre-op Amicar and made sure she was stable for the upcoming surgery.

The next day there was an unusual quiet when I approached Vicki's bedside. She told me that she was not having surgery because of her fear of being disabled and that she could easily accept her demise. I tried to explore her fears, but it was no use her mind was made up.

She profusely thanked me upon her transfer to a regular room and told me that I would understand her decision  more clearly when I was much older.

Vicki died 2 days after her transfer when one of the aneurysms suddenly ruptured. I know she died in peace and on her terms, but it was about 30 years too soon. She was right about one thing though, 40 years later I am beginning to understand and I can see those glowing green eyes like it was yesterday.

Friday, June 5, 2015

Overheard in the OR

Foolish comments overheard in the O.R.

After an anesthesia resident inadvertently intubated the esophagus, the attending quickly replied, "You realize there is minimal gas exchange across the wall of the stomach."

"We really rect  um." An attending always said this after completing the lower potion of an AP resection. We all were obligated to chuckle.

In disputes between the surgeon and anesthesia about the need for blood transfusions, it was always prudent to side with the surgeon. Anesthesia would be quick to cite the volume of blood in the suction containers and the surgeon would claim that it was all irrigating fluid. When the nurse was asked about the volume our response was almost always the same: "Oh, yes a couple of liters of irrigant , Doctor."  That remark always reminded me of the typical response from a drunk motorist when asked about his alcohol consumption, "Just a couple of beers officer." Two was always the universal number for estimating fluid volume.

I quickly learned to never ask the surgeon how he wanted the specimen named. The response was always "Joe" or "Fred." The correct question was always "How do you want me to label the specimen?"

Once, on  a very long partial nephrectomy, the surgeon was meticulously suturing tiny pea sized bits of fat to the kidney. My fingers were getting tired from loading needle holders and after about an hour of this I actually asked him: Why don't you just sew one big glob of fat on there and be done with it?" He barked back at me "It doesn't work that way, fool."  I still don't know what made me ask something so foolhardy.

We actually had a surgeon who insisted that  Bovie  smoke was good for you. He also smoked Camels and I always suspected he was wrong about the Bovie smoke. At least, he didn't make any health claims about the cigarettes.

Handling instruments had lighter moments.  Everyone tried to come up with  new appellations for a hemostat, there was pusher, Kelly, snap, tag, Crile, and pinch among many forgotten others. The smaller ones were mosquitos and the longer ones peans.  Surgeons used to love to smack the back of inattentive residents hands and the preferred instrument for this was a sponge stick. There were also suggestive remarks about how to properly handle a Babcock. We also had a left handed surgeon whose instruments ratcheted in reverse, a real pain for the scrub nurse and we always joked "He needed a left handed scalpel too."

"Turn up the vapor, he's trying to help!" Surgeons always made this command to anesthesia when the patient begins to wake up in the middle of a case. Of course, if anything bad happened as a result of this, the circulating nurse is blamed.

"It's not in here, we're closing." Surgeons standard reply when informed the sponge count was off. It was an unwritten rule that if a foreign body like a sponge was left in the patient, the scrub nurse and circulator would be fired.

I guess it's time to cease this nonsense. I really do appreciate people who take the time to read this foolishness.