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.

Sunday, September 25, 2016

Epinephrine Evils - A Trio of Heathers Straight From Hell

Allright, it's time for some fun and games. I am breaking a promise to myself to abstain from blogging about present day healthcare. I make it a practice to avoid watching the television, but while on one of my frequent MD visits, the fancy newfangled flat screen TV was showing the House Committee  interrogating  Mylan Pharmaceuticals  jet setting CEO Heather Bresch. It was a  fortuitous circumstance that medical care was close by because  she made me physically ill and even the legislators were disgusted and admonished her sickening greed by hiking the price of an Epipen over 500%.

Suddenly as Yogi Berra so aptly stated "It was deja vu all over again." Another Heather and her malicious use of epinephrine popped into my aging brain. Kristin Heather Gilbert was VA nurse serial killer that murdered patients with IV epinephrine. Those with strong stomachs can google her name for the unsavory details.  I figured if I could connect the dots with these Heathers from Hell, I could break my promise to myself about abstaining from current issues. My suspicions were right on, these Hellish Heathers do have some things in common.  My promise to avoid blogging about  personal health issues (don't get me started on that one,) politics and religion still stand

To play this game simply match the "Heather" pictured on the left to her favorite epinephrine delivery device. The correct matchups are revealed at the end of this post. How's that for a sneaky, underhanded trick to encourage your readership?  I better stop hanging around with these Heathers. They really do creep me out.


What does Heather Bresch, the greedy Mylan Pharmaceutical CEO and Kristin Heather Gilbert a VA nurse and serial killer have in common other than their names. The answer: they both used epinephrine for novel and unintended purposes. While Heather Bresch used a dirt cheap drug, epinephrine to get filthy rich, Kristin Heather Gilbert used it to impress her boyfriend with her cardiac resuscitation skills. Unfortunately the cardiac arrests were caused by Nurse Gilbert overdosing her patients with epinephrine. Two very twisted ladies using a "life saving" drug to fulfill their own personal goals without any consideration of what they were doing to vulnerable patients. Neither one of these Heathers  ever apologized for their actions.

 In 1989 Nurse Gilbert joined the staff of The North Hampton MA Veterans Affairs Hospital. In 1990 she was even featured in a VA publication, The Practitioner. Likewise, Heather Bresch was recognized in Esquire magazine as a 2011 "Patriot of the Year." It's a sad world when it's considered patriotic to accumulate wealth at the expense of vulnerable patients that require medications. Both of these ladies were apparently considered exemplary examples of humankind according to the articles published.
The parallels of these two women are truly stunning. Nurse Gilbert was frequently described as a habitual liar for most of her twisted life. She falsely claimed to be related to Lizzie Borden, the infamous axe killer.  Heather Bresch falsely  claimed she obtained a MBA from West Virginia University  and officials at this school falsified transcripts to reflect classes she never attended. The lies and falsification resulted in the resignation of the university leader, but Ms. Bresch was promoted at Mylan. I imagine that pulling off this academic deception empowered her and set her on her current trajectory of promoting the Epipen and the subsequent crazy price inflation of her product.

Ms. Gilbert had a lover that worked at the same VA hospital on the security force and hospital policy mandated his presence at all cardiac resuscitations. He quickly became impressed with Nurse Gilbert's cardiac arrest skills. In the mid 1990s investigation revealed that the arrests were caused by iatrogenic injection of epinephrine administered by Mrs. Gilbert. At trial in 2001,  it was suggested her motive was to impress the boyfriend. She was convicted of 4 of the murders and is serving a life sentence in a Texas Federal prison. It was speculated that she was responsible for 80 - 100 murders, but this could be much higher as 300+ patients died while under her watch.

Ms Bresch's motives were far less lethal, but I am certain she was on a crusade to impress share holders and boost Mylan stock price. Both of these Heathers turned a blind eye to the vulnerable patients impacted by their nefarious actions to impress a third party that should have been completely out of the picture.

Both of these women had the ability to compartmentalize their lives. Nurse Gilbert had been married and had 2 children which gave outward appearances of normalcy. Ms. Bresch's father Senator Manchin said his daughter was a very kind person and would give anything to someone in need. I guess he was  never underinsured and try to purchase an Epipen for an allergic child.

Both these ladies misled people and put their needs above others. I guess the serial killer, Kristin Heather is the worst part of this very bad lot. When I think of innocent and vulnerable children being deprived of an important medical treatment, it makes me wonder. One thing is for sure, they both would have been publicly shamed in front of their classmates and given the boot from a diploma nursing school. Our behavior was very closely monitored and one false move and you were history.

According to our student handbook, we were never allowed to be in the dorm while possessing money with the exception of a small amount of change for the pay phone. The school emphasized that it provided everything we could ever need including: housing, uniforms, linens, books, lab supplies and 3 meals per day if you could arouse yourself for the 6AM breakfast. Although we did miss out on Heather Bresch's millions, we had every thing we needed to learn nursing and that was all that really mattered.

Overall, stories like these evil Heathers add fuel to an underlying felling of depression. When I was a youngster the best way to avoid dark moods was to immerse myself in the work of the OR. It was tough to feel bad after a long case that went perfectly with Dr. Slambow extolling my virtues and saying with gratitude that he could have never done it without me.  Those bright OR lights boosted a dreary mood . Now as  an oldster, it gives me a sense of pride and peaceful satisfaction to look down at my Bovie burned finger and arthritic knees knowing that I helped someone at their most vulnerable and critical time and never gave a thought to the $4.95 per hour that I earned. You can verify that with some of my old paystubs (Just search Fools Gold- It's Payday.)

 I doubt any of the above Heathers will ever find such peace. I suspect it is fun to jetset about on private aircraft or live in a fancy neighborhood, but when you are old, the good feelings come from memories of people you have helped along the way such as the trauma patient you worked on all night  in the OR and then watched him walk out of the hospital to his waiting  family. I'm not all  that religious, but I am certain there is a special place in Hell for people that use sick, vulnerable people for personal gain. These Heathers are a tsunami of evil, death, and greed.

I should probably stick with my foolishness and old school nursing stories, but seeing Ms. Bresch  so arrogantly testifying before that congressional committee got my old iron poor blood to boiling. Everything is so different today.

The puzzle at the beginning of the post is very simple. Top photo is Heather Bresch and her grossly inflated Epipen. Middle is Heather Snootphull, a notorious drug fiend that tried to get high by inhaling epinephrine nasal spray. Lastly on the bottom is serial killer Kristin Heather Gilbert and her ampules of epinephrine. I betcha she injected a billion dollars worth of that drug at Mylan's prices.

Wednesday, September 21, 2016

Epipen Foolishness and A Real Money Maker

In all my years of nursing practice I have witnessed a total of 3 anaphylactic reactions and none of them were life threatening. Anecdotal accounts are really worthless so I looked it up. The annual death rate from anaphylaxis is 0.63 per million. You really are more likely to be struck by lightening (1 per million.) The lifesaving merits of the Epipen have been grossly overhyped by Mylan Pharmaceuticals.

Heather Bresch  the disgusting Mylan CEO not only boosted the price of the Epipen, she used her mother ( a school board leader bigshot)  to peddle this "life saving" Epeipen to school districts. It would have  greater social value to peddle lightening rods.

I made my vast fortune with my scrub nurse skills, but everyone can always use more money. Here is my proposal direct from the Old Fool product development institute.

Cardiac arrest is very common. If you have one of those fancy new AEDs nearby you might survive, but with one caveat. All that time your heart stopped your body was anaerobically metabolizing glucose creating a Life threatening acidosis. Just ask Heather Bresch if you don't believe me

To the rescue from Oldfool pharmaceutials comes a breakthrough new product. Sodium bicarbonate in autoinjectable devices. Just find a handy vein and go to town. Sodium Bicarb will buffer that nasty acidosis in nothing flat.

Friday, September 16, 2016

A Picture Story

Pictures really are worth a thousand words. This story is circa 1967 and from the golden days of big open surgeries to remove a tiny piece of pathology.  Just about every case on the schedule was for an -ectomy or removal of something. We used to carefully time the incision to  specimen in the bucket interval and the surgeons used to treasure the bragging rights of being the quickest.  It was very crude compared to the repair and replace laproscopic culture of today.

My favorite photo is #6 with that gamine looking  circulating nurse eyeballing the scrub nurse. I used to get that look from my favorite supervisor, Alice, all the time. I was always tempted to "accidently" toss a loaded, used, sponge ring forceps in her direction. "OOPS.. so sorry about that Alice.

The cloth gowns and drapes, compete lack of eye protection, glass IV bottles, and huge soda lime canister on the anesthesia machine all look very familiar to an OldfoolRN.

Monday, September 12, 2016

The Problematic Protruding Proboscis

Hair encroachment, protruding proboscis
and probable perineal fallout. Aseptic atrocities
of the highest order. Alice will be right with you.

The problem of nostrils escaping from a surgical mask was an uncommon occurrence because Alice, our beloved operating room supervisor dealt with it in a very harsh manner. The most common rationale for this practice was that it made the mask feel less occlusive for the wearer. The usual excuse for the harmlessness of this practice was "I don't breath through my nose so the practice is completely benign."

Alice had a very unique way of testing the claim of only breathing through the mouth. She would take 2 dental rolls which were dense gauze devices about the same diameter as a cigarette. Then she would instruct the careless mask wearer with the exposed nares  to tip their head back. Now for her practiced coup de grace, she deftly inserted a dental roll into each overhanging nostril. "There that should not bother you in the least since you are not breathing with your nose" Alice proclaimed.

I have been scrubbed with several residents after Alice finished her nostril occluding ministrations and it was hard to maintain a serious demeanor when you are handing surgical instruments to someone resembling a walrus. Those two dental rolls dangling from someones nostrils looked just like tusks. It did not take long for the offender to beg the circulating nurse to pull the plug on the dental rolls and cover his nose with a mask. Alice then remarked, "Some people have to learn things the hard way." The dental roll nostril plugging was most unpleasant.

Alice had the restraint and good judgment to avoid the dental roll ram - rodding procedure with attending surgeons, but all residents and nurses were fair game. Attending anesthesiologists usually got away with the exposed nostril stunt claiming, "My nose must be exposed to detect any anesthetic agent released to the ambient environment." Since old time anesthesia circuits did leak, it was a very viable excuse.  This excuse combined with a speedy dive under the ether screen  to purportedly check a line worked like magic when Alice was making rounds.

Urologists were also very fond of having nostrils overhang their mask and usually got away with the exposed nostril trick in the cysto room. The rationale used here was that an exposed nose was less likely to fog the eyepiece of the scopes. Alice rarely made rounds in the cysto rooms so this became a favorite nostril exposing zone. If a careless  urologist tried to extend the exposed nostril trick to a surgery OR, Alice would quickly pounce and volunteer to reposition their mask. If the offender was an attending, Alice would merely slide the drooping mask up. Residents were fair game for the dental roll ram-rodding procedure.

I was so paranoid and afraid of Alice that I would frequently tape my mask securely in position high  on the nose when she was on patrol. Thankfully, I was never subjected to the dental roll nostril plugging procedure. An inch of preventive tape on the nose and mask was worth a pair of patent nostrils.

Saturday, September 10, 2016

Dr. Dog on Duty

Thanks to Karl for emailing this lovely photo. It's too good to keep to myself.

Tuesday, September 6, 2016

Scrub Nurses Flying High

Give me enough of these and a
place to stack them and you will
need a pilot's license AND a nursing
license the next time you are scrubbed
Beethoven had the fifth symphony, Sousa had the Washington Post March, and  Oldfoolrn had  the distinction of being a surgical elevation platform builder extraordinaire. I'm on the taller side and developed an early appreciation of having the scrub nurse on a level above the operative field. It is so much easier to properly deliver an instrument to the surgeon when working from above. It also gives you the best seat in the house when visualizing the technical aspects of the surgery. I think just about everything works better when going downhill except perhaps a patient's vitals. Sorry for the momentary lapse into foolishness.

For the  height compromised scrub nurse I could construct an elevated platform extending from her Mayo stand all the way to the back table using standard, readily available platforms which were supplied  in every room. If more than the alloted 6 platforms were required, I would be off on  a scouting mission to an adjoining OR to steal borrow a couple of extra platforms. It was considered bad form to aggressively yank a stool out from under an observing medical student. The best strategy to use here was distraction,  " There is an interesting aneurysm clipping in the next room, why don't you check it out?"  The med student quickly vamoosed leaving behind the coveted platform. Just remember to act dumb (it was easy for me) when the angry medical student returns and replies, "I thought you said they were doing an aneurysm clipping. That I&D of an abcess made me sick to my stomach. It was disgusting." Meanwhile the scrub nurse is regally perched on the medical student's platform enjoying her lofty perspective and happily passing instruments from above to the surgeons in the lowlands.

For the really short scrub nurses I devised a custom built platform that got pint sized nurses high in the sky. I removed the horizontal metal pan from a non functioning litter. This piece of steel was the perfect length reaching from the midget scrub nurse's  Mayo stand all the way to the back table. From either end I elevated the litter bed on ordinary platforms. This Rube Goldberg  height enhancer even had a built in safety feature. I left one of the siderails functioning and it served as a safety fence to prevent the miniature scrub nurse from falling backwards off the platform. It worked like a charm and my short colleagues just loved it.

For a couple of weeks all went well with my jury rigged scrub nurse elevation platform. Short nurses were clamoring to climb aboard and they even claimed the surgeons were better behaved and yelled less when they towered above them. It's much more difficult to badger and berate someone who is taller than you. When my ever present supervisor, Alice, learned about my custom elevation device, she went ballistic, "What's this ridiculous hodge-podge of components? Dismantle that abomination immediately." That was the end of that. It was fun  while it lasted and gave the vertically challenged nurse a new perspective. Alice always got her way.

If you think my litter elevation contraption was unsafe, note the photo on the left. Using anesthesia stools as the person on the far left is doing invites mishaps. Anesthesia stools are height adjustable by rotating the seating platform. Spinning round and round while sitting might be fun, but not while standing. These anesthesia stools used as elevation devices are tuntables of death or serious bodily harm. Stay off of them.

Circus trapeze artists have safety nets, baseball players have warning tracks and elevated scrub nurses need a safety net too, especially while they are elevation novices. In time nurses learn they can only shuffle from side to side on elevation platforms. It usually takes one good fall to learn this valuable lesson. Here is an interim safety tip for platform elevation beginners. Strip the padded mattress from a litter and carefully place this behind your meticulously  constructed platforms. We used to have bright red foam litter pads that worked perfectly. The bright red mat functioned just like the ball player's warning track and the foam silenced and cushioned a fall. I do not know any scrub nurse that fell off a platform more than once. To paraphrase Neil Armstong, "That's one small back step off the platform and one giant crash when you fall to the floor holding a heavy surgical instrument." Be careful out there when you are working high in the sky. That unpadded terrazzo floor is an unforgiving surface.

There was one type of neuro case that called for elevation for even the tallest of scrub nurses. Any craniotomy with the patient in a seated position called for special elevation tricks. In the early days we had a heavy duty Mayo stand that could be positioned about 5 1/2 feet in the air. Even the tall nurses needed platforms to work from this dizzying height. At about the time I was nearing retirement a specialty neuro instrument table was introduced.

This table was one piece and eliminated the separate back table and Mayo stand set up that I knew and loved. I always had to imagine a corner of this monster Phelan Neuro  table as the Mayo stand to keep things orderly. If we were working with Methylene blue which was one of Dr. Oddo's favorite marking agents, I was in business. I physically drew a Mayo stand top outline  on the oversize single table drape. It worked like a charm for me, but some of my co workers thought it was really a silly thing to do.

Another one of my signature tricks was to take my straight Mayo scissors and cut an intricate filigree design into the top of the wax paper bag that we tossed used suture scraps into. Dr. Oddo always said that it was going to be a tough case if he noticed a plain trash bag on my Mayo stand. "Uh Oh, somethings up.. oldfoolrn did not have time to decorate the suture bag," was his ususal reply. I never felt the artistic urge when dealing with late night or trauma cases so I just went with the plain old suture trash bag.

I'm starting to get off track again, so it must be time to wrap this up. I really do appreciate all of you who indulge in my foolishness and it amazes me how many of you read this in the middle of the night. Sometimes I fantasize about that phone ringing in the middle of the night to jump out of bed and scramble over to the hospital for a  trauma case with Dr. Slambow. It really sounds like fun now that I cannot clearly recall scrambling to set up instruments or feeling totally beat up by the late hour and gruesome trauma.

Friday, September 2, 2016

A Toss Up

Maybe some of you bright young whippersnapperns could enlighten an Old Fool about what is going on here. I have narrowed it down to a couple of possibilities. Either the seated nurse is about to catheterize the supine patient or the supine surgeon is performing a new age hemorrhoidectomy on the seated patient. I guess it's a toss up.

I like the notion of OR table portability. With those wheels and the person on top in a driver's position it looks like this thing could me driven from one OR to another in a jffy. This would be perfect for the patient having two different surgeries in the same session. After having that total knee replacement in the ortho suite he could be driven straight to the general surgery room for that much needed hemorrhoidectomy.  For added flexibility and quick  access to different sites may I suggest the addition of a rotisserie option to this table.

I just hope the anesthetists know how to use those old school ambu bags during transport and can hook the patient back up to the anesthesia machine in the new room before the patient awakens.  On second thought, why not just attach a vaporizer to the table for in transit anesthesia?