Saturday, October 29, 2016

IV Taping - Sticky to Sticky

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

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

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

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

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

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

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

Tuesday, October 25, 2016

Lifesaving Lunacy

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

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

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

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

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

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


Wednesday, October 19, 2016

Coal Shoveling Nurses

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

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

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

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

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

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

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

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

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

Saturday, October 15, 2016

White Coat Ceremonies for Nurses

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

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

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

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

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

Tuesday, October 11, 2016

Morphology Malarkey

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

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

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

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

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

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

Sunday, October 9, 2016

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday, October 5, 2016

What is a "TRUE" Medical Emergency?

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

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

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

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

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

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

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

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