Wednesday, December 28, 2016

Venereal Disease Patient Enlightenment (Old School)

Old, hardened, and down right mean nurses were enough to stimulate the worst in terms of nightmares. Bad dreams that could bestir me from my deepest sleep were close at hand when thoughts of these brutal bats in white arose. They were as tough as they come and capable of smoking an unfiltered cigarette  in two deep puffs. It was an amazing experience watching a cigarette burn down 3/4 inch with a single puff. Their perpetually brown, nicotine  stained fingers always looked like they were involved in a messy code brown. At least one can hope that it was nicotine stains.

 Years of witnessing adverse and unfair outcomes in their patients while working for poverty wages was a catalyst for the formation of a bitter, righteous, and judgmental personality profile. If these tough, white starched gestapo nurses suspected a patient's behavior had a causative component to their health predicament; look out because someone is about to be taught a painful lesson by these old "That'll learn ya" nurses.

The hospital where I trained was a designated facility to treat referrals from the public school system for a variety of infectous diseases. Students that suffered from run of the mill  bacterial infections received very good care unless they had the misfortune to be diagnosed with either syphilis or gonorrhea.  These ailments  were termed venereal diseases before the current terminology of sexually transmitted diseases came about. Venereal disease was loaded with stigma and negative connotations which made it a perfect target for corrective actions at the hands of these painful practitioners with punishment on their agenda.

These old nurses had witnessed the gruesome complications of secondary syphilis with tertiary symptoms such as profound dementia from nervous system involvement.  Infected  students needed to be taught a lesson for their own good. The accepted  treatment for these venereal dieases consisted of a series of painful Bicillin injections administered over a two week course and these old nurses used to get involved in heated arguments over who had the pleasure of inflicting this painful punishment treatment. A stroll through the outpatient waiting room often revealed a trembling youngster curled up in a chair while in the background a couple of nurses would be heard claiming their next victim patient.
Bicillin given with care, is a painful experience. The medication is a thick gooey substance with the consistency of toothpaste that burns like fire when forced into a muscle. These old nurses had ways of making the injection even more memorable painful. As students, we passed through the outpatient area frequently. A common sight was a tearful youngster hobbling from one of  the treatment rooms while vigorously rubbing a wounded rump. The elderly, smirking nurse soon followed twirling the spent glimmering  Bicillin  Tubex  injector like a proud drum major with a baton. We always wondered what was going on here.

On our senior rotation some of these punishment minded ancient  nurses let us in on their  pain inducing trade secrets that were truly bone  chilling. In nursing school we learned tehniques to minimize injection pain, but these old bruisers had quite the opposite in mind for their hapless charges.

The sadistic, aged nurses  said one of the best techniques to enhance injection pain was to inject the viscous Bicillin into a tense muscle by having the victim patient bear weight on the hip being injected. Exposure to cold with open windows in winter enhanced shivering which induced even  more muscle tension. Cold was also an effective agent to make the Bicillin even more thick and irritating.  According to these old nurses, a tense shivering buttock was ripe for injecting with thick ice cold Bicillin. These punishment minded nurses also claimed to have Herculean hand strength that enabled them to inject the thick Bicillin with enough speed to actually tear the   gluteus  muscle. "If you can hear above the crying and screaming, you can actually listen to the muscle tearing," one of them related. Ouch, I envisioned the thick Bicillin acting like the business end of a hemostat being opened while buried in the muscle. That must really smart.
Luckily for the infected students, the Bicillin was made available in prefilled cartridges with a fixed, non-interchangeable 18 guage needle or I am certain these old nurses would be looking for a 16 gauge monster needle. Dulling of the needle did increase pain during skin penetration and this was done by deftly inserting it through the tough rubber on a multi-dose vial a couple of times prior to injection. These punishment minded nurses thought of everything. "If you can see the skin around the needle insertion site retract 1/2 an inch in or so before penetration, you have achieved an appropriate level of needle dullness. This should elicit an audible response from the patient," was the nurses explanation of the procedure.
The ubiquitous isopropyl alcohol foil wrapped pledgets so common today were not available for skin prep  40 years ago. These old nurses were fond of cotton balls soaked to the point of dripping for their prep. Wet alcohol that remains on the skin prior to the injection can be tracked deep into the tissue with the  injection which really stings. Most nurses carefully dry the skin before injecting, but not these punishers that dreamed of alcohol soaked and  quivering buttocks awaiting their painful ministrations.
Nurses were taught to carefully rotate injection sites and make a note of this in the medical record. Punishment nurses followed the same principle as WWII pilots that "bombed on the leader." They carefully administered subsequent injections in the exact same tender site as the previous "leader"  nurse. Recipients of this type of treatment often carried lumps the size of golf balls in their hips from the painful repeated injections.

As a youngster, old nurses could really creep me out. I could see where their mean spiritedness came from but doubt that it benefitted anyone. I guess the most kind way to describe their actions would be to say they were misguided. I sometimes wondered if these aging nurses faced consequences for their self -induced lung cancer from heavy smoking. What's good for the goose is good for the gander.

 I'm thinking about a future post explaining overdose  enlightenment protocols that these punishment minded nurses used.

Wednesday, December 21, 2016

Left to their own devices, just about everything deteriorates into a ridiculous hodge-podge of disorder. Entropy truly rules the world. Scrub nurses love order and nothing bothered me more than a cluttered Mayo stand. I am trying to bring some order to this blog by using labels to establish some crude organization to this blog. I really do appreciate indulgers of my foolishness and appreciate your readership.

Happy Holidays, Happy Hanukkah, Merry Christmas, and may your  sponge counts always be correct as your Babcocks shine brightly in the overhead light!

Friday, December 16, 2016

"Twas the Night Before Surgery"

'Twas the night before surgery when all through the OR
Not a Bovie was smoking, not even a bipolar
The drapes were assembled on the back table with care
In  hopes that Dr. Slambow would soon be there

The patient was all narcotized and snug in his bed
While floor nurses insured that nothing was fed
And his roommate in a cast and him on a snooze
They just settled down like a drunk on cheap booze

When out on the expressway arouse such a crash
Bodies thrown from vehicles became  victims of a bash
Away, away, to the hospital they were hustled in a flash
Patients off to St. Profit's to be stripped of their cash

 Half their blood volume lie on the new fallen snow
Not a great thing for hemodynamic flow
When, what to my wondering eyes should appear,
But a  young paramedic with an 18 gauge  spear

With a little old tourniquet so lively and quick
I new in a moment he  would feel a big 'ol stick
More rapid than a sump pump in a flood
They pushed in more of that red stuff called blood

Now volume expanders! now lactated ringers!
Pump that fluid in 'til we see color in his fingers
Raise that bag to the top of the pole
Pump away..Pump away.. til his vitals roll

And then in a twinkling straight up to the OR
The elevator cliked and clanked from floor to floor
Wheel him right up next to the table
Call in the nurses and transfer if able

He was covered in blood from his feet to his face
Better lay out a morgue pack just in case
A sucking chest wound was making such a sound
If we don't tube him really quick he'll be moribund

Tell that elective patient all narcotized in bed
His gall bladder has to wait, we have a trauma instead
The scrub nurse and surgeon are fatigued and half dead
Better wait on that cholecystectomy till the nurse gets a bed

Tuesday, December 13, 2016


Old time surgeons were at the top of the hospital food chain, the captain of the ship, and sometimes misguided blowhards with overstuffed egos. Overconfidence combined with a condescending, paternalistic attitude toward patients  added up to surgisplanations which minimized operative risks and the true extent of surgery, overstated benefits and touted the operators surgical superiority. If anyone questioned these surgisplainers their response was "I just explain procedures in the language a patient can understand."  They were elderly and often wore expensive wool suits that smelled of moth balls.  I think these are the surgeons Dr. Slambow had in mind when he pontificated that, "The only surgery that really benefits the patient is repair of traumatic injury."

A semi-demented old coot of a surgisplaining  gynecologist always explained a D&C with the same practiced, scripted, delivery, "I'm just going to do a little bit of Dusting and Cleaning in there." This was delivered in a demeaning and  condescending tone of voice to rightfully frightened ladies from an obese, imposing man. He was a jerk of the highest order and if he had been accurate in describing his operative method it would have sounded like this: "I'm going to visualize your cervix by inserting a weighted speculum that tips the scales about as much as my overhanging pandus, then stabilize your cervix by piercing it with two converging sharp points of a tenaculum. While I yank put traction on the tenaculum, I will ream out dilate your cervix with stainless steel cylindrical devices called dilators that progress in diameter to the size of my stogie  so I can scrape the inside of your uterus with a curette. I learned the finer points of curettage by mimicking my cat pawing like a sabertooth tiger at his scratching post. You don't have anything to worry about.

A foreign body  be it a stray sponge or rogue instrument found in a patient after surgery meant that the scrub nurse and circulator on the case would be immediately fired and the surgeon had to come up with some surgisplanin regarding the need for re-operation. This situation presented itself when I was working in neuro ICU with a patient that had undergone a spinal fusion.   I was so tempted to make a copy of the X-ray report and anonymously mail it to the patient, but never did. If I had it to do over, I think that I would have made that copy. The neurosurgeon's surgispanation; "the X-ray showed us something that was not visible during surgery (yeah..because you did not see it and the nurse could not count to 10) that we need to go back in and correct. When I was a scrub nurse, nothing made me feel worse than re opening a partially healed surgical wound. Incising healing tissue just goes aginst the grain. Things like that are just not supposed to happen. The patient had the sponge removed and did just fine post-op. She walked out of the hospital none the wiser of the errant sponge that was left behind during the initial surgery.

There was an old geezer of a neurosurgeon well past his prime  that always had a clever surgisplanation for his patients. His description of a crainiotomy went like this, "We are going to make a little trap door in your head so we can fix you up as good as new." That's it. Now it's time to sign the consent.

If there was a prize for the most understated surgisplanation this one would win the grand prize. Here is what the truth of the matter amounts to. We are going to shave your head bald and after anesthesia induction you will be  positioned in a very dangerous upright  sitting position where it is possible for ambient air to enter a major vessel and cause serious disability. Then I'm going to cut through your scalp which will bleed like the dickens and you better hope the scrub nurse can load Raney clips lickety split. When we get to that nasty AVM, I will try to remove it from vascular circulation before it bleeds too badly. Then we will close and finally, I will drill holes in your bone flap to wire it back in position, Most patients that have there brain handled like this have serious personality changes but don't worry you have good health insurance.

Thankfully these surgisplainers are extinct. The last time I had a procedure, the surgeon carefully explained all possible complications. It was really hard for anyone to trust old time surgisplainers whether they were patient or nurse. I know they used to creep me out.

Thursday, December 8, 2016

Nursing Joins the Money World

There were some sure fire ways to get the boot from a 3 year Diploma school of nursing back in the late 1960's; stealing drugs, falsifying nursing notes, serial uniform code violations, failure to sign in and out of the dorm, having your room light on after 10PM and perhaps the most heinous was having currency in your possession. The student handbook was very explicit on that last infraction.

Students are not allowed to have sums of money in their room our on their person while in the nursing dorm or hospital. It is permissible to have less than $1.50 in change in the student's possession for use in the dorm telephone or for the 25 cent deposit for the use of the sewing machines. Violators will be referred to the School of Nursing Directors office. This violation may result in a determination that  the student is unacceptable for the practice of professional nursing.

The school did provide for virtually all of the student's needs including  books, housing, uniforms, meals, and bed linens. For recreation there were pool tables in the basement, a sundeck on the roof, and a large lounge complete with heavily patrolled conjugal visiting booths with the admonishment that there must be 2 sets of feet on the floor at all times. The nursing school bus made biweekly trips to the Cook County School of Nursing for dips in their beautiful swimming pool.

I think the rationale for the money restriction was to reinforce that you were totally dependent on the school for all your needs. We somewhat derisively referred to the school as "Mother," but it did meet everyone's basic needs for 3 years. All you had to do was follow the rules. We started out with 78 prospective nurses and 24 of us survived to graduation.

Another reason for the no money rule was to reinforce that you were here to "dedicate yourself to the service of mankind." This mantra was repeated very frequently to the extent it felt like being brainwashed. This was a charity hospital and even the doctors were very careful about conspicuous displays of wealth. Dr. Slambow, my surgeon idol, proudly motored to the hospital in his $2,000
Volkswagen Beetle. If he were around today, the first thing he would do is put all the young MDs of today driving BMWs in their rightful place.

Nursing is a calling that has nothing to do with remuneration. Rewards came in the form of caps, bands for caps, and of course that highly coveted pin. According to administrators, angels in white don't need pension plans or decent pay.  If our instructors ever got wind of the notion that we were practicing nursing for the money you were history.

I was watching videos on YouTube of nurses openly discussing salaries for different nursing positions. This would have been professional suicide back in the 1960's and 70's. The first thing we were told about interviewing was to NEVER ask about salary as that would have been the end of the interview.

I think that young whippersnapperns of today have so many financial burdens that we never dreamed about  such as school loans and grossly overpriced textbooks that they have to be concerned with finances. School loans have made education unaffordable. Nevertheless, when I hear a nurse discussing salary or asking for money on a blog for services it sends shivers down my spine. I was harshly conditioned against this line of thinking in my impressionable  adolescent days. I completely understand it, but it creeps my subconscious mind  out because from my experience when nurses talk or ask for money, very bad things happen and you soon find yourself on the outside looking in.

Don't fret, I could never monetize this foolish blog. Who would I "partner" with?  Perhaps hearing aid battery companies or maybe even denture adhesive, I think Polident works best. OOPs I didn't mean to say that. It must be getting past my bed time. I will never sully the "OldfoolRN" media brand (I learned that term from some of you youngsters) with those annoying adds or self serving "partnerships." I learned my lessons about nursing for money at a very young age and those values have stuck like a thick coat of tincture of benzoin.

Nursing provided me with anything that I really needed. Nothing fancy, but the basics were certainly met............Thanks so much for tolerating my foolishness!

Tuesday, December 6, 2016

A Stethoscope Sellout

A scan of my battle scarred, trusty Tycos stethoscope.
No, I don't have one of those new-fangled telephones
that takes a  picture to post on the computer..

My initial excitement soon subsided after reading a blog post about stethoscopes. An important nursing symbol and vital tool of the trade was reduced to a laundry list of currently available stethoscopes along with their prices listed in USD. Christmas is not the only thing that can be reduced to nothingness by crass commercialization. There is a heck of a lot more to talk about stethoscopes  than the current products available from Chinese sweat shops. No wonder people in some foreign countries hate us. How would you like to sit and polish stethoscope bells for the measly sum of 45 cents per hour?

 My all time favorite stethoscope was a Tycos combination model and I spent many happy hours auscultating with  my eyes glued to the back of the diaphragm housing  that proudly proclaimed "Made in Asheville NC." Gazing  at the proud proclamation of manufacturing location seemed to make heart sounds more distinct, I bet those North Carolinians are nice folks. They certainly produced a mighty fine stethoscope back in the 1960's.

I used to wear my Tycos draped around my neck with the earpieces on the left and the bell on the right and now my stethoscope  has a permanently induced  curve to it just like Princess  Leia's buns. Here is a tip for you whippersnapperns; occasionally  change the direction of dangle  from left to right as your stethoscope hangs atound your neck to avert that nasty permanent curvature  problem.

The tubing on my old Tycos scope had a nice supple, almost slippery feel to it. One night while feverishly hanging units of packed cells, I discovered a new use for  my stethoscope. Each unit of blood was supplied with little stickers that provided the identification number of the unit. All I had to do was place the ID stickers anywhere on the stethoscoupe tubing and it was temporarily stuck there until I had a break in the action and could apply them to the chart. That stethoscope tubing was the medical equivalent of sticky note adhesive - it was the perfect parking spot for any type of sticker which could be removed later for the chart. A present day application for this nifty feature might be if your drug seeking patient claims an allergy to an NSID, just make out the allergy sticker and plaster it to your stethoscope until the moment of truth arrives.

Yesterday's nurses were experts at using whatever was available to meet a patient's needs. One of my class mates was working as a school nurse when a young student collapsed with a tongue swollen so acutely that it occluded the airway. No problem for this Macgiver style nurse as she quickly cut a length of tubing from her handy dandy stethoscope and deftly inserted  the lifesaving tube intranasally to bypass the occluding tongue and establish an airway. To prevent the distal end of the nasal airway stethoscope tube  from advancing too far into the nose, she fashioned a safety pin stop.
The kid was gas exchanging like a marathon runner. At the hospital, the nasal airway was swapped for a naso tracheal tube and after steroids and Benadryl, the youngster lived happily ever after.

There is so much more to stethoscope stories than a listing of their prices.

Thursday, December 1, 2016

An Obituary Translator

Aging opens new doors and inspires new pursuits. Lately, I have found a new interest in  perusing a collection of old obituaries accumulated over the years. Almost all of my coworkers have gone on to their great reward in that green ceramic tiled O.R. temple in the sky. At least for them, the OR is back where it belongs on the highest floor. I never felt comfortable when working in an OR that was located below that traditional top floor locus. Having been raised in a sky God culture maybe I will enjoy that top floor OR suite again in my afterlife having served my time in OB purgatory.

 While perusing my collection of old obituaries, I noticed that some  obituaries contained half-truths and downright lies in a belated attempt to bolster dubious accomplishments of some people that were hard core blowhards with questionable abilities.  It's not wise to speak ill of the deceased, but some of these phony embellishments are in dire need of correction. Without further ado, (don't you just love it when oldsters talk like that?) I present the actual  text from the obit followed by my foolish, but truthful translations. All identifiers have been redacted. (I hope.)

This orthopaedic surgeon was also affliliated with The County Zoo and performed surgery on gorillas and other large primates.
I did not make this one up, but did change the name of the zoo to further blur the surgeon's identity. This surgeon would operate on virtually any carbon based life-form, dead or alive. I was scrubbed on the thoracic surgery side  of a severely traumatized auto accident victim with the above orthopedic surgeon working as a separate team on a complex femoral fracture. The thoracic surgeon declared the patient dead, but we could not get this one track ortho man to cease work on the fractured femur. He was like one of Pavlov's dogs and the conditioned response to set a fracture in man or beast / dead or alive was his signature.

Unfortunately, the one track orthopaedic thought process sometimes has it's head buried in the sand. With a mind that sometimes has it's head up it's own rear end, mindlessness of  other vital medical issues produces a colo-rectal surgical  mentality  that is definitely not patient centered. Enough said!

Dr. Y was known for his compassionate and caring manner with a kind smile or a heartfelt embrace to share with family and friends.
The closest I ever came to a "heartfelt embrace" from this surgeon was the time I dodged  a hemostat flung at me with great velocity and I collided with his slow to duck resident. Maybe that kindly smile was obscured by his mask or only present when he hit pay dirt with his  hemostat missiles ,but I highly doubt it. It was more of a smirky, smart alecy smile.

When asked, "Who are your patients?" This sports medicine orthopod replied, "Anyone who is an athlete, or was an athlete, or anyone that enjoys reading sports oriented periodicals."
This well to do orthopedic  surgeon was into medical marketing before advertising corrupted healthcare. Unlike specialties like gynecology, which limits it's practice to 50% of the population, this doctor took on all comers. I used to marvel at the irony of his office décor which consisted of pictures of  steroid fueled line backers delivering crushing, bone shattering blows to hapless ball carriers.  Gross illustrations of compound fractures in the making. This might have been good for his business, but very bad for his battered patients. His office décor that  promoted and glorified such trauma inducing behavior made me wonder why oncologists did not have cigarette ads on display in their offices to help bolster their patient load.

He was a person with a vision; we are what we are today because of people like Bob who did an outstanding job of laying our foundation. Blah..Blah..Blah
This is from the obit of a bigshot health system CEO or back in the day what we referred to as hospital director. Nurses like me made about $1000 per month while the hospital director received about $1400 per month. He used to show his paycheck to prove he was one of us. Times have certainly changed, I wonder what the ratio of CEO to nurse's pay is today.

One of my secrets to long term survival as a nurse was to avoid any hospital or nursing administrative big shots like the plague. The OR was an ideal place, as administrators never showed up there. I would have rather scrubbed for an 8 hour surgical marathon than attend a 45 minute administrative meeting of any kind. Office sitters  and meetings seem to go hand in hand. Meetings bring out the core elements of their very nature of sitting and jaw-jacking without having the slightest clue of clinical activities.   Time to stop - I'm getting carried away.

When appropriate, he could be tough as steel. He ran a strict, no nonsense operating room and that was the only place he was heard to swear.
The writer of this gem must have had limited exposure to this loudmouth of a  surgical blowhard. He used nasty language just about everywhere. He was certainly no Dr. Slambow who considered it poor form to utter benign expletives like "balderdash" or "phooey." The most common and understandable stimulus for cussing in the OR is unexpected equipment malfunction at a critical stage of surgery such as a stapler not stapling or an aneurysm clip slipping out of position. The doctor mentioned in this obit cussed at anything and anyone. If a nurse was too slow in handing him the tie for his gown it was time to let her have it with both barrels. This was not a pleasant person.

Dr. X was a nationally recognized expert in coronary artery surgery. Those who knew him were stunned when he died of a cardiac arrest - a heart attack-  on July 2, 1989. He was stricken while exercising on a treadmill at his Lake Forrest home.
This cardiovascular surgeon was obsessed with deceasing heart disease risk factors. He was very thin and often counseled patients with a normal BMI of 20 or so to lose weight. When he wasn't in the OR he was engaged in aerobic exercise. This was perhaps the most ironic obituaries I have read. I guess the message here is that you cannot beat genetics or fate when it comes to death.

When a patient's family approached Dr. Slambow with accolades for his life saving abilities as a trauma surgeon he always had the same reply, "I just patched him up. Tonight was not his time to go and I did not really have much to do with that." Jack Kevorkian's patients are probably the only people who are really sure about when the time of death comes. For Old fools like me it's best to live one day at a time and savor the moment. You never know what's down the road.

Thursday, November 24, 2016

I'm Thankful for Autoclaves

If you are working anywhere near an OR and have access to an autoclave all you need is a turkey for the festivities to begin. Thanksgiving  was one of the best holidays to be on call for because traumas were not so common. It used to be rare to shoot or stab some poor sole while a turkey sat  on the table, but perhaps times have changed. Anyhow my featured post is an oldie but a goodie about autoclaving our thanksgiving meal while on call in the OR. You cannot beat an autoclave for cooking up moist, delicious turkey.

Wednesday, November 23, 2016

The Operative Report

I'm a real sucker for a good read and I'm not talking about the high brow stuff like 19th century British literature; but comic books, Mad magazine, pharmaceutical ad copy, small town newspapers and my all time favorite operative notes which eventually evolved into the operative report.

Today, I suspect these important documents that reveal a blow by blow account of the surgery for the medical record  are done by some type of  electronic computer transcriber that probably deletes the surgeon's editorial or grandiloquent ramblings. Old time operative notes were sometimes handwritten with hand drawn illustrations that rivaled Frank Netter's medical art work. Dr. Slambow always had a red pencil on hand along with blue and black ink pens for his illustrations which proved to me the notion that surgery is  indeed part art and part science.

  Most reports were fairly accurate with technical information such as the type of suture used, sponge counts and anatomical reference.  Some surgeons down played serious problems while others could make a sebaceous cyst excision sound like open heart surgery.

When perusing operative reports that minimized problems, I used to say the surgeon had been struck by hyporeportenosis to amuse my fellow nurses. Once I finished reading a real gem of underreporting that grossly underestimated blood loss and muttered my clever new "hypo" terminology to Nancy, a fellow scrub nurse, and she said, "You better not let Dr. Bruiser hear that." The good doctor appeared on the scene just in time to hear her admonishment to me and about all I could do was act dumb. He began asking about what I didn't want him to hear, so I muttered something about the autoclave cycle taking too long. Whew..another close call. Loose lips really do sink ships or get blabber mouth scrub nurses like me fired.

Blood loss was always a hot button issue for any surgeon and rather than a defined amount  like 100cc, terms like negligible, minimal, or inconsequential were used. Another common explanation for excessive blood loss  was,  "I can't determine the exact blood loss because of all the irrigation we used. That is not blood in those suction containers-it's irrigating fluid, just ask nurse fool."  Anesthesia usually had a pretty good notion of actual blood loss and the surgeons idea of  EBL or estimated blood loss was usually way too low, so the term NBL or negotiated blood loss was the amount recorded in the report after the dust settled from all the anesthetist vs. surgeon arguments. It was about as close to the actual blood loss you could get. Incidentally, a wise scrub nurse always sided with the surgeon in any dispute with those on the other side of the ether screen.

Later in my scrub nurse life, the fun of reading operative reports declined, as dictation became the norm. I really loved those old school operative reports hand written at the scene of the crime in the OR suite immediately following surgery. Some of the old handwritten reports were even "validated" by blood or prep solution splatters because they were always physically present near the actual surgery. Transcribed reports somehow lacked the authenticity or intimacy that those blood spattered reports communicated.

Our surgical  transcriptionists were located in an office just one floor below the OR, and sometimes they would venture up to the OR to clarify a point or try to meet up with the surgeon if they liked the sound of his voice. They would intercept nurses at the double swinging entrance doors to the ORs with their inquiries. Once a harried transcriber approached me with a fist full of reports and asked me if I could help clarify the terminology of the dictator. "You've come to the right place, this OR is a dictatorship and it's loaded with dictators." I replied with a smirk on my face. She did not appreciate my foolish humor, but I used to jokingly ask Dr. Slambow if he was the dictator the transcriptioists were asking about. He tolerated my nonsense well and even grunted a phony laugh because he valued my Mayo stand instrument handling skills.

OR reports always started out boring with pre op and post op diagnosis and a brief patient history. Then they could be very interesting. One surgeon loved the adjective "meticulous." Every time he tied off a bleeder it was "meticulously ligated." When one of his patient's returned to the OR a few hours post op with hemorrhage all the nurses had the same thought. "It looks like one of those meticulously applied ties slipped off or came loose."  As soon as the offending bleeder was located and tied off again, he was back to his old tricks. Sure enough the replaced ligature was meticulously applied just like the original.

Dr. Slambow (uh oh, I almost typed in his real name) liked  to end his operative reports with this statement: "At the conclusion of the case the patient was able to transfer from the table to the gurney under his own power."  I can personally vouch for the veracity of his statement. The process leading up to the patients self-transfer activity necessitated very light anesthesia toward the end of the surgery. This produced some very exciting moments, There are copious (our instructors loved that word) nerve endings  in the skin and the final step of suturing the skin often produced a dangerous situation on that thin OR table. The pain of that suture needle thrusting through highly innervated tissue  induced that flight or fight syndrome and the patient tried to exit stage left, directly into my Mayo stand. Dr. Slambow would say something to the effect. "Fool.. The heck with sterile technique, grab his legs before he kicks someone or flies off the table." All this so the good Dr. could conclude his operative report with his time tested and favorite ending about self transferring.

Surgeons also used operative reports as a mechanism to persuade hospital administrators to purchase the very latest instrument or device they lusted after. There was a left handed surgeon that received reverse ratcheting (left handed) instruments of just about any permutation imaginable. He would describe the odd positons he had to assume with right handed instruments and the next thing we received would be a set of left handed extra long  mixters. Scalpels do not favor handedness and some older nurses used to joke with him about providing him a left handed scalpel. Novices like me knew to avoid joking with these old sourpusses.

These paper reports and their associated carbon paper, staples and occasional validating OR blood or prep stain are gone for good, but they  certainly were good reading back in the day.

Thursday, November 17, 2016

Why Did Operating Rooms Have Green Ceramic Walls?

A modern white washed abomination of an operating room that
has all the ambience of a  waiting room at the bus station. What
happened to the green ceramic tiled temples with terrazzo floors?
Much thought and deliberation was dedicated to the design of old time operating rooms. There was sound reasoning behind the selection of green ceramic tile walls and dark terrazzo floors.  These were not meant to be places where health care personnel fiddle around with computers, jaw - jack and mouth flap to one another, or gaze at flat screened monitors in a washed out colorless environment. This was  where the surgeons practiced their profession in a serious and sometimes somber environment. Where the rubber met the road. No monkey business was tolerated in this sacred green tiled environment.

These green ceramic  tiled temples were indeed sacred places where the patient was always at  the center  of a planned anatomical alteration to expeditiously eliminate pathology or repair traumatic injury. The room communicated this objective by the single-mindedness of it's stern ambience. Green was also thought to promote relaxation in patients prior to induction.  No one would mistake an operating room for a waiting room at the Greyhound station.

The color scheme was developed in response to the most important color present in the OR which is obviously the redness of blood and tissue. Green is the complimentary color to red and this was selected as the optimal background color  for surgery.

A surgeon who looks up from the dark red wound and glances at the bright,  illuminated  white-washed wall will find himself momentarily blinded by constricted pupils and it will take precious seconds for his eye to adjust back to the less well illuminated wound. This problem is averted with the eyeball friendly green walls. I suspect the architects of these white wannabe ORs have never lifted a scalpel or tied off  a bleeder. The lack of input from workers in the trenches has been a problem in hospitals since the times of Florence Nightengale.

Surgeons were always apex predators in the hospital food chain. If they wanted to keep their patient in the hospital for a week or two post-op; no problem. If they wanted to hand pick a favorite scrub nurse so be it, (This is how I became Dr. Slambow and Dr. Oddo's scrub nurse.) I kept my foolish mouth shut, my eyes open and tried to deliver the correct instrument at the appropriate time. If the surgeon preferred a green tiled operating room, that's what they got. Office sitting hospital administrators and architects rolled over surgical tradition like a well oiled power mower when white became their  color of choice for ORs. It's just plain wrong.

Mans' creations are sometimes at odds with nature and in the long run, nature always has the final say. Dr. Slambow always backed up his arguments by citing principles of Darwinian Evolution. According to him, man evolved in an environment of fields and green bushes that were the same shade as green ceramic tiles in the OR walls. And up above the illumination from the sky mimicked the overhead OR lights. The dark earth floor was replicated with beautiful terrazzo floors. Over millennia, natural selection adapted man to work under these optical conditions. It's simple common sense to reproduce these time proven optical conditions for the exacting work of surgery.

Another serious deficit  of these new fangled ORs is the absence of windows to establish a connection to the natural world. Surgeons of yesteryear would often stroll over to gaze out the window for the  view of  distant Lake Michigan to give their weary eyes a break  from close-up work and return to their surgery with a newly refreshed vigor.

Maybe an Eskimo operating in an igloo at the North Pole has the correct genetic make up to perform surgery in one of the modern white washed room, but I don't think white ORs would be optimal for most of the human gene pool.

There might be hope for a return to the time tested green tiled Operating Rooms. I remember when electronic components like VCRs (yes, I still use one) were produced in a silver coloration for a couple of years and then switched to black. This color change cycled back and forth (black- silver, black-silver)  over the years. Maybe we are into a white OR cycle and someone will wisely return to green.

Saturday, November 12, 2016

A Shocking Enema Known as the Harris Flush

Before the advent of TPN and tube feedings there were enemas for nourishment, Avertin or pentothal enemas produced anesthesia (Abbot actually produced a prefilled pentothal rectal syringe and it was not prudent to confuse it with a Fleets,) stimulant enemas of various caffeinated beverages  were also used. Would you like cream and sugar in your coffee enema? Neomycin antibiotic enemas were commonly used before prostate biopsies or intestinal surgery, and Kayexelate enemas were a very messy way of reducing blood potassium levels. Anthelmintic enemas were used against pinworms and sometimes included a secret ingredient (dilute turpentine.)

I'm certain I have forgotten some types of these backward treatments, but there was an enema for just about any ailment. Old time nurses often had special enema recipes that they guarded with as much vigilance as a restaurant would with a specialty entrée recipe. When the time tested enema can was replaced by the clear, disposable plastic bag enema in the early 1970's, old nurses were mesmerized by the visible rise and fall of the solution with the patient's respirations. You could not see this phenomenon with the opaque metal can and old nurses thought that watching the enema solution oscillate in the bag with inhalation and exhalation  was more fascinating than open heart surgery.

Carminative or anti-gas enemas were in a class by themselves and this is the procedure for  a "Harris Flush Enema"  as described in a 1930's  AJN article. We did a similar procedure sans the electric light bulb as a heat source and called it a "tidal wave enema." The enema bag was alternately raised and lowered so the solution flowed in and out of the colon. The degree of browness in the enema bag served as a visual indicator of the in and out flow of the solution.  Bubbling in the enema tube or bag was also a good sign that gas was being expelled. Some patients experienced "blowouts" where by the gas was blasted past the inserted rectal tube with frequent unpleasant (for the nurse) results.

The thought behind the heating of the solution was that if maintained at body temperature or above, the enema set up could remain in place for an extended period of time allowing the patient to expel gas. Old time abdominal surgeries disrupted peristalsis and pain from retained gas could be severe. Here is the procedure as outlined by the old AJN, I have inserted a few editorial comments in italics.

                                                          THE HARRIS DRIP
Purpose: To carry off gas and waste

3 feet rubber tubiing
Irrigating can
Rectal tube with Vaseline ( I guess lubafax was yet to be invented. We received demerits if Vaseline got anywhere near rubber tubing because it caused deterioration and could bankrupt the hospital and don't even think about using a pair of  those budget busting gloves!)
Emesis Basin
Extension cord and light (This is where it gets interesting)
1 inch strips to tie the electric light
2 Large safety pins
Fire extinguisher (I added that one. Better to be safe than sorry)

Procedure: Connect the tubing and the rectal tube with the can and clamp off.
Put onto the can sodium bicarbonate 6 drams; water to make 40oz

Place the can on the bedside table. Allow air and solution to run out of the tubing into the emesis basin. Lubricate the end of the rectal tube and introduce it into the rectum.
Remove the clamp.
Raise the can and allow the solution to flow into the rectum. Lower the can about 1 foot and allow the fluid to run back into the can. Gas will also return. Repeat several times.
See that the tubing does not dip down off the bed; it may be held in place by pinning it to the muslin draw sheet.
Place the electric-light bulb in the solution so the metal part does not become wet. (sounds like a good tip, might want to have consult for the burn unit and an anal plastic surgeon as well.)
Place the plug in the wall outlet and turn on current.
Cover the can and electric light bulb with a towel.

Points to remember:
Change the solution as often as it becomes soiled.
Keep at an even temperature.

I think a better name for this procedure would be lightening in an enema can. One false move with that light bulb and it's a tossup; which is a greater risk electrocution or a rectal infusion containing broken glass?

Wednesday, November 9, 2016

Election Day 1972

Richard Nixon appeared on the political landscape in a very stormy time. There was the Vietnam war, looming inflation, and as always, unemployment. There were many divisive issues lurking about and people were really involved in the various arguments that were flying about. Reminds me of our current situation.

I remember walking to work on election day in the dark, long before polling places opened. In Chicago, voting always had a kind of underhanded, cynical theme attached to it. One of the favorite half true and half funny jokes was "Don't forget to vote early and often."

I remember thinking how great it would be to relieved of all this political mayhem when I finally arrived at my destination, the tiled temples of the operating rooms which were safely isolated all the way up on the very top 7th floor of the hospital far removed from toxic political themes below. Everything that I ever needed was here and the nonsense and noise of the world seemed pleasantly removed from my consciousness. Peace at last.

My co-workers were like family. Yes, we were at times, a dysfunctional lot when it came to interpersonal relationships, but we would all do just about anything for a patient or a colleague. Everything from donating blood for a trauma or playfully pinching one another with a sponge ring forceps if they made the mistake of bending over to reach something under the table while too close to the kick basin. From personal experience, I can say that really does hurt depending upon the mood of the person handling the forceps. The only way to avoid the unpleasantness of the sponge ring forceps encounter was to lean under the table by bending laterally rather from the waist at a right angle. It might have looked unusual, but it was very purposeful.

This was back in the day before seasonal affective disorder caused by increased darkness was recognized, but I really did love those bright, OR lights. They did generate lots of heat which contributed to their comfort inducing quality on cold winter election days. I often thought that standing under those bright  lights  helping patients with people that cared about me was as good as a beach vacation, maybe even better.

Election day moved by very quickly and toward the end of the shift, Dr. Slambow asked for volunteers to help him with an after hours case. I jumped at the opportunity, not giving it a second thought. When the case closed at about 7PM, Dr. Slambow asked if any of us had voted and we all had the same answer, "No, we forgot all about it."

Dr. Slambow announced he neglected to vote too. We all were wise enough to keep our mouths shut. If Dr. Salmbow was ever questioned about civic duty, he launched into a lengthy, bitter diatribe regarding his experiences as a trauma surgeon during the Battle of the Bulge during WWII. The stories were not pretty.

After the fallout from the present day political shenanigans, I often long for a warm, very brightly lit, green ceramic tiled ceramic oasis where there is no name calling or wall building. It sure was peaceful. I'm pleased my long term memory is intact to relive those days, now if I could only recall what I had for supper!

Sunday, November 6, 2016

Silk Urethral Catheters- The Gateway to Nurses Performing Procedures

Urologists can pull some truly terrifying instruments from their bag of tricks; sounds, bougie-a-boules, dilators, resectoscopes, and filiforms come to mind.  Some items are best lost in history, such as  urology tools that were rigid, unyielding, and only for use by the very experienced physician. I recollect a truly terrifying instrument, the Kollman dilator that deserves a separate post.

It took years of experience to successfully and safely pass old time metal urethral catheters without damaging the prostrate or wreaking havoc with tender urethral mucosa. I have  vivid memories of a story an aging urologist told me about the time he inadvertently transected a hypertrophied prostate while attempting to relieve a distended bladder by using a metal urethral catheter. The notion of a metal catheter plowing through very sensitive  tissue with an awake patient arouses primal fear in everyone. I suspect that really does smart!

Ram-rodding rigid metal catheters into a highly innervated
orifice lined with delicate mucosa is not my idea of a fun time.
It's time to page the doctor to pass these steely stiletto-like
catheters, unless, you have one of those newfangled nurse
friendly, slippery and  flexible silk catheters.

Old time urethral catheters also were made of glass. whenever glass objects are inserted in a body cavity, the potential for breakage is always present. I have heard anecdotal accounts from older nurses relating that glass catheter breakage was the impetus for the development of silk catheters.

One glass catheter story involves a difficult labour that necessitated a Cesarean Section. While having a glass urethral catheter inserted, the patient had a very robust uterine  contraction breaking the glass catheter off in the bladder. After the baby was delivered the physician was faced with the difficult task of removing the glass catheter without causing injury.

The very first silk catheters were constructed by using a glass catheter as a sort of template. The silk was woven around a glass catheter and a varnish like substance applied to maintain the shape of the catheter. I'm not sure when the first silk catheter was constructed, but by the mid 1930's, silk urethral catheters were in widespread use. Natural silk has an off-white color and silk urethral catheters were often dyed by applying Methylene blue prior to the varnishing stage. The end result was a flexible, pretty blue urethral catheter.

If you are interested in perusing an unusual Methylene blue story, just type "A Blue Finger Bigot" into the search box on this blog. Someday I will get around to figuring out links! It's hard for an oldfoolrn to learn new tricks and so easy to stray from the task at hand....My apologies. Now it's time to return to the tale about silk catheters.

Our instructors in nursing school loved to show off the school's collection of silk urethral catheters. They differed from modern flexible Silastic or rubber catheters in that the wall of the silk catheter was very thin. An 18 FR. silk catheter probably had the same sized lumen as a modern 20 or 22FR catheter. While modern catheters are inelegantly  packaged by sandwiching them between a piece of paper  and a plastic-like covering, the old time silk catheters were individually packaged in an elaborate  long thin felt lined blue box that exuded class. They certainly don't worry about fancy packaging today.

I  have never used a silk catheter, but every older nurse sang their praises. The silk catheters had just the right amount of rigidity for insertion, but were very soft and forgiving to urethral mucosa. They were much less traumatic than a rigid metal catheters and nurses began to routinely perform catheterizations.

I guess everyone has to start somewhere and these silk catheters opened the door to other nursing procedures such as starting IVs. Oldfoolrns just called the procedure an IV start, but I see you whippersanapperns have coined the fancy terminology of "initiating a peripheral intravenous cannulation." That sounds much more sophisticated and I wish I had thought that one up. My old school terminology sounds pretty dumb. It's a good thing we were not as dumb as we sounded.

The next time you are starting an IV (OOPS.. I mean initiating an intravenous cannulation.) or setting up an arterial line take a moment to reflect on that old time nurse that started the nurses on the path to performing procedures with the silk urethral catheter.

Anonymous commenters, I would love to hear from you. I did not realize that there were restrictions. I hope that I have fixed it so anyone can comment on my foolishness.

Wednesday, November 2, 2016

Night Nurse

As a youngster I believed that I could do just about anything I put my mind to. Receiving that call at 3 AM advising me  there was a "good" (Dr. Slambaugh's vernacular) trauma waiting for  me in the OR was no problem. It was a struggle to bring my  consciousness to a full boil and the rhythmic, repetitive  nature of scrubbing did not help in waking me up, but once surgery was in progress, the noise of the world went away and I was in one of my all-time favorite places. It did not seem to matter that it was the middle of the night and I was expected to be functional the next day.

Some time after I retired, the damage of fooling around with my sleep cycle became obvious. After months of sleeping at night and being awake all day, I began feeling really good. The deleterious action of night work  was revealed to me as that headachey, run down feeling left for good.

The bottom line here is I am really surprised, puzzled, and humbled by the number of people reading this foolish blog of mine at 3AM in the morning. I don't check page views that often and if one person takes the trouble of reading my foolhardy tales per day that is sufficient for me. Last night about 80 people indulged in my foolishness between 3 and 4AM. I thought time zone changes might offer an explanation, but these viewers were in this country.

I sometimes worry about you. Am I contributing to messing with your Circadian rhythm? Am I disrupting your important work? Are you going to get caught up on your sleep come the next day?

You night viewers must be a very special group: not that many nurse office sitters, utilization reversers reviewers, or nurse  infomaniac  informatics are awake at this hour. If you are working in a clinical area I have experienced some of your nocturnal pains. I don't think I would have had the stomach for foolishness at 3AM even as a much younger fool. In my mind you are a very special group of people.

If you are reading my foolhardy ramblings in the middle of the night please leave a comment that you are OK and I'm not contributing to that nighttime malaise we all know too well. Thanks for reading my foolishness.

Saturday, October 29, 2016

IV Taping - Sticky to Sticky

Recently a bright, young whippersnappern skillfully started an IV in my old, wrinkled up hand  during a hospital procedure. An impressive array of task specific material was used to secure the IV. The first order of business for this bright young nurse was to slap a piece of tape across the hub of the catheter and then plaster apply a transparent covering and then finally cover the whole business  with a fancy flat donut shaped gizmo.   This might work for an old geezer like myself that is just going to lie in bed, fat, dumb, and happy, but there is a much more secure method for more active patients like that epileptic seizing or the poor sole detoxing.

 This taping trick was demonstrated to me when I was a much younger fool by an old wise nurse that was very experienced with wild and wooly patients. It is one of the more useful procedures I utilized and a lot more fun than administering  Kayexelate enemas or attempting to force a Gelfoam slurry down an NG tube during a bad GI bleed.

Archimedes said give me a lever and a place to stand and I will move the world. Here is another very powerful force; adhesive dressing tape when stuck  together sticky side to sticky side forms a formidable bond. Any object (IV catheter, NG tube, Foley or whatever) that is between the two sticky surfaces is going to stay there. Please pardon my foolish illustration, but my lack of writing skills probably could not describe the taping procedure. This is really an effective way to tack down an IV catheter so please bear with me.

A. Tear two 1/2 inch strips of tape about 5 inches long from a standard 1 inch roll of tape. I am impressed with the vast array of tapes available today; dermaclear, micro pore, mega pore, or whatever. The only tape I had available was that J+J dressing tape that took the strength of a gorilla to tear apart. Some nurses used scissors to cut it, but I just loved the sound of that tape ripping and patients were impressed that I could tear it with my bare hands.

B. The illustration shows the 2 strips of tape and I have colored one black to indicate which is the sticky side. Take the sticky side up tape strip and center it under the hub of the catheter so there is about 2 inches or a little more on each side. Fold these two pieces of tape down at a right angle to the catheter leaving a margin of sticky side up tape about 1/4 inch on each side of the catheter. If the patient is really rambunctious or you are working with a larger lumen tube like a Foley, make the sticky zone bigger. This sticky on sticky zone is where the rubber meets the road. It doesn't really require very large area when properly aligned.

C. Now we are about to unleash the incredible strength of sticky on sticky by placing the second strip of tape directly over the hub of the catheter engaging the sticky side up portion of the first piece of tape. If done correctly, the sticky on sticky parts of the tape are fully engaged around the catheter firmly anchoring it in place. If you want to avoid problems at tubing change times, keep the IV tubing free of the sticky on sticky zone. Now you can apply your transparent occlusive dressing and the insertion site is readily available for inspection for problems.

The nurse that started my IV did not loop the tubing because it was a short term procedure and I was not very boisterous (an understatement if I've ever heard one.)  If you combine the sticky on sticky catheter securing method with a sticky on sticky secured looped tubing you have a formidably tacked down IV that should pass the "jerk" test which was named after me the originator of the test (Oldfoolrn.) Go ahead and give that IV tubing a hearty yank. It's not going anywhere.

Tuesday, October 25, 2016

Lifesaving Lunacy

Maybe all the healthcare advertising about lifesaving hospitals or nurse "writers" tall tales about nurses saving lives wore me down, but I think the final straw was Mylan Pharmaceuticals marketing their "lifesaving" Epipen. Less than 100 people per year die from anaphylaxis and there is no guarantee an Epipen could have "saved" their life. Even an auto injector syringe required symptom recognition and application of this  grossly overpriced device.

In the meantime, I need a palate cleanser from all this "lifesaving" nonsense. Nancy one of the finest OR nurses I ever worked with frequently answered inquires about her wellness with s snappy response. When someone casually asked her how she was doing, her reply was, "I'm busy saving lives."  One day I asked her, "Do you really believe that?"  She laughed and said "Of course not, but it sounds good." Being facetious is a far less transgression than actually believing you are a saver of lives.

I think some of the  present day lifesavers truly believe their own nonsense and it's time to set them straight. Dr. Slambow, my favorite trauma surgeon, had strong feelings about doctors and nurses as lifesavers. His belief was that we could repair injured anatomy and control bleeding, but the actual recovery is out of our hands. Enabling recovery is a far cry from saving a life. Don't ever let Dr. Slambow  hear a doctor or nurse claim to be a lifesaver. They would be in for a severe tongue lashing.

 Doctors and nurses who  inflate their ego with lifesaving notions put an undue burden on themselves by fostering the delusion of their lifesaving capabilities. It's a tough reputation to live up to. When a patient dies on the table it's not right to think you are a killer and when someone survives it's just as wrong to think you saved a life. It's simply too much of a burden to bear.

I was socialized into a healthcare system that never used braggadocio or swagger to self promote, heck advertising was forbidden and nurses often had a lowly self image. I can't tell you the times I've uttered, "I'm just a nurse." Our self promotion was by our action which often meant crawling out of your warm bed on a cold Chicago winter night for a 3 AM trauma case.

Rather than ego inflating tales of lifesaving nurses, perhaps it's more constructive to take a contemplative moment and realize you did your very best and the patient had a great outcome. Nothing can compare to the experience of seeing a traumatized patient arrive on a litter and walk out of the hospital.


Wednesday, October 19, 2016

Coal Shoveling Nurses

As a young foolish nurse, I was admonished by much older peers on many occasions and in retrospect, deserved it. After a lengthy tongue lashing, the senior nurse would often conclude her bitter diatribe  with the qualification, "I was shoveling coal at this hospital before you were even born." Coal shoveling was a badge of honor for these older nurses and they frequently pulled the "shoveling coal card," especially if a smart alecky young upstart nurse suggested or thought a new way of doing things was superior to the old fashioned ways.

Until the advent of scrub suits as  the  uniform attire for student nurses, coal shoveling nurse heritage dictated a proper nursing student's uniform. All the diploma school uniforms were very similar. A blue or grey colored dress covered with a pristine white apron. Of course the white apron was neatly folded and carefully stored while the nurse worked her magic with the coal shovel.

One of the develpments that really rattled older coal shoveling era  nurses to the core was the introduction of disposable equipment in the late 1960's. Glass, stainlees steel,  latex rubber, and heavy muslin cloth were the benchmark in determining the quality of hospital supplies according to these seasoned old nurses. Anything that was  made of plastic or felt lightweight was immediately suspect and deemed inferior.

One of the pioneering disposables was a clear plastic enema  bucket and tubing to replace the standard heavy duty duty steel  cans with latex tubing and hard black rubber nozzles. At least early attempts at disposable enema equipment mimicked the old one by maintaining the bucket. If the switch had been from metal cans to the bags of today, old school nurses would have been totally lost. Older nurses called the disposable enema equipment "toys" and eschewed using such unimpressive, light weight equipment.

Coal shovelers  had many bags of tricks and one of their favorites was hiding old school nursing supplies and equipment that much younger nurses had determined to be obsolete. (Just in case.)  Old nurses always had a contingency plan.

 Our intermittent Gomco suctions were often mounted on a difficult to access cabinet because the big bottle patially blocked the door. These hard to reach cabinets were often packed with old school enema cans, latex tubing, clamps, and nozzles. It made sense  because Gomcos and enemas were both used on GI cases. "I shoveled coal in this hospital so I can use any enema can I please!"  Old time nurses certainly had a sense of entitlement, though it was  well earned.

Older nurses absolutely hated disposable needles and syringes. They had invested labor intensive  resources in learning to properly assemble a glass syringe with matching the correct barrel to the correct syringe. Sharpening needles was an art form and the special needle sharpener tool and it's proper use a source of great pride. If young nurses made pejorative remarks about the foolishness of needle sharpening they were certain to get the coal shoveling lecture delivered in spades by a chorus of oldster nurses. Until the mid 1970's there was often a rotary needle sharpening tool hidden away in a special unused cabinet or ward locker. I have even witnesses old time nurses sharpening disposable needles just to keep in practice. Old habits die hard.

Old nurses were also on constant lookout for ways to reuse disposable equipment. I vividly recall one elderly nursing supervisor suggesting that used "disposable" endotracheal tubes could be repurposed for retention enemas or barium enemas. " The cuff was the perfect lumen to suitably block exit from the colon. "I bet these endo tubes are radio-opaque so the radiologist could verify proper position in the sigmoid colon. I'm bringing this up at our next procedure committee meeting, "  said one old heavily wrinkled supervisor.  Whenever one of these elderly repurposers came across the ONE TIME USE  warning on disposables it just added fuel to the fire and the conclusion was that one time use as an endotracheal tube and one time use as an enema tube was perfectly acceptable. Twice the bang for the buck.

The next occasion one of you whippersnapperns don a complete surgical glove to insert a Foley, take a moment to remember  that you are standing on the shoulders of oldfoolrns like me  that could slide that Foley in place using only 2 (two) sterile fingercots. I never shoveled coal, but I do have a lengthy repertoire of  ancient nursing skill sets.
Tuck those uncovered fingers into a fist and
now grab that Foley between your index finger
and thumb. The hard part was "rolling" into that
first finger cot without touching it.

Saturday, October 15, 2016

White Coat Ceremonies for Nurses

I was shocked when I learned a local nursing school was holding a white coat ceremony to honor their students  entry to actual clinical practice. Excuse me, but nurse's have a historical and rich tradition and it has nothing to do with those microorganism infested white coats that those high and mighty  doctors wear.  Did you ever hear the term "white coat hypertension?"  It's called that for a reason. White coats do not communicate the comfort and  caring image that nurses bring to the bedside, especially for cranky oldsters like myself. Let the MDs keep their filthy  white coats. Nurse's have something a whole lot better that has real traditional and symbolic  meaning.

It's called capping and any diploma school graduate can attest to the emotional and spiritual elements of a candlelit capping ceremony. Yes, I know that nurses no longer wear caps, but that is no excuse for abandoning one of the time honored and sacred of  nursing traditions. Delivery personnel no longer utilize horses, but truck drivers continue the tradition of belonging to the Teamsters Union. Priests conduct Mass in electrified buildings, but continue to use candles.

Just because nurses no longer wear caps, it's not OK to abandon decades of tradition. You do not throw the baby out with the bath water and then like a parasite attach one self to a physicians white coat. It's just plain wrong and a slap in the face to oldfoolish RN's like myself. Capping is the name of the ceremony that marks a nurses advancement to actual bedside practice. It's been like that for many decades. Why monkey with a good thing?
Let's see you whippersnapperSNs come up
with a White Coat Ceremoy card that has
the charm of this 1950's gem that cost the
princely sum of 15 cents!
Recent  history shows that nursing , especially you academic types, likes to "borrow" ideas from other professions and incorporate them into a nursing context. What the devil is "nursing research?"
Nurses should be doing clinical based research like physicians, pharmacists, and other health professionals are doing. We  don't hear of "doctor research" or "pharmacist research." It's called clinical research and it's done for patients. Borrowing ideas and traditions from others, especially those that poorly reflect traditional nursing values  leads us down that rabbit hole of lost identity.

Soon we become utilization review nurses or computer   nurses whose only preoccupation is generating business or saving insurance companies money. What distance have  we put between the nurse and bedside? I don't think this is progress.

I apologize for my uncouth ranting, my arthritis is driving me nuts today. I have a few higher minded posts in mind for the future so please be patient. Thanks for reading my foolishness.

Tuesday, October 11, 2016

Morphology Malarkey

Recently while visiting one of the teaching  hospitals here in Pittsburgh, I overheard a bright young physician claiming, "The MORPHOLOGY  of this EKG tracing is similar to the one before all the trouble started." It's a good thing Dr. Oddo, an international, Chicago neurosurgeon I used to scrub with did not overhear that young doctor muttering about morphology. I made the mistake of using that M-word term in the midst of a  surgery with Dr. Oddo and received a tongue lashing that made a life long impression. That young resident stirred up a distant memory from my ancient nervous system.

A little background. Before Dr. Oddo received his MD, he had acquired a PHD in one of the branches of a biologic science. I think it was zoology, but don't quote me on that. He was snobby, overly particular and a classic anal retentive personality. For some reason, I simply loved working with him and we were actually on friendly terms outside his OR.

When he launched into one of his blowhard lectures about trivial concerns, I always tried to act overly attentive. He could lecture for hours describing the difference between braided and single strand stainless neurosurgical wire. He would then quiz the residents about every minutia regarding the wire. On one occasion,  he tried to trick me up about which form of wire was easiest to handle and I was ready for him. "I prefer the way the overhead lights reflect off the braided wire. It's much easier to see. In order to handle something you have to see it first."  Dr. Oddo emitted one of his Haruumphs when he really didn't know what to say. His bizarre questions were usually met with stone silence. I usually had a stockpile of generic "answers" waiting for him in the back of my mind.

Neurosurgeons like to use tiny little sponges that we used to call "pattys." One day I was preoccupied with counting a new batch of patty sponges with the circulator when Dr. Oddo called out for a dura hook which is the instrument shown in the illustration on the right. I had my eye on the sponge count in progress and out of my less acute peripheral vision, mistakenly handed Dr. Oddo a nerve root retractor. (The instrument on the left.)
Dr. Oddo was not happy with my wrongful instrument passage. "That's a nerve root retractor, Fool, I asked for a dura hook. I think you need a new pair of eyeglasses or a new brain." I was attempting to come up with a good excuse and replied, "Dr. Oddo the morphology of the instruments is very similar."

That response generated WWIII from Dr. Oddo. "In your case, MORPHOLOGY is a word uttered by a dumb person trying to sound smart. Morphology is a term restricted to biologic reference. It has nothing to do with surgical instruments."  I apologized for my ignorant oversight and it was back to business as usual. One thing that I really liked about Dr. Oddo was that after he let off steam with his harsh and sometimes nasty comments you were once again his favorite scrub nurse.

It sure is a good thing that Dr. Oddo was not present to hear the bright, young physician  at that contemporary Pittsburgh hospital refer to EKG morphology. I smiled to myself and knew that 40 years ago the fur would have been flying had Dr. Oddo caught wind of it.

Sunday, October 9, 2016

A Lady of Pleasure, An Anaerobic Culture, and A New Life

Babies can be very expensive. Our obstetrical set fee schedule and the way it was implemented made prenatal, delivery, and post natal care affordable to virtually anyone. Theoretically, the patient paid a fixed  amount of money ranging from 50 dollars to 500 dollars for all the OB services necessary to deliver and care for the baby.  In practice many of the patients paid nothing. A charity hospital really did offer care when needed to just about anyone showing up. What a refreshing situation and such a contrast to health care today. Uh, oh don't get me started on that one!

The clinic was staffed primarily by OB residents and nursing students. A diverse group of medically underseved women attended the clinic. I often questioned why women of limited means were always referred to as "medically underserved." There were many plenty of doctors and nurses in the vicinity so this was really a contrived term. I guess medically underserved sounds better than needy or impoverished.

As student nurses we were responsible for weights, checking vitals and then getting patients settled in one of the exam rooms for a resident to assess. A petite, quiet, very young woman with shockingly blue eyes named Lisa caught my attention as she looked unusually apprehensive. Her stylish dress was a marked contrast to the other prospective mothers in the waiting area. I chatted with her while checking her vitals and without hesitation she revealed that she was a prostitute and this was her third pregnancy. The previous 2 pregnancies had been terminated in the first trimester with the assistance of "her boss" assumed by me to be her pimp.

"I really want this baby" she said with dogged determination. "The father is  a very smart lawyer. I was very busy at that last big  convention a couple of months ago so it must have been fathered by one of those lawyers." Tenaciously she proudly stated, " My girlfriend and I will raise this child and I want this baby to become someone." This lady seemed committed to raising the child. "I never had much of a chance and I want more for my baby."

I helped her up onto the exam table and positioned her stirrups. Dr. Rebondo came in and did one of his comprehensive check ups. At the conclusion of the exam we always obtained an anaerobic culture from the cervix  to check for gonorrhea. The doctor handed off the culture applicators to me and I immediately plunged them into an anaerobic culture bottle to maintain an oxygen free environment. Lisa was watching me with a puzzled look on her face as I fiddled with the culture bottles.

We used to call them trans-grow culture bottles because the bacteria would replicate in the  media while in transit to the lab. These bottles were clear glass and the growth media was a nasty looking brown/green color. To maintain anaerobic conditions the wooden applicators were snapped off at the bottle neck after being submerged in the culture media and the caps tightly closed. The crunch and crack of breaking the wooden applicator always seemed to startle some patients so I usually explained what I was doing.

As I helped Lisa back up from the gyne table she happened to glance off to the side where I was standing. With shock in her voice she asked me, "Did that come out of me?" I quickly deduced she was referring to the  anaerobic culture bottles with their nasty looking brownish culture media. I realize prostitutes have negative self-image problems, but I could not imagine what frame of mind caused her to think the bottles were from her body. She was genuinely worried.

I explained that she was looking at the culture medium and this was not a bodily substance that came from her. Her relief was immense and she thanked me repeatedly for the explanation. She asked how much longer I would be in school and told me she would ask to see me after the baby was born.

One day before senior banding ceremonies there was a note in my mailbox that Lisa was on the post partum  floor and asked to see me. I  eagerly hustled over to the unit only to fimd Lisa cradling a beautiful baby girl. She was glowing with pride and said she was working on a name. Time went by and Lisa faded from my memory.

Many years later I was orienting a new group of student nurses to the OR. I happened to comment that our 2 cysto rooms at the end of the hall had previously served as delivery rooms. Our OB suite with integrated delivery rooms was fairly new.

 A petite, young student nurse that looked very familiar with those crystalline blue eyes remarked, "I was born at this hospital. Is this where I was born?" I affirmed her birth place and just to make conversation asked when  her birthday was. "It was June 3rd."  Something about the date and her familiar appearance immediately clicked, but I still  could not place her.  Memorable moments from nursing school are seared into my consciousness and June 4th was the date of Senior banding which occurred one day after Lisa gave birth. It took me some time to put all this together, but eventually,  I learned something interesting. The young student nurse was Lisa's daughter named Colleen. I hoped that Colleen's birth  had renewed Lisa's life and brought forth a new beginning. She certainly did a fine job of raising her daughter under challenging circumstances.

Wednesday, October 5, 2016

What is a "TRUE" Medical Emergency?

Whatever happened to the time when physician's office phones were answered by a friendly, caring person instead of  today's  ominous recorded voice intoning: "If this is a TRUE medical emergency hang up and dial 911? " I suppose this is a lame-brained attempt to limit liability, but it does raise some interesting questions.

There is so much emotional leakage from the medical office worker making these recordings. Everytime I listen to my gastroenterologist's phone menu, a new negative emotion becomes apparent. I get the stressed, pressured, burned out  feeling backed up with a generalized malaise and lack of concern. I don't think this is what the good doctors want to communicate to their patients, but back to the TRUE medical emergency questions.

What if a no good, lying, sociopathic pharmaceutical company executive crashed their corporate jet and was sprawled out on the tarmac like a pile of road kill?  Is this a "TRUE" emergency even though the victims were not truthful and  filled with falsehoods? I don't know. I guess it's time to call the doctors office again and run through that gauntlet of phone prompts to make a determination. If we do manage to get through to the good doctor, how can we respect his assessment skills or diagnostic acumen if he is too lazy to even find someone to answer the phone?

Although obscured by the abrupt interruption of life, trauma always presents opportunity for redemption and renewal of life even if it is radically different from the pre trauma persona. Hopefully, a taste of suffering will enable the pharma big shot to imagine the suffering of others and the evils of cashing in on the pain and vulnerabilities of others that happen to be less fortunate. (So sorry for my crude editorializing, sometimes I get carried away. Blame it on the aging process.)

What happens if a false medical emergency transitions to a true medical emergency while the listener is occupied with the multiple phone prompt choices?  I tried to answer this for myself by dialing 911 when I was about 6 phone prompts into the menu and all I got was that annoying high pitched screech of electronic mayhem. It was then that I realized that in my shock and illness induced fogginess that I neglected to hang up as the uncaring smart alecky voice instructed. OOPS... my bad.

In the good old days we had a better way of classifying emergency cases. The really TRUE emergencies were called "Ambulance Cases" and even had a dedicated entrance to the hospital that was actually a big garage door with a big sign above that cleverly announced: AMBULANCE CASES.  Yesterday's paramedics were ambulance drivers. There were no trauma bays or fancy electronic gizmos standing by, just a group of doctors and nurses that would do anything to save  a patient's life.

Does that ambulance case need blood? If his type matches mine, we will get a direct transfusion going STAT. Here is my arm and that antecubital vein is ripe for harvesting so stab away with that 16 gauge  needle. I'm glad I could help and no I could care less what insurance carrier the patient has.

The many TRUE emergencies that did survive back in the good old days is truly astounding. Sometimes the caring and dedication of the doctors and nurses worked miracles and no we did not have any of those new-fangled telephone answering systems. Thank God I was a nurse back in the dark ages before TRUE medical emergencies were even thought of.

Friday, September 30, 2016

The One Man Band Concept Comes to the OR

I simply love one man bands. The notion of one person or one object having more than one function is fascinating and has led to things like Swiss Army Knives and the Shop Smith woodworking tool that is a drill press, lathe, router, bench saw and who knows what else all in one. Unfortunately, the operating room is an area of specialization. Each instrument and person has one specialized purpose. It's time for a new paradigm in surgery where doctors, nurses, and instruments take on more than one function. Here are a few possibilities.

Too much perfectly good product (I learned that term from those smart alecky business types that run hospitals today) gets tossed. It seems like we had to set up suction on just about every case and then throw it out regardless of condition. On some minor cases the suction container was empty at the end of the case. It just so happened that these minor cases had the most frequent episodes of nausea upon emergence from the anesthetic. It's tough to work up much of an emesis after being NPO, but I have seen it happen. I think that raw gastric content without food to act as a buffering agent can be even nastier than the usual garden variety of emesis mixed with an assortment of foodstuffs.

Now grab that  empty suction container and proudly present it to your upchucking patient. This trick worked like a charm until the end of my career when some genius designed a closed system suction bottle. Bring back the old school coatainer that you can zip the top off and you have a dual use product. Not exactly the equivalent of a one man band, but at least we are back on the right track.

A nobel prize awaits the inventor of a truly functional combination needle holder/scissors. This device would have marvelous utility and could free up a harried scrub nurse for important things like counting sponges and cleaning bloody instruments rather than assisting with the actual surgery. I can't tell you the number of times I have been happily buffing up  a Babcock  with a 4X4 so it shines like the bumper on a '57 Cadillac, only to be rudely interrupted by the surgeon bellowing: "Fool get down here, I need you to cut suture for me." There are now combination needle drivers (as you whippersnapperns are so fond of calling them) that are capable of cutting suture. The present  design greatly limits their usefulness. The scissors part of the instrument lies inside the needle driver making it necessary for the surgeon to work with essentially 2 instruments of different lengths. Muscle memory is a powerful mistress and if you want  to drive a surgeon totally nuts, supply him with instruments of differing lengths. There is never a happy ending with this type of muscle memory confusing instrument and the end result is an outburst of swearing. Hey, maybe we could repurpose that suction container as a cuss bank.

What we need here is a needle holder with the gripping jaws exactly the same length as the scissors part. I am thinking of something with a dual head design akin to a bicephalic creature with both the scissors cutting element the same length as the needle holder jaws.

An old school hybrid anesthetist / circulating nurse was sometimes called into duty on late day or  emergency call cases when there was a shortage of personnel. I am certain this would not be tolerated in today's regulated health care world with all the electronic monitoring devices behind that ether screen, but with a BP cuff and precordial stethoscope these were much simpler times. Once a case was under way the anesthetist would call the circulator over and ask for coverage while he attended to an induction in another room. Once surgery was underway he would scamper back to the original room. This did not happen often and once a sleepy resident was aroused to cover it was back to business as usual.

I was scrubbed once with a novice circulator who seemed anxious about her newly found role as an anesthetist. The attending anesthesia doc ran out of the room for an emergency, but offered succinct instructions for the newbie anesthetist: "Every time you take a breath squeeze that big black bag."

I know nothing of laproscopic surgery, but this discipline seems fond of multifunction devices. I recall a few years back, Olympus announced the Thunderbeat a  combination ultrasonic tissue cutting tool and bipolar cautery. Maybe something was lost in the English translation, but I would be plenty nervous if someone wanted to insert a device named Thunderbeat near my spleen or pancreas.

It does seem like a good idea and in retrospect, I wonder why someone never came up with a dual purpose Metzenbaum dissecting scissor and bipolar cautery. It could be named the "Smokeysnips." If someone could figure out how to add a smoke evacuator to this instrument it could serve several needs; a cutting device, a cauterizing device, and a smoke evacuator.

Here is another 3 in 1 device. We used our trusty Mayo scissors to snap the metal band off multidose vials so the contents could be poured into color coded medicine cups on the scrub nurse's Mayo stand. Unfortunately this really dulled a good pair of sharps so a dedicated multidose vial remover would have great utility.

Since our ORs were on the 7th floor, the windows lacked screens. Occasionally a Chuck Yeager of the insect world would make his entrance to the OR. We did have flyswatters, but you could never find one when you needed one. Combine a multidose vial opener and a flyswatter with perhaps an Oxygen tank wrench and Presto, a multi function instrument of unprecedented value.

I'm saving the best for last. After a long case the first thing I loved to do was tear off my mask without untying it. That ripping noise of the attachment strings separating from the mask was down right satisfying. Next on the agenda was a quick eyeglass clean up. Blood, prep solution, bone chip residue and unidentified material had an affinity for eyeglasses. If an enterprising mask supplier could add a strip of microfiber to the part of the mask, it could be used to clean eyeglasses post ripping off shenanigans. I really could have used something like that.