Thursday, November 24, 2016

I'm Thankful for Autoclaves

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

Wednesday, November 23, 2016

The Operative Report

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

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

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

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

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

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

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

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

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

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

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

Thursday, November 17, 2016

Why Did Operating Rooms Have Green Ceramic Walls?

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

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

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

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

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

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

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

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

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

Saturday, November 12, 2016

A Shocking Enema Known as the Harris Flush

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

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

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

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

                                                          THE HARRIS DRIP
Purpose: To carry off gas and waste

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

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

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

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

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

Wednesday, November 9, 2016

Election Day 1972

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

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

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

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

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

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

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

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

Sunday, November 6, 2016

Silk Urethral Catheters- The Gateway to Nurses Performing Procedures

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday, November 2, 2016

Night Nurse

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

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

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

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

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

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