Saturday, May 28, 2016

What Happened to Operating Room Sponge Racks?

Before operating rooms were appointed with expensive, sophisticated electronic devices, they were supplied with "furniture." I found an old circulating nurse checklist in my nursing junk pile archives  and an important element of her duties was to make sure the room was properly "furnished" before the start of a case. That beautiful chrome device to the nurse's left in the above illustration is a gleaming sponge rack. Pity the poor fool that had to clean this device, those gleaming spikes were blood magnets and a well used sponge rack looked like it was a refugee from a torture chamber. We used to wheel bloody sponge racks into the ortho cast room where there was a floor drain and a high pressure water supply to clean them. It was fun to douse the bloody racks with hydrogen peroxide and watch the bubbly red  and fizzy show that ensued. That stuff cleaned up blood so well you could hear it work.

Here is how that functional piece of gleaming  furniture worked. There are usually two flavors of sponges that we carefully kept track of. Laparotomy or "lap" sponges and smaller 4X4s or in our old time vernacular "stick sponges" because they were always used on a ring forceps or sponge stick. Fold the 4X4 in half and then fold in half again snap it into a sponge ring forceps and PRESTO, you just made a sponge stick. I always thought of sponge sticks as the kindling to  launch a very nasty diatribe from Dr. Slambow. If a hapless resident mopped up blood from the wound with a windshield wiper like motion the fireworks began. Dr. Slambow would bellow, "You just wiped away all the clots, Are you training to be a barber surgeon? Next time dab the blood, never wipe."

Lap sponges came in groups of 5 and 4X4s always came in groups of 10. The sponge rack had several rows of vertical spike like rods on the top and more rows underneath with the rods much closer together. There were 5 spikes in each row on the top and 10 spikes in each bottom row. The laps get hung on the top spikes via a loop on the corner of each sponge and the 4X4s get skewered on the spikes below. The more timid nurses wore gloves during this procedure but were at risk of being accused of trying to bankrupt the hospital by overconsumption of  valued resources like gloves. When the case is over, check to make sure each row of the sponge rack is complete or you have the sponges necessary to complete a row left over on your Mayo stand. Your sponge count is correct and you may advise the surgeon that it's OK to close up.

In real life, surgeons did not pay a whole lot of attention to the circulating nurse announcing that the count was correct. If the surgeon was told the sponge count was incorrect, the standard response  was, "It's not in here, I'm closing."

Sponge racks were an efficient way to maintain an accurate sponge count, but they also had secondary benefits. In a previous post "What's the Prognosis Doc," I neglected to mention the sponge rack drip sign. If a sponge from an upper rack drips blood onto a lower rack, things are not going well. This sign was most common in trauma surgeries and was a grave prognostic indicator.

Men really are more sensitive to visual stimuli and the sight of a sponge rack loaded with blood soaked sponges got more attention than a girlie pin up photo in a soldier's barracks. The sponge rack was a graphic visual display of blood loss.  This could be a real boon to the nurses in the classic anesthesia vs. surgeon transfusion argument. The sponge rack told the story of blood loss  and  usually left the nurses out of the classic transfusion  argument.

When anesthesia attempted to use the volume of blood in  the OR suction bottle to bolster their argument for blood replacement, I knew what to say. Dr. Slambow would insist that the volume of irrigant  was huge and the suction bottle was not a reliable indicator of blood loss. He would then nod to me and I would nonchalantly reply, "Oh yes, I have used a couple of bottles of irrigant." It was a classic reply just like the drunk who told the cop he had consumed just two beers.

Sponge racks also spurred my contemplative thoughts. Looking at he blood soaked sponges,I marveled at where all this blood had been as it constantly coursed through someone's body. It had been batted about by heart valves, squeezed through tiny openings, exchanged gas in the alveoli, and absorbed nutrients from the gut. It seemed strange to see something that had been in constant motion just sitting there. The pattern of the bright red blood on the sponge was the operating room equivalent of a Rorschak ink blot test. I have personally seen lots of angels and crosses etched in brilliant red on the hanging lap sponges. I usually tried to only see good or encouraging images in the blood stains, but I swear once on a gunshot trauma victim there was an accurate image of a pistol. YIKES.. I better just stick to counting the sponges.

Part of my daily routine after coming home from working in the OR was to sit down and watch "Andy's Nickelodeon Theater on WGN (channel 9) TV. My favorite part of this show was watching Three Stooges Shorts. I became convinced that a sponge rack would be a perfect prop for one of their routines. Dr. Slambow was always hollering at new scrub nurses about their casual handing off of surgical instruments. He relished a very hearty slap of the instrument into his waitng hand. If a novice scrub nurse passed an instrument without the slap, he would bellow, "Let me have it so I can feel it!" I imagined that this would have been the perfect time to lob a blood soaked lap in his direction. The sponge had that gooey, sticky feel to it just like one of the Stooges pies. "Here is blood in your eye." I would holler back as I lobbed the sponge.

Like many other elegant objects made of durable metal, sponge racks were killed of by the widespread use of plastics. In 1970, give or take a year someone came up with an alternative to sponge racks. The kick basin was lined with a plastic bag and the  overwrap from an instrument tray was draped over the plastic bag. The scrub nurse tossed sponges into the kick basin and when there were 5 laps or ten 4X4s in the basin, the circulator  grouped them together and tossed them under the overwrap. This newfangled method worked well, but the visual impact of a loaded sponge rack was gone forever.

Friday, May 20, 2016

Derifil - Nose Plugs in a Bottle

Before the advent of air conditioning and ventilation systems, hospitals were a virtual cafeteria of disgusting olfactory stimulation. The various offensive smells would just hang in the halls of the hospitals. Often times you could tell which ward you were on just by the character of the different smells. I think the worst was probably the detox ward. Combine the pungent stink of paraldehyde with every effluent a body could expel and you get the picture.

I remember a job interview where the meticulously attired supervisor asked me what my priorities would be if hired. The response popped into my head and I spouted out without much thought, "The ward smells just terrible. I would do something to mitigate the stink." The boss looked somewhat bemused, but offered me the job.

Traditional odor control involved opening as many windows as possible, using fans, dumping soiled linen as quickly as possible, and cover-ups like Airwick sticks positioned on door transoms. These odor camouflaging sticks looked like large green candles and did manage to add another olfactory flavor to the mix. I hated the smell of these green monsters as much as the scent from expelled lactulose enemas. I know it sounds paradoxical but those Airwick sticks had the nastiest "clean" smell that I have ever inhaled.

There was a revolutionary pharmaceutical product that was introduced at our hospital in the early 1980's. It was called Derifil and the product insert with this drug made some spectacular claims that had nurses enthralled.

This stuff was a chlorophyll derived medication administered orally in a beautifully colored greenish/black pill. We were totally fascinated by this pills color. Some said that it was the greenest black color they had ever seen and others insisted that it was blackest green color. Anyhow, it was very unique.

The medication was touted as an internal deodorant that actually quashed odors within the patients body before the stink could be expelled. It was said to quench the odor of stool, emesis, and even wounds draining purulent goo. I never figured out how a patient with vomiting could retain an oral dose, but the product insert did indeed specify that Derifil would destink an emeisis. We thought the hospital should obtain candy dishes to dispense this miracle drug. Just fill the dish to the brim and pass out the green/black miracle pills to every patient in sight with double doses on the detox ward especially prior to administering Lactulose enemas.

The Derifil era at our hospital only lasted for a couple of years and was quickly forgotten. This stuff was definitely effective at mitigating the odor of stool and doctors would order it for some patients that were squeamish about their new  colostomies and were preoccupied with the odor.

Derifil was introduced before pharmaceutical companies were clever enough to medicalize and come up with a pathological sounding name for the disorder and physicians did not recognize odor control as a serious medical issue. Maybe if the drug companies marketed Derifil to combat OOD (offensive odor disorder) the odor control game could have been propelled to a new paradigm. Without clever marketing, Derifil came to be regarded as a lifestyle drug before anyone even heard of lifestyle drugs. Physicians and patients alike failed to see odor control as a significant medical problem.

I also think that lack of  compliance with the odor control regimen may have been an issue. Who wants to acknowledge that they stink so bad they have to take a pill? People have evolved through the years an ability to tolerate their own body smells no matter how bad. I have been in attendance at many code browns (a great new term I picked up from you whippersnapperrns) where the nurses and aides are gagging and resisting the urge to run away while the patient lies there without batting an eyelash. People are basically immune to their own bad smells and not keen on taking a drug like Derifil.

Derifil seemed like a good idea at the time, but it quickly fell out of favor. I wonder, with new pharmaceutical marketing techniques this medication could be resurrected and become a commercial success.

Tuesday, May 17, 2016

Now That's Transparency

Every now and then a news source reports about a new study showing an increase in medical errors. Unfortunately this problem has a very long history. I don't think many hospitals are keen about publicizing their mistakes. Years ago hospital mistakes were blamed on nursing staff  even though others may have contributed to the problem. Working in the OR it was common knowledge that any foreign body left behind would result in the firing of both the circulator and scrub nurse

I was very careful and very lucky to have never been involved in a foreign body case. There was a case in which a sponge was left behind and the matter was quickly hushed up. The patient was told that a second surgery was necessary to tidy things up. Back in the day patients asked few questions.

I stumbled on a hospital that is trying to change the way medical errors are handled. Brigham and Women's Hospital in Boston is actually publishing medical errors and the corrective actions taken.  The blog is at . It really brings new meaning to transparency. I was impressed.

The site really shows some eye-popping scenarios. The account of a nurse getting a TPN line mixed up could have had a really bad outcome. Luckily, the error was caught before serious damage ensued.

Friday, May 13, 2016

Gowning and Gloving at the Airport

While waiting around the airport the other day, I had a strange sense of been there done that while watching the TSA screening process. Just like Yogi Berra said; " it was deja vu all over again." Visions of gowning and gloving surgeons began dancing through my ancient nervous system as I watched the no nonsense screeners at work. Some of them were even wearing gloves and of course screeners and scrub nurses both wear special costumes uniforms for their performance. The TSA and gowning in the OR  were different sides of the same coin. They both have the common objective of averting very bad entities: nasty infections and even nastier terrorists.

Both processes involve high drama before the acts even get off the ground. Just as some of the passengers were relaxed and some harried, each surgeon had a unique style of gowning and gloving. Dr. Slambow was like the harried businessman, he would practically run into his gown like a racehorse galloping for the finish line and then ram rod his hands into his gloves with so much gusto, it felt like he was dislocating my elbows. Sometimes passengers would try and make friendly conversation with the screeners but like Dr. Slambow,  the TSA was  all business. On late night, actually early morning emergency cases, I would greet Dr. Slambow, "Good morning Dr. It's my pleasure to be working with you again so early in the day." He would gruffly reply, "Cut the crap Fool, It's time to hit it!" The screeners possessed that same no nonsense demeanor as they went about their duties.

While the TSA has to be vigilant with terrorists like Omar Farooq (I think that was his name) who tried to conceal explosives in his underwear, old time operating room nurses were preoccupied with containing that dreaded threat to asepsis known as perineal fallout. During the gowning and gloving surgeons were carefully screened to make sure the cuffs of their scrub pants were contained by elastic cuffs or even rubber bands. You can never be too careful when dealing with threats like this. Indeed, underwear can contain some very dangerous threats to well being whether it be to airline passengers or surgical patients.

In old school operating rooms that used agents like Cyclo we had to be very diligent to check our
footwear for conductivity by standing an a testing gizmo. I see these TSA folks have the very same preoccupation with checking footwear. I never realized how much trouble people could get into just by wearing shoes.

After passing through the TSA screening gauntlet passengers are given the opportunity to replace shoes and belts and collect their belongings. There were similar rituals in the gowning and gloving procedure. The circulator always helped the surgeon tie the belt, actually more of a strap around his gown and then of course there was the post gloving ritual of rinsing the talc off a gloved hand. Just part of getting every thing in order before getting down to business.

I was so enthralled by the TSA screeners that I almost inadvertently addressed one as Dr. Slambow and was about to reassure him that I had a thoracic set-up on my back table before coming to my senses. I was probably lucky to avoid a complete body search after inappropriately rambling on about sharp surgical instruments. This aging business can be dangerous if one gets too careless with mindless banter. I should have learned from my scrub nurse experience that it's always best to keep the old pie hole shut.
Surgery at the airport? .Oh, Magoo  you've done it again!

Holey mackerel! These screeners even have fancy X-ray machines just like we had in the ortho rooms. I think I'll ask that nice young surgeon how he is going to remove that hair dryer from that little old lady, oops there I go again. It's time to zip it before I get in trouble again. Now I know how Mr. Magoo got into so much trouble in those Saturday morning cartoons.  I am thinking about another Magoo outing to a pharmaceutical executives convention where he gets the drug company CEOs confused with organized criminals.

Tuesday, May 10, 2016

A Student Nurse Physician Tribute

"A multitude of physicians and surgeons have drifted into the lives of student nurses in our graduating class. It was easy to differentiate between the physician who was to be a trifle careless in his dress, slow in speech, and the surgeon on the othr hand tended to talk swiftly, dress meticulously, and gesture boldly. But physician and surgeon alike, we nurses feel that so rare an opportunity to give well-earned praise, must not
be overlooked.

We have seen their ceaseless, unselfish effort to lessen pain and bring a smile to those suffering, and many of us have learned valuable lessons in caring for the sick by their examples.

There is no process which can reckon up the amount of good which medical art and science has conferred upon the human race. There is no moral calculus that can grasp and comprehend the sum of their beneficient  ministrations. They have dispelled the gloom of the sick room. They have called back the radiance of the lusterless eye and the bloom of their fading cheek.

And finally when exhausted in all other resources and baffled in their skill, handmaid of religion and philosophy, they have blunted the arrows of death and rendered less rugged and precipitous the putting to the tomb."

I found this quaint and touching tribute in a 1950's nursing yearbook. Physicians were indeed apex predators at the top of the hospital food chain. It was reassuring to know who was really in charge of things. There were no patient satisfaction surveys or utilization review nurses telling doctors what to do. Medicine was a proud, respected profession and physicians were not cogs in the wheels of a health care system.

As a nurse, if you provided a valued service to a physician, you had job security. I was not overly concerned with Alice, my supervisor in the OR because I knew Dr. Slambow would always stand up for me because to him, I was valued as a scrub nurse. It was a nice feeling.

Friday, May 6, 2016

Happy Nurses Day

I perused some very touching posts on Allnurses about nurse's hands and they got me to thinking about my old, wrinkled, and age spot riddled hands. In my youth they were very nimble and served me well. I will always be grateful for the time I had working as a nurse and the people I met along the way. Here are a few things my grubby old lunch hooks have engaged in.

My hand has held the hand of patients during many anesthesia inductions. Each one was different; some were firm, some were shaking, some were soaking wet, and a few were covered in blood. They all somehow relaxed a bit as I held their hand and they finally drifted off. It was one of the most meaningful gestures (I hope) to patients.

My hands have cut thousands of surgical ties each exactly the same length (give or take a millimeter here and there.)

My hands have given many their last bath while my mind was wishing them peace in their afterlife. Far too many could not find their peace in this life.

My right hand has a piece missing from my index finger after a foolish encounter with a Mallis bipolar cautery forceps. I should have been more careful. Haste makes waste.

These hands have dropped more than one glass IV bottle. I vividly recall that combination breaking glass and IV solution explosion.

These hands have received amputated limbs after the hand off from a surgeon. Our hospital actually leased burial plots from a nearby cemetery for their final resting place. I sometimes wondered what future anthropologists would think if this site was ever investigated with a dig.

These hands have held a Gelfoam patch on a bleeding site while praying it would stop.

These hands have counted thousands of sponges and accounted for every last one. (Hopefully)
I tried my best and am not aware of any foreign body mishaps which was grounds for getting fired.

Late at night on a few emergency cases these hands were not all that steady. I did come up with some strategies for this, please see my post " Fools Foils for Fasciculating Fingers"

I guess now that I've stooped to self promotion it's time to wrap it up. Happy nurses day to all. I really do appreciate those who indulge in my foolishness.

Thursday, May 5, 2016

Keep Those Bedside Cut Flowers Vibrant

A nice bouquet of cut flowers was a pleasant bedside diversion for the frequently long hospitalizations of yesteryear. Decades ago bedside flowers were a very common occurrence. We used to stack them on top of  Gomco suction machines which had a perfectly sized flat surface for this purpose. I used to love viewing the beautiful, fragrant  flowers perched over a huge glass bottle filled with offensive, purulent drainage on the suction machine. It was the hospital version of Yin and Yang.

Care of the cut flowers was frequently  in the hands of nursing staff and with lengthy hospitalizations it was important to preserve them as long as possible. From the Old Fool RN whippersnapper enlightenment institute I am going to reveal an old time trick that really preserved those beautiful bouquets. This may sound whacky,  but much like my Thanksgiving autoclave turkey trick, really did work. The proof is in the pudding as they say.

This is a very wise young student nurse. Notice how carefully she is arranging her patient's flowers in that shiny metal vase. That  fancy metal vase is actually a male urinal (before the advent of those abominable plastic ones)  and yes, it's filled with that magical flower preserving liquid, urine. This is a proven technique that really is science based. The urea found in urine contains nitrogen which is a real boon to plants. Urine also keeps those plant stems patent so the nitrogen nutrient in the urea can move up the plant. This is not another one of those cutsie  hacks that nurses confabulate for amusement. It really does work.

I have seen hospital bedside bouquets last for up to a week when their stems are submerged in that golden yellow miracle excrement. Perhaps with the ultra short hospitalizations and outpatient procedures this is not so important but it's always good to keep in mind when you have an extended hospitalization.

Monday, May 2, 2016

Adventures in Asepsis or I've Got Your Back

What's wrong with this old school photo of a big time surgical procedure? First of all the television in the upper left hand corner is blank. Who forgot to pay the cable bill? Sorry, I can't seem to dispense with the foolishness, it's part of my nature as I age.

The central character in this post is actually the surgeon stationed next to the scrub nurse who is ignoring at least two rules of aseptic technique. His back is turned away from the scrub nurse's sterile field mayo stand and the fact that the back of a surgical gown is never sterile. But lo and behold he figured a way to get around rules. Check out his back. Some clever soul has clipped a sterile towel to his back. Is this  a legitimate way to extend the sterile Field?

The truth of the matter is that I have been a practitioner of this questionable act. If the surgeon was reaching for anything toward the head of the table his unsterile back could be facing my Mayo stand. The towel on the back trick did create some suspenseful moments. Towel clips work by the convergence of a pair needle like tips. To safely apply towel clips to a surgeon's back the first order of business was to have the good doctor lean backwards to obtain some separation between his scrub shirt and bare skin. It was not good form to pierce the surgeon's dermis with the towel clip, although at times it was tempting. Dr. Slambow would always joke with the resident and tell him that I was very experienced doing this and then added, "It won't hurt a bit."

The other important point was that you only get one chance when deploying a towel clip. It cannot be removed once ratcheted or it will bring contamination to the surface of the sterile field. Once that towel was in place it had to stay there.

Nursing supervisors usually hated this practice because it was a deliberate flaunting of rigid authoritarian rules. When my supervisor questioned me about this practice, I always deferred responsibility to Dr. Slambow.  Nurses had to submit to surgeons and Dr. Slambow knew how to quiet Alice's protests. He usually said, "Alice, it's time to zip it, what else are we supposed to do?" He really was a master at quieting Alice down.

I really thought this was an interesting way to get around rigid rules, but I don't think it is what today would be called "a best practice." I'm really curious if this practice is ever implemented today.