Wednesday, November 25, 2015

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.

Friday, November 20, 2015

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.

Monday, November 16, 2015

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?

Thursday, November 12, 2015

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?

Monday, November 9, 2015

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.

Wednesday, November 4, 2015

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?

Tuesday, November 3, 2015

No Comment

"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.

Sunday, November 1, 2015

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.


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?