Saturday, January 30, 2016

Endoscopy Pioneers

There is nothing in the literature regarding a trans nasal prograde colonoscopy. The scope is hopelessly tangled in the small bowel so please cease with the ramrodding before you tear something!

Wednesday, January 27, 2016

Chest CT Mystery Solved: Plombage Treatment for Consumptives

Before the advent of antibiotics, TB was treated by isolating the patient  consumptive from the rest of society in sanitariums.  Almost every county in the country had a sanitarium where the treatment consisted primarily of rest and relaxation. Despite the resources invested in sanitariums, they were certainly not curative. A cure would have to wait until the mid 1940s when streptomycin was discovered. It always made me realize the limits of hospitals when the cure to the problem came from outside the sanitariums.

There was even a surgical procedure to relax the lungs called "plombage." The rationale for this procedure was to force rest on a lung infected with TB. To facilitate this, the chest was opened and a lung was collapsed by packing the chest with wax, olive oil, or small Lucite balls. The CT scan in the previous post shows a chest cavity packed with Lucite balls which are actually about 2/3rds the diameter of a ping pong ball. Lucite was thought to be a good space occupying material as it was inert and light weight. I was never involved in the initiation of this procedure, but did many cases where the Lucite balls or paraffin wax packing  was removed from a chest. It seemed like our hospital was the Cook County Center of Excellence for plombage packing removal-we did a lot of them.  The last of the plombage procedure was done in the late 1940's so I doubt anyone is walking around with Lucite balls or wax packed in their chest today.

Before the start of a thoracotomy to remove the plombage packing, Dr. Particular, our chest surgeon  always asked the scrub nurse to autoclave a tablespoon with the rest of chest  instruments. The concave surface of a tablespoon perfectly mated with the curvature of the Lucite plastic balls. After residing in someone's chest, these balls were very slippery and difficult to get a handle on. Dr. Particular could quickly coral them with his tablespoon technique.  He would slide the tablespoon under the ball and stabilize it with his index finger and yank it out. The tablespoons could also be used to dig out the paraffin wax that was also used as packing. I saw one case in which both wax and Lucite balls were used. I guess this further proves the old adage that when there is more than one treatment for a problem-none of them are effective.

Plombage balls looking somewhat worse for the wear after removal from some poor soul's chest cavity. Paraffin was also used as chest packing and it always reminded me of scooping ice cream when it was removed with a tablespoon.

The theory behind plombage was that resting an infected lobe of the lung would be curative. Dr. Particular always said this theory was not true, but collapsing the lung tissue and depriving it of oxygen might have been helpful because the tubercle bacillus was aerobic. Dr. Particular always seemed sympathetic to the patients that had plombage because he always bellowed out during the removal part of the surgery, "finally we are being of service to this patient."

After surviving the initial plombage procedure without hemorrhage or infection, patients faced long term risks. The most common long term complication was fistualization involving bronchus, esophagus or migration to the skin.

Usually when a surgeon asks his scrub nurse to autoclave an unusual or eclectic item, the prognosis is not great. I think I might have mentioned this in a previous post "What's the Prognosis Doc?" I have been asked by surgeons to autoclave buttons, paper clips, toothpicks, and even an automotive drum brake adjusting tool. Happily, the plombage patients usually did very well after having the space occupying material removed from their chest. It always felt good when you fixed something or corrected a problem.

I wonder what current treatments will seem crude and even barbaric in the future. Maybe with the advances in immunotherapy, toxic chemotherapy will look primitive. The current treatment of mental illness is not really curative. Some of the psychotropics are akin to weeding a garden with a hand grenade, but that's another story.

Congratulations to OldDoc who correctly figured out the chest CT mystery. Thanks to all of you for reading my ramblings and I appreciate the privilege of sharing your time with my foolishness.

Tuesday, January 26, 2016

Chest CT mystery

Any guesses what this slice of a chest CT scan shows?  I've got a story to tell about it that involves table spoons and a thoracotomy.

Saturday, January 23, 2016

Wednesday, January 20, 2016

Coroners Case

One of the elements of working in nursing that I really treasured was the colorful cast of characters met along the journey. Whenever we had a death in the operating room (almost always a failed trauma) it was time to notify the Cook County Coroners office. In Chicago, even death was highly politicized. Deputy coroners were appointed based solely on political connections and lacked any credentials except for the fact they were close buddies with their ward alderman. They had as much scientific acumen as Bart and Homer Simpson.

Like Bart and Homer, they usually appeared on the scene in pairs and worked in concert. They all smoked cigars, wore trench coats, and sported  wide brimmed hats.  I think they were called fedoras. Another requirement for the position was a BMI of at least 30. I once observed one asking about the depth of a stab wound and then inserting his Pentel mechanical pencil into the wound to about 2/3 rds of its length and then casually replacing it in his pocket. They also possessed unique skill sets such as removing gold rings from edematous post mortem  fingers. The key to this was bracing yourself with a foot in the armpit and pulling on the ring with great strength. The ensuing argument between the deputies about who got the ring or the wristwatch could be very volatile.

There was the classic urban legend tale about the stockbroker that died at Union Station in downtown Chicago. When his wife opened the box to claim his personal effects it yielded a Chicago phone book and a Sunday edition of The Chicago Tribune. His wallet and valuables were no where to be found.

Deputy coroners always had a sense of humor. While checking out a corpse with massive head trauma, they discovered a tin of aspirin tablets in his pocket. "Look, he died of a headache"  one of the deputies exclaimed.

When the deputy coroners showed up for one of our operating room deaths they were always preoccupied with "leakage." They really hated getting any bloody drainage on any of the huge fancy  black bags they transported the body in. I used to keep a "leak plugging bag" in my locker that contained discarded sheets of Gelfoam that I scavenged from cases  and a sculutetus binder. Because their livers were cirrhotic, victims of bar fights frequently had wounds that bled out post mortem. My sure fire technique was to cut a sheet of Gelfoam to cover the wound, apply an. ABD  pad, and then the sculutetus binder. The deputy coroners thought I had supernatural hemostatic properties and they were always delighted to see me on duty. It made me think about launching a career in Chicago politics as I was beginning to cultivate connections. It is a good thing that siren call of the operating room kept me grounded in more honest employment. I think the guilt of some of those political shenanigans would have killed me long ago.

One thing.that was unique about Chicago was the openness of  corruption. Aldermen sold "Ad books" and if you purchased an ad ( The ads usually read: "The Husko Family supports Alderman Slippery) you then had a right to get complaints about city services or zoning promptly taken care of .
 I have lived in other cities that I think were just as bad as Chicago, but politicians always acted arrogant and above the misdeeds. In a twisted sort of way Chicago seemed more honest and trustworthy. You knew your standing.

Times change. The deputy coroners and their mischief have  been replaced by a medical examiner system.  Everything improves with the passage of time.

Sunday, January 10, 2016

Nurse Caps - The Cupcake

At one time there were 4,000 three year diploma nursing schools in this country, each with it's own specific style of cap. This nurse is proudly wearing her Bellvue cupcake cap, so called because of it's resemblance to an inverted cupcake. I've been fortunate to work with a few cupcake capped nurses and they were all really good nurses. Maybe that accounts for my fondness of this type of cap.

I don't know if this is a valid observation, but I've always thought of the cupcake style cap as an East cost phenomenon. Lots of cupcakes to be found in New England, but moving Westward, the folded flat (my crude term) seems to take over. I actually wrote a post about the way a flat square of Argo starched cotton was folded into a cap at our school (nurses cap folding - an ancient tutorial.)  The unique aspect of our folded flat was that it had to be worn parallel to the face or you were in for a heap of demerits. Yes, at uniform inspections our caps were measured at the top corner and bottom to make certain that it was parallel to your face.

A cupcake cap wearer explained to me that there were some valid reasons for wearing the cap on the back of the head and parallel to the face. It seems that she had the had the unfortunate experience of having her top of the head cupcake cap fall off at inappropriate times such as during clinical procedures like dressing changes or catheterizations. If the cap was positioned on the back of the head it could not fall off onto the wound or get dunked in a bedpan. Another reason for the back of the head positioning was to help prevent bumping into overhead traction or ceiling mounted IV racks.

There were various permutations of the cupcake cap ranging from the beautiful domed Bellvue cupcake to a flat sort of pancake style cupcake. Some schools even got fancy and added a black band to the cupcake. This frilly banded cupcake is really over the top. A nurse wearing a cap like this really commanded respect and was probably quick to put a foolish folded flat capped nurse in her place. I don't think I would put up much of an argument with a nurse wearing a banded cupcake.

 It looks like this black band even has an elastic-like quality to it that would hold it in place. Often times with the folded flat cap nurses  would have to add a thin bead of Surgiube or Lubafax to the band to hold it in place. This trick worked every time.

One of problems encountered with the cupcake was  how to secure it to your head. White bobby pins worked well with the folded flat, but would distort the symmetry of a cupcake cap.  Bobby pins were really noticeable on the cupcake cap and  messed up the aesthetics. The short rimmed cupcakes ( actually pancakes) even lacked enough surface area for the bobby pin.

This problem was easily resolved with the use of a "brain patch" which was a square piece of cotton slightly smaller than the diameter of the cupcake. A square piece of Telfa also worked well as a brain patch. The brain patch was secured to the hair with bobby pins and then a long white hat pin was threaded through the cupcake under a corner of the brain patch.  The long pins were usually threaded on both sides of the cap to secure it. The cupcake below is shown  with the pin to secure it under the brain patch.

We were never permitted to wear nursing caps unless on duty in the hospital. This required wearers of the folded flat caps to use unwieldy cap carriers. Cap carriers always littered the break rooms and sometimes would provoke an argument if you picked up the wrong one. Nursing caps frequently were heavily scented with cigarette smoke and other unsavory hospital smells. It was not prudent to go around sniffing caps or cap carriers.

Cup cakes often had the advantage over folded flats when it came to these transport issues. Some of the less fancy ones could be flattened and easily carried without the use of a cap carrier.

It seems to me like about the mid 1970's nurses started looking for reasons to abandon their caps. Orthopedic nurses claimed that caps were always in the way because of overhead traction apparatus, ICU nurses complained about ceiling mounted IV racks, and psych nurses claimed that caps intimidated their patients. By the mid 1980's cap wearing was made optional at many facilities and in the mid 90's, I think caps disappeared for good. I think what really did the cap in was an attitude issue on the part of nurses. Diploma nurses were socialized into believing the cap was the ultimate reward a nurse could receive; more important than even fiscal consideration. This was a real boon to hospital administrators with payroll cost. Caps were relatively cheap. Nurses began to realize a cap did not really help them buy food or housing and began receiving fair wages. Young nurses thought caps represented a servitude mentality which they probably did.  A whippersnapperrn once summed up nurses caps nicely saying "respect the nurse cap , heck yes - wear a nurses cap, hell no."