Thursday, March 31, 2016

Left Handed Surgeons

This illustration shows a neurosurgeon dissecting with his presumed dominant left hand, with a  suction ready to go in his right hand. I spent many happy hours with our internationally known neurosurgeon, Dr. Oddo and was always impressed with his ambidextrous abilities. He was equally adept with either hand. Whenever I asked about his versatile handedness he always replied, "It's best not to think too much about things like that. I just use whatever hand feels best. Just shut up,fool, and keep that suture coming." (I always waited until the end of cases to pose philosophical questions figuring that a combination of fatigue and relief that the critical segment of surgery was over would reduce inhibitions and produce answers to my foolish inquiries. Sometimes this strategy worked yielding valuable insights.

After spending many lengthy sojourns underneath the OR table adjusting the foot pedal of the Mallis bipolar cautery, I noticed Dr. Oddo always used his left foot to actuate the pedal. From this, I concluded Dr. Oddo was left footed. I extrapolated this finding to figure that Dr. Oddo was probably a natural southpaw who had been converted to using his right hand by societal pressure or his lengthy medical training. His left laterality preference was revealed by his left footedness.

Unlike some of my colleagues, I actually enjoyed crawling under the OR table to adjust the Mallis bipolar foot pedal. It was kind of like a mini-vacation from all the noise and mayhem going on above the table at the operative site.  No flying bone chips to dodge and no putrid Bovie smoke to inhale.The drapes made the area under the OR table feel like a  cozy tent pitched in the middle of the wilderness. It was a nice quiet place to pause for some refreshment until the surgeon hollered to adjust the lighting or the scrub nurse pestered me to open more suture. It was a nice respite while it lasted.

Now I knew why Dr. Oddo  insisted upon having a left handed set of Raney clip appliers available at all times. He was a closet lefty.  The ratchet mechanism of the left handed Raney clip applier released in the opposite direction as a right hander.  ( Those purple things around the scalp margins in the above picture are Raney clips and they prevent blood from oozing all over the operative field.)  One of my claims to fame as a scrub nurse was the ability to load 2 Raney clips at a time, even Dr. Oddo was impressed. This was the only left hand specific instrument he ever requested which was a testament to his ambidextrous abilities.

Sometimes Dr. Oddo's  ambidextrousness befuddled me. Instrument trafficking (thanks to whippersnapperns for coining that term, it fits like a glove) involves several elements; timing, correct hand placement, and with enough oomph that the surgeon can feel the instrument slapped into his hand. Whippersnappers sometimes are shy about instrument slapping, but it's called slapping for a reason. I've never had a surgeon complain about the slap being too hard, although one did call me "old school" for aggressive instrument slapping. I think it was a compliment.

My signature instrument trafficking trick was to smack a needle driver loaded and ready to go into the surgeon's right hand while simultaneously sliding a pickup forceps into his left hand. This always happened at the close of a case when everyone was in a relaxed state of relief that the critical portion of the surgery was over. Surgeons just loved receiving two instruments in one motion or maybe they were just ecstatic that they were almost done. Anyhow, I never had any complaints about my trafficking technique until I scrubbed with Dr. Oddo.

Sometimes he would work with the instruments as trafficked (needle holder driver in the right hand and pickups in the left) Other times he would give me a nasty look, I could easily read a scowl even with a mask on, and switch hands so that he was suturing with his left hand. Of course, I had instinctively placed the needle holder in his right hand.   Out of the blue, I'm thinking.. pick a hand Dr. Oddo...Pick a hand and stick with it...  and it inadvertently  capers across my tongue.  Dr. Oddo screams at me, "Mind your own business fool and keep that 3-0 coming." After the case, Dr. Oddo approached me and actually apologizes and explains that when he was a resident, the attendings  would always implore him to "pick a hand." This caused handedness to become a hot button issue with Dr. Oddo. I never again just slapped an instrument into a specific hand, but always tried to be aware of which hand he was using.

I once worked with a neuro fellow that had done his residency at the famed Mayo Clinic and was accustomed to gloving up with his left hand first even though he was a right hander. It seems that the two Mayo Brothers were left handed and as a tribute to them all surgeons gloved left hand first. I was just getting used to the practice when Dr. Oddo took note of it and started asking pointed questions of the fellow. I was shocked when he dressed the resident down saying, "This is not the Mayo Clinic and that old fool scrub nurse has enough to worry about at the beginning of a case. I want everyone gloving the same way, right hand first." The humiliated fellow readily concurred. I thought maybe Dr. Oddo was taking out some of the frustration he received as a left handed resident on the poor fellow.

There was a left handed general surgeon that had a complete major set of left handed instruments. The needle holders, clamps, and scissors were left hand specific. I could never get used to releasing the ratchet in left handed instruments and was constantly fumbling around. Luckily there were a couple of left handed nurses available to work that room. We had a left-handed specific general surgery room where even the anesthetist was left handed. It worked out well. I was a committed right handed person and could never feel comfortable releasing ratcheted instruments in my left hand.

I then tried using the left handed ratcheted instruments in my right hand, but somehow the thumb is not designed to slide the ratcheted side of the instrument upwards. Somehow left hand specific instruments just were not my thing.

I did some research on the internet about left handed surgeons and the terminology and tone was overly complex and full of bafflegab and bolderdash. Scalpels, sponges, and pick-ups are not hand specific. The only difference is with ratcheting instruments opening and closing in the opposite direction. If the left handed surgeon simply operates from the left side of the table, I would think everything should go well. As a right hander, I don't think I could ever be comfortable with clamps ratcheting the "wrong" way or working from the left side of the table. I was lucky that there were left handed nurses to work with left handed surgeons.

Saturday, March 26, 2016

Trauma - Something to Easter About

Every old school nurse has a graveyard in the back of their mind filled with a little shop of horrors regarding gruesome cases that have percolated over the years..  I try and stay distant from some of the darker memories, but there is something about Easter celebrations that bring to mind old trauma surgery memories. It must be the theme of suffering, death, renewal, or maybe even the full moon that causes memories to surface. Maybe it has something with the days getting longer as more daylight always translates to more trauma. Trauma is fond of long, warm days when more people are out and moving about in their motor vehicles

People that suffer major trauma and manage to cobble together a recovery even though it's often times not something we would think of as recovery are very special and have a spiritual and inspirational quality about them. I don't even like to think of them as "patients" because of what was accomplished by their inner strength. It's tough to predict which  people can make an adjustment to major trauma and reinvent their lives.  Sometimes people that appear to be leading superficial lives come to new meaning after their injury. I've seen people give up drugs, quit gangs, and commit their lives to helping others after being injured. It really can be an amazing Easter-like rebirth when you witness what some people can accomplish after major life-changing trauma.

First things first-I need to unload some of the downright disheartening memories. The things that are the exact opposite of "comfort food." Like comfort food these things stay with you not because they are filling, but  because they burn an image into your mind. Not even a good dose of foolishness attenuates them. In no particular order, the following comes to mind.

The image of bottle after bottle of   O  negative blood  (bag after bag today) being pumped in with the realization that most of the poor soul's   blood volume was now splattered all over the dashboard of their 1960 Chevy Brookwood station wagon or pooling out there  on Lake Shore Drive.

In many ways the injured persons hands and faced defined their humanity. Seeing an older persons face covered in blood with pooling in their wrinkles always got to me. Clots could become impacted in the  wrinkle creases. I remember one stabbing victim that I removed a huge umbilical clot that formed just as a result of pooling blood  during the prep.

 I always felt better after the induction and draping and it was time to go. Dr. Slambow always said "Things can only get better from this point on." Dr. Slmbow could also make a fairly convincing argument that the only problem surgeons should treat was trauma, but of course he was a trauma surgeon. We also had a nephrologist whose mantra was the only reason for the heart's existence was to pump blood to the kidneys, but that's another story.

I remember a young man whose hand was hopelessly mangled in a book binding machine necessitating an amputation. I kept his hand on my Mayo stand soaking in a basin of normal saline with his shiny gold wedding band reflecting the overhead lights. In the back of my mind I maintained the delusion that somehow it could be re-attached. After the young man was transferred to a Gurney and left the room, I reluctantly  put his hand in a specimen bag.

The blood /bone chip slurry left on the operating room floor after a case was something that sticks in your mind. Plain old blood; no problem. Plain old bone chips: no problem, but that gelatinous, gooey combination somehow represents thatprimative primordial goo that all life evolved  from. Maybe I'm getting a bit carried away. That blood bone chip slurry was really tough to clean up and maybe all that extra time spent with it gave time for the realization that someone's loved one met with an unthinkable event.

Elective surgery always includes some pre-operative rituals to blunt the stark brutality that is about to occur. The careful draping, meticulous set-up of instruments, the surgeon calmly and almost leisurely asking the anesthetist, "May we start now?" Trauma surgery is completely different. I recall Dr. Slambow yelling "Go..Go..We don't  have tie to set up or drape and if I cannot stop that bleeding that airway won't mater." It was just a different mindset when it came to trauma.

 I came across this inspiring video of a modern trauma team in action and was deeply touched by the progress that that has been made since I was on call for a case. The orthopedic resident, Jim Bond, came across with a sense of humbleness  and warmth that was lacking back in the good old days. From the way he introduced himself to patient's families simply as "Jim Bond" to the way he mentioned to the  victim's parents that prayers would be needed. We did not have physicians like that.
Old time docs could be very judgmental at times and shift the blame to the victim. "That's what happens to people who choose to ride motorcycles." comes to mind as an old school attitude. It sure was nice to see such a compassionate young doctor.

The other thought I had after viewing the video was how easily it is to be  misled by such gross orthopedic injuries.  The focus is narrowed to working on  mangled extremities while ignoring possible occult intra abdominal or intrathoracic injury. This problem used to sneak up on us all the time. I remember being grateful that we were done and a hidden obscure problem  pops up.

The recovery to a new and completely different type of life for  trauma survivors resonates with Easter themes. I just  loved the scene at the end of the video where the man, sitting in his wheelchair triumphantly pushes on the switch to  open the doors. Life goes on.

Sunday, March 20, 2016

Sutureself Blog

I am an aficionado of operating room tales regardless of where they occur along the time-space continuum. I stumbled upon this contemporary blog and there is  even a neat illustration of a clamp/scissors combination instrument that is stuck in my mind like one of those songs you hear over and over. That illustration reminds me of the retractor/suction combination I always wanted to invent, but never got around to. It's really cool, especially if you admire surgical hardware.  Check it out!

Friday, March 18, 2016

Phisohex - A Green Bottle at Every Sink

This stuff was everywhere in old time hospitals - every sink and every horizontal surface near a sink held  a bottle of this microorganism murdering miracle. It delivered a one/ two punch by disrupting bacteria cell membranes and precipitating intracellular  protein. In the operating room we had gigantic shaped dispensers that looked like a mini-funnel cloud. The miraculous white soap was forced out of the dispenser by pneumatic pressure supplied by a squishy black foot pump. Stomping on the footpump always felt kind of slippery to me and reminded me of tromping on dog waste. Sometimes, I even reflexively checked the soles  my foot covers to make sure they were free of stinking dog poop.

Miss Bruiser, my favorite instructor from nursing school even managed to incorporate the operating room foot operated Phisohex dispenser with  her teaching technique. Miss Bruised was obsessed with fingernails being  their correct length (1 mm.) and having the subungal space (the area underneath the distal nail) aggressively scratched out with a metal file before scrubbing for a case. After the mandatory 10 minute scrub if she suspected we neglected the subungal scraping, she would jump with all her might on the Phisohex foot pump blasting our hands with a surprise bolus of Phisohex. "It's time to start all over and don't forget the subungal curettage this time" she admonished with a nasty smirk.

Phisohex contained 3% hexalchlorophene  and one of the raw ingredients was fomaldehyde, which always made me question how such a toxic substance was safe. In the early 1970's some studies suggested that Phisohex could be a neurotoxin, especially with newborns. This was puzzling to me because Phisohex was used extensively in the nursery. Why was it being used with a population that research suggested was particularly at risk?

Once a product like Phisohex attains such widespread use a sort of inertia develops and some crazy applications manage to evolve. Pre-op showers with Phisohex and pre-op surgical site scrubs were common and then upon arrival in the OR proper the standard prep was another Phisohex scrub followed up with a final coating of Zepharin. In urology, it was common to administer a dilute Phisohex retention enema before prostate biopsies. I could never decipher the rationale behind this (pardon my lame pun) because most of the bowel bacteria were gram negative and Phisohex was most active against gram positive microorganisms like strep and staph.

Even the cafeteria smelled of Phisohex. It was just  as common as Whip 'N Chill desert and those yucky scrambled eggs made from dried egg powder. There was nothing to wake one up as quickly as a plate of reconstituted dried powder scrambled eggs and a snoot full of that Phisohex odor.  I learned from one of the cooks cafeteria workers that their automatic dish washing machine actually gave the dishes a spray of Phisohex prior to the rinse cycle.  Compared to the cafeteria smells, even Bovie smoke smelled OK. Everything is relative including noxious smells.

Around 1970 or so studies began showing that Phisohex at the 3% level was indeed a neurotoxin and there were also suggestions that in high exposure to personnel like nurses it could be a teratogen.
 I guess it was no coincidence that a colleague had a baby whose face resembled the dispensing head on a Phisohex bottle. I am also wondering if I can blame my cognitive decline on heavy duty exposure to Phisohex. When I was a youngster I could spell just about anything without even thinking. Residents even asked me how to spell operative terms and I rarely let them down. Now when I type those nasty little red squiggly lines pop up constantly and I'll be darned if I can remember what I had for lunch. It must have been the Phisohex.

Tuesday, March 15, 2016

Brand New Operating Rooms - Brand New SNAFUS

Our wonderful new operating  suite of 11 rooms labeled "A" thru "K" had been under construction since 1971 and now 3 years later was open for business. They had been designed by an architect that had no previous OR design experience, but he would eventually marry the OR  supervisor who wisely departed before the grand opening ceremony. We all knew how he got the job. Not a single staff nurse was consulted about the design. A love-struck inexperienced architect being influenced by a blow hard supervisor with no recent clinical experience; What could go wrong?

The rooms had all sorts of grand features including a conveyor belt system running underneath the rooms for linen and garbage removal. In operation, the only thing this system did was make unpredictable very loud bangs and BOOMS during such critical surgical events like aneurysm clippings or aortic clamping. Of course the agitated surgeons vented their angst by screaming at the scrub nurse who had nothing to do with the racket. The conveyor belt system was up and running a grand total of  3 days before it was mothballed for good. We hiked back up to our old abandoned  tiled temple of an operating room suite and retrieved our faithful old wheeled trash bins and carts. They worked like a charm as they had for the 60 previous years.

The next dilemma was the room nomenclature. Our old rooms were numbered "1" thru "12" which was a simple, time tested measure. When someone said room "4" everyone was on the same page. Over the new OR intercom room "B" sounded just like room "D"  We should have taken a tip from police officers and given each letter a uniform call sign. We started making up novel call names for the letters. "I'm in room "H" as in hemorrhage and need all the packed cells I can get!" was probably typical. We came up with some really descriptive call signs for the lettered rooms, but soon learned it was better to avoid monikers denoting surgical complications. Some of the less imaginative surgeons were becoming agitated.

Our new locker rooms were located one floor above the actual operating rooms. To access the ORs, a short elevator ride was necessary. Stepping out of the elevator was akin to the curtain raising on an X  rated theater production. The elevator opened directly in front of the huge window looking into a cysto room giving the elevator occupants a shocking (to some nonmedical personnel) prime time view of someone up in stirrups awaiting God knows what of a urological  procedure.  I always thought urology instruments were some of the most frightening looking and thought provoking. I used to wonder, "How is that huge resectoscope going to fit in that tiny little opening?"

 The surgeons and nurses did not bat an eyelash as the elevator doors unveiled the cysto room sights, but some of the schedulers and secretaries were shocked. Soon one of the administrative personnel constructed a make shift curtain from a surgical drape partially obscuring the view from the elevator landing.  The chief of urology was appalled and ripped the drape from the window bellowing, "This is a teaching hospital. Not a top secret research lab. If anyone doesn't want to see what's going on here they can drape their eyes."  I guess that was an old, foolish attempt at the "transparency" business we hear ad nauseum today. The drape was never replaced, but in a compromise move, the OR table was moved so as to be at a right angle to the door.

This next SNAFU haunts me to this very day. There was a time tested sterilization procedure in the old tiled temple for our instrument trays. They were carefully wrapped, tagged with autoclave tape and sterilized in one gigantic autoclave in central supply. This autoclave was nearly the size of an Eldorado and carefully monitored with each firing recorded on graph paper.

The neophyte OR designer came up with a concept that bordered on genius if you listened to the OR supervisor now turned architect's fiancĂ©. Each operating room "A" thru "K" was equipped with a puny little double-doored autocalve. The unwrapped instrument trays were shoved into the mini-autoclaves from the outside hall and sterilized for a 3 minute cycle which was consistent with how we had "flash" sterilized individual instruments in the old tiled temple. This mini autoclave stroke of genius idea created a painful hot potato scenario for the hapless scrub nurse.

When the autoclave door was opened in the operating room after a 3 minute cycle, the nurses were first greeted with a blast of steam and the scrub nurse then had scalding hot instruments to handle. I can tell you from personal experience that latex surgical gloves have virtually no insulating property. This issue was especially acute with heavy instruments like retractors and speculums. We tried to cool the scalding hot instruments with irrigant but this was like treating cancer with a band aid.

After a few weeks in operation, it was noticed that our infection rate in the new operating rooms had soared. Of course it was the nurses fault. Administration even cultured our nostrils and told us to sharpen up our aseptic technique.

 I am no expert on thermodynamics but always wondered about the time it took for the instrument trays to reach an effective temperature, figuring that if they were hard to cool, they were hard to heat.. One day a representative from the autoclave manufacturer showed up and told the supervisors that the autoclaves were never designed to sterilize a complete instrument tray in 3 minutes and that the autoclaves were being used in a way that was inconsistent with their design.

I have never witnessed as much finger pointing and she said-he said monkey business following the autoclave SNAFU. The correction was to extend the autoclave cycle to 10 minutes after reaching the correct temperature. I don't think it was ever nailed down where the 3 minute cycle idea initiated.

When the 4 story  Rich Insurance Dude Pavilion was constructed in 1970, the planners envisioned a hospital high rise in the sky probably inspired by the Sears Tower.  A ton of money was spent on a heavy duty foundation to support this hospital skyscraper of the future. A few years ago when I returned for a visit, I noticed the skyscraper concept never got off the ground, To this day, the pavilion is a measley  4 stories tall  and they are back to sterilizing their surgical instruments in a central location. Not all big-time plans work out as planned.

Thursday, March 10, 2016

A Dozen Roses and a D&C

The long awaited opening of our brand new operating room suite in the Rich Old Insurance Dude
Pavillion  was about to open. We had taken advantage of the holiday season, which was typically a time of markedly reduced case load to move our old equipment into our new digs. About the only thing left behind were our old Bovies that resembled Maytags. Our fancy new electronic Bovies looked like toys in comparison and did little to inspire confidence in older nurses.

 I used to wonder why the patients were so cooperative about not needing surgery while the docs took time off, but I never was able to solve that riddle.

One of my favorite co workers, Nancy, happened to be scheduled with me  on a January, Saturday AM in 1974  to open the new suite. We were not expecting any cases and had planned to organize and put away endless boxes of suture material. We did do  a few dress rehearsals and were ready to go if we received a case. The old operating rooms with their beautiful terrazzo floors and green tiled walls were gone for good. The tiled temples were closed.

Nancy was always in a jovial, bubbly mood regardless of the situation which often contrasted with what was going on in the OR. I remember her almost inappropriate cheerful banter at the close of a failed trauma case. "OK it's time to draw straws to see who gets to take care of the body," she chimed in while holding 2 lengths of discarded 00 silk suture material in her hand. It was always nice to work with someone in a good mood, even though at times it didn't feel quite right.

At about 11AM we received a phone call from the ER that we were getting a case. Nancy was delighted and excited that we were going to be the very first 2 nurses to do a case in the brand new pavilion OR. "Maybe they will construct a statue to honor the first 2 nurses to do a case in the new pavilion." I muttered something under my breath and began to hurriedly set up the new room. To mollify Nancy I quickly constructed a paper certificate on the back of an operative report form that stated. "NANCY AND FOOL WERE THE FIRST NURSES TO DO A CASE IN THIS O.R SUITE."

I quickly attached my paper plaque to the entry door using some good old J&J adhesive dressing tape. Everything was ready to go with the room so I strolled out to the prep and hold area to greet our patient.

As the litter approached, the first thing I noticed was how tiny and child-like the patient appeared. It was a terrified, trembling  16 year old girl that was having painful uterine bleeding. I reassured her that we would take good care of her and I also added, "I'll stay with you until you are asleep." This seemed to reassure her a bit.

Just as we got past the scrub sinks, Nancy jumped out from behind the door and hollered, "Congratulations, you are our first patient!" and with that, plopped down a dozen red roses in her arms. Unbeknownst to me, Nancy had slithered away to the gift shop to obtain the roses while I was fetching our patient.

I will never forget the look in the young patient's eyes. I have never seen someone experience so many different emotions in a brief moment. She went from terrified, shocked, amused, and totally bewildered in a matter of seconds. I was speechless for a moment and then told the patient that we would leave the roses on the cart until she woke up. I held her soaking wet, trembling hand until she was anesthetized and was greatly relieved when the case was underway. To this day I can see that young girl's face and it's really haunting. Her face was a veritable cafeteria of emotions. I was relieved when everything went well with her case and she was fine.

When Dr. Repulso, the surgeon saw my paper plaque on the door, he asked "Why did you leave my name off ?, I am the first surgeon to do a case here."  I quickly scribbled a plaque for Dr. Repulso and taped it above our plaque. The surgeon always was the captain of the ship. When Alice, the supervisor came in on Monday she ripped my plaques down so our glory was short-lived. It was nice while it lasted and I will never forget our very first patient.

Monday, March 7, 2016

Perineal Fallout - A Scourge in the Operating Room

After making a brief mention of countermeasures to prevent perineal fallout in my last post, I received a couple of questions via email. I decided the best way to answer them would be to interview an expert, Alice, an operating room  nurse from the greatest generation here to enlighten us aging baby boomers and whippersnapperrns as well.  Alice hates foolishness, so if you don't want to be permanently stuck in the cysto room hanging endless bottles of irrigant, pay close attention.

Alice, (background)  wearing perineal fallout detecting headgear
on duty in the  never ending war against infection inducing perineums.

Alice, "What exactly is perineal fallout?"
If you recall from your most basic anatomy class, the skin is composed of layers. The outer layer is continually being sloughed off into the atmosphere forming a potentially infectious fog that spreads like radiation. It is especially prevelant where skin rubs together in areas like hairy masculine thighs or other skin folds.  

Is perineal fallout a gender issue restricted to men?
No of course not. In my Operating Rooms, women wear scrub skirts as orderd in the Bible. Just read Deuteronomy 22:5. Women wear undergarments under their skirts that trap and contain perineal fallout so it's not a big issue.. Who knows what those hairy surgeons have under those baggy scrub pants, but I suspect there are huge colonies of microorganisms just itching to be set free and cause a very nasty infection.

What can be done to prevent dreaded perineal fallout?
Like everything else in nursing, an ounce of prevention is worth a pound of cure. Men should always have perineal fallout contained by ankle constrictions. I'm from the old school and back in my day we had scrub pants with elastic ankles. This worked like a charm. The best substitute for elastic cuffs, that I've come up with is rubber bands so the next time you unwrap your copy of The Chicago Tribune, be sure to save the rubber band and bring it to work. Waste not - Want not.

Years ago we had other measures to combat those pesky crotch bacteria. One of my all time surgical heroes, Joseph Lister, sprayed carbolic acid  all around the room during surgery. I don't want any complaints about that caustic fog of carbolic acid burning your eyes or constricting your airway, it's one of the sacrifices we make for our patient in the never ending battle against perineal fallout.
A wardrobe failure of catastrophic proportion resulting in spontaneous
release of perineal fallout. This is the operating room equivalent of the Chernobyl
disaster. Fallout all over the place. Even the "Alice approved" rubber banded ankle
trick is useless as a containment measure. Maybe Lister's carbolic spray needs resurrected.

Alice was a true crusader in the battle against perineal fallout. Sometimes nurses that came before me harbored customs and beliefs that were not rooted in science. The way I viewed the perineal fallout issue was that any escaping microorganisms would wind up on the floor which was by it's nature is contaminated. So what is the big deal?

 It did not really pay to argue with people like Alice. Empirical beliefs that stood the test of time were usually very fixed. I don't know if modern nurses have encountered this issue, but perineal fallout made for much argument and discussion back in the day. About the only people Alice could cajole into her rubber banding were hapless first year residents. Too much arguing with attending surgeons was hazardous to continued employment.

Alice would really have fun with OR staff and nurses in general now that everyone wears scrub pants which were her true nemesis if found sans her ever present rubber bands.

Thursday, March 3, 2016

Operating Room Shoe Covers - Paper vs. Cloth

Operating room footwear was all pretty much the same. Traditional white clinic nursing shoes
modified with the placement of a metallic rivet through the weight bearing area of the portion of the shoe underlying the ball of the foot. I used to wonder, "Why not postion the rivets in the heel?" I guess if the rivets were in the heel, standing on your tippy-toes would break the grounding path for electricity.  We always seemed to standing on our toes reaching for something or to see over a burley surgeon's shoulder.

A Modern elastic paper shoe cover. I bet these would not
work in the Cyclo room. Where is the conductive strap?

The purpose of the metallic rivet was to ground out static electricity to the grounded floor of the operating room. We had one room of the OR suite dedicated solely to the use of Cyclopropane which was highly explosive. I'm thinking about  that for another post "Anesthetics that Go Boom." Cyclo was on it's way out even at the beginning of my career, but it was deemed wise to maintain at least one room  for teaching purposes.

Before entering the "Cyclo Room," (Curious how that sounds like psycho room) we had to step on a gizmo that actually checked our shoes for conductivity. A green light meant it was OK to enter the room and a redlight on the gizmo meant you had better check to make sure the conductive strap from the cloth shoe cover lined up and contacted the rivet in the shoe. An experienced nurse could tell by pedal sensation (I made that one up) if the strap was lined up with the rivet. You knew it when you felt it!

Cloth shoe covers were a true thing of beauty compared to the disposable paper/plastic  ones available today. The manner in which the  saturated deep green color of the shoe cover contrasted on the elegant grey terrazzo floor was a sight to behold. (If interested please see my "Terrific Terrazzo Floors" post)  The cloth shoe covers did not stretch like the one size fits all nobody of today and came in 4 different sizes. We used to hide our own personal sized cloth shoe coverings in unusual places so there would always be a set available that fit. This led to some amusing moments such as "Who hid their shoe coverings in the bottom of the coffee can? The answer was always "That is not a coffee can..That is  my shoe covering can. Keep your grubby hands off them."

One thing about modern health care (other than nurses taking better care of  computers than patients)that really bugs me is the fact that everything that was  made of  substantial material like metal, glass, or cloth is now made of paper or plastic. Somehow it just does not seem right. Whippersnapperrns are missing out on the heft and feel of  things like metal bedpans, glass IV bottles, mercury syphgmomanometers, and cloth surgical drapes, masks, and shoe covers.

OK back on task. Cloth shoe covers had no elastic in them. they were held in place with a drawstring device which worked much better than  constricting elastic because the closure pressure could be varied and did not constrict your foot at the ankle. Overall, a much more elegant way of attaching foot covers to shoes.

Modern paper/plastic shoe covers have another annoying (at least to me) characteristic in that they produce a rustling noise as you walk. They sound a bit like the muffled,  crackly noise of cellophane being handled. To me the disposable shoe covers were reminiscent of a stroll through the woods on a Fall day with the leaves crackling underfoot. Cloth shoe covers were stealthily silent and more suitable for use in the operating room.

All surgeons and nurses were supposed to wear shoes which were encased in the cloth coverings. A few renegade surgeons like Dr. Slambo liked to wear rubber boots in the OR which was  a habit he picked up while serving as a Trauma surgeon in the Army. Every now and then one of the OR supervisors would confront Dr. Slambow about his footwear choice  and he always told them, "I need these boots to wade through your rigid, authoritarian crap, so dummy up."  That would usually be the last time the supervisor attempted to confront Dr. Slambow. He was not one to be trifled with.

Every OR Supervisor seemed to have there own particular gripe. Some complained at length about fingernails while others thought scrub nurses should try to mitigate Bovie smoke with a suction.  Alice, a firey redhead always concentrated on footwear and related problems. She really liked the surgical residents (none of the attendings  listened to her)  to wear rubber bands around their ankles to "catch perineal fallout" so as to avert contaminating the OR with imagined crotch microorganisms. One day she approached one of Dr. Slambow's  residents with her ever present rubber bands and Dr. Slambow unloaded  and screamed  "Alice, he does not need rubber bands on his ankles because today he is wearing underwear."   That seemed to muzzle Alice, at least for a couple of weeks.

One time Alice approached me after along and difficult case with Dr. Slambow and said "Fool sometimes during cases you don't get excited enough when bad things happen." Alice liked to rant and rave and jump around during emergent situations. Dr. Salmbow overheard her criticism of me and quickly put her in pace saying, "Alice that's like saying we did not loose enough blood. You can never be too cool." That kept her off my back for a few days. She really was a nut.

Clinic shoes equipped with grounding rivets and cloth shoe covers were the pinnacle of operating room footwear design. Clean, conductive, comfortable and quiet. Clogs, tennis athletic shoes,  and paper shoe coverings can never duplicate the cloth and Clinics of yesteryear. Too bad some of the finer things are gone forever.

Tuesday, March 1, 2016


Before entering nursing school, I received an envelope in the mail suggesting that to make life easier, I should memorize some abbreviations and acronyms. There were the usual BID, TID, QOD and some interesting acronyms that should have served as a warning that there were stormy seas ahead. I dutifully memorized them and foolishly discarded the list. Here are some old and not so old terms that I remember encountering along that long nursing highway.

Acronyms can be a shortcut to convey much information with a small amount of writing. We used to try and pack as many of them as possible into nursing notes as our instructors really were fond of them. I think it was an entrance to the nursing fraternity. Anyway, some of the more foolish ones can be amusing and also serve to diffuse stress. There are tons of them listed on the internet and I have seen all of these in use at one time or another. There is one that I must confess to making up "NITWIT."  Computers are fun, but it agitates me to no end when they take nurses away from the bedside.  I was walking down the hall of a modern hospital mumbling "nitwits" as I passed every computerized med cart and the acronym just popped into my head. Somehow it seems to fit.

HONDA - Hypertensive obese non-compliant diabetic adult. There are a bunch of car themed acronyms, but this is the only one I can recall.

FORD- Found on road dead.  Often teamed up with MVA - Motor vehicle accident. This is an old one.

SPAK- Status post ass kicking

V V  - Vitamin V- We always used this for Valium. I notice whippersnappers hijacked this one and use it for Versed.
HAWK- Healthy and well kid

LAMA- Left against medical advice. We used to just call this one AMA, but adding the "L" is a nice
               touch. In the VA we called this one AWOL.

NOSHIT - Nothing out, super huge impacted turd. This is an old school acronym which was  used frequently. Closely related to GOEKI - Going out, enema kicking in.

MESS- Medically eclectic septic surgery. I've had a ringside seat to these fiascos. They start out as "routine"  surgeries and something unexpected is found. Performing an appendectomy the surgeon notes "Hmm.. That cecum is inflamed too, might as well take some of it out." The problem was not really "appendicitis" but Crohns disease. A septic MESS is a sure thing.

OASIS- Outcome and assessment information set

AIR- Airborne isolation room

COMA- Consciousness obtunded maybe asleep

TURD - Totally unnecessary rectal digital

HOODWINK- Healthcare optimal operatives with increased nursing knowledge. Somehow this one seems very appropriate.

T to T - Tatoo to tooth ratio as a contemporary  indicator of mental illness. An old school indicator was wearing more than six rings. A ring on the thumb counted as 2.  Tatoos were uncommon and usually meant the patient was a veteran. In the OR, tattoos could be a major distraction. I remember one case where the patient had a battleship tattooed across his chest and the surgeon spent more time worrying about approximating the skin edges so as to match than any other aspect of the case.

LFA-  Low friction arthroplasty. This was an old school acronym for early hip replacement procedures which were also referred to as "Charnleys." Every time I handled that flimsy little acetabular plastic prosthetic cup which was held in place by glue only, I wondered, "How can this thing be durable enough to support a patient's weight?"  Guess What?  It did not hold up for long and revisions were common. The surgeon's fee for performing a total hip replacement in 1970 was an astounding $1,000.

SWI - Something wrong inside. This used to be a surgeons favorite acronym which was used as a rationale for exploratory surgery. Often times these procedures turned up something disastrous and whippersnappers have come up with a term "Peak and shriek" that nicely describes the situation. I wish I could have thought of that one years ago. It's descriptive and so appropriate.

NITWIT - Nursing In Transition with Integrated Technology.  OK, I made this one up. It really bugs me to see nurses in a modern hospital totally absorbed in their computers. A stroll down the hall reveals patients half falling out of bed between split siderails and trays of food out of reach. Split siderails loaded with electronic controls are another sore spot. The simplest is usually the best. What happened to the old full length side rail.

It's getting past my bedtime. Thanks for indulging me in more foolishness.