Thursday, April 28, 2016

IV insertions - Upside Down and Backwards to Boot

A good scrub nurse always sides with the surgeon in a dispute with anesthesia and should always be attentive to what's going on in the operative field. Nevertheless, there can be some interesting things happening on the other side of the ether screen (oops..I'm showing my age here.) I probably should have said anesthesia screen.

One of the anesthesia attendings was always up to something different which at times bordered on outright foolishness. He loathed endotracheal tubes and intubating, preferring the old school mask, but that's a story for another post. He even asked others to call him by his first name which was unheard of back in the day. His name was "Bob," but I always called him by the proper, Dr. Frolic. One of his favorite tricks was to insert an IV catheter backwards so that it was pointing to an extremity rather than the heart. He then berated and belittled anyone that told him that he put the IV in backward.

I think this got started by his attempts to find a good vein by looking in difficult to access or unusual sites. Every old nurse or doc  knows that the back of the forearm can be a gold mine in the search for a good vein because not many people look there. Dr. Frolic loved this site and had the patient flex their arm at an acute angle at the elbow and rotated their shoulder toward the head of the table. With the patient twisted up like a pretzel, it was easy to loose track of the correct insertion orientation.

The number one objection to his technique was that the IV would not infuse properly because it was facing  resistance from the return  bloodflow. The venous blood would be flowing right into the open end of the IV catheter.  Dr. Frolic was quick to point out that the vascular resistance in the vein was the same regardless the direction of the catheter. The forces of gravity driving the infusion and vascular resistance were the same regardless of IV catheter direction. By further explanation he said there was actually a therapeutic advantage to the backward IV because the rapid bloodflow toward the IV catheter tip served to disperse the medication better thus reducing vein irritation and possible phlebitis. He used a spitting into the wind analogy to illustrate his point. He told the person (usually a nurse) that objected to his technique to go outside and spit a big glob of mucous into the wind. "It will come back at you in a slew of smaller mucous pieces," proving my dispersion point. "If you spit a mucous glob in the direction of the wind it will stay in one discrete piece. Now which would you prefer entering YOUR venous system."  End of discussion.

The other objection to his technique was that with a small vein, the IV catheter could occlude the venous lumen. Dr. Frolic dismissed this argument by explaining to the objecting nurse that veins are elastic so this was not an issue. I did notice that the good Dr. always selected "garden hose" type veins usually in the back of the arm for his insertions so the lumen of the IV catheter would not totally occlude the vein making this objection  a moot point.

Dr. Frolic's backward technique did indeed work for the duration of the surgery. I don't know if there were any long term problems associated with backwards IVs. In the good old days IVs were frequently left in place just for the duration of the surgery. Very few meds were given IV so venous access was not a big issue like it is today.

This fact points out another dubious benefit for the backward IV site because it faces the foot of the OR table. At the end of a case, the surgical drapes are always pulled down from the direction of the anesthesia screen to the foot of the table. If the IV tubing is attached to the drape, it is simply pulled out with the removal of the drape. Dr. Frolic used to refer this as the automatic IV discontinuation feature whenever he neglected to make sure the IV tubing was free of the drape. To legitimize or provide credibility to his whacky methods, Dr. Frolic would come up with technical sounding names. He called his backward IV trick: "ulnar splinted retrograde transcutaneous venous cannulation."

Another IV insertion trick in Dr. Frolic's bag involved inserting the IV with the bevel of the needle facing DOWN. His argument for this technique was that there was less of a chance of penetrating or damaging the side of the vein opposite insertion. The sharp bevel tip of the needle was further away from the opposite wall of the vein reducing the chance of injury. The other advantage to this technique is that the complete lumen of the needle or catheter is within the middle of the vein. If the needle is inserted "correctly" or bevel up, a portion of the needle lumen could be blocked by the wall of the vein at entry site.

Much later in my nursing life, I did try Dr. Frolic's needle bevel down insertion trick. The one adjustment I found necessary was that the needle insertion angle through the skin had to be at a much more acute angle than with the traditional bevel up technique. This also required a more rapid reduction of the angle once you were into the vein. His bevel down technique did work especially well when drawing blood. The blood flowed into the vacutainer more quickly and there was less injury to fragile veins. He may have been on to something with the bevel down method, but I would not wanted to try it as a student with an instructor watching.

I never really had the gumption to attempt a backward (away from the body core) IV insertion. I did not think his spitting into the wind analogy had much science behind it. From my observations, his backward IV did work in the OR, but I don't know how it functioned long term. Sometimes important breakthroughs are discovered in a serendipity manner, but foolishness for the sake of foolishness is not a great idea. If the truth be told, as a youngster, I was not really very foolish but I'm making up for it later in life!

Friday, April 22, 2016

Now, That's What I'm Talking About!

Scrub Nurse in proper scrub dress, but get that hand out of your pocket unless you are reaching for that ever-present wash cloth to mop the surgeon's sweaty forehead. Those lights are hot and we did not have air conditioning in many of our rooms. Positive pressure  HVAC  ventilation systems were decades in the future. Beautiful terrazzo floors being stomped on by genuine cloth shoe covers... Oh yeah.. Cloth masks, caps, and of course drapes. Glass IV bottles. Classic overhead lighting with a diffuse primary light and satellite spot. I just love that giant ring adjusting hand grip on the main light and the bicycle grip on the satellite. I can almost feel them in my old foolish wrinkled up hand with Dr. Slambow saying, "Thanks for shedding some light on the subject, fool." (He always said that and chuckled and of course I joined in with a little laugh.) It was always prudent to laugh at a surgeon's attempt at humor.  Back in the day the circulating nurse always adjusted the lighting. There were none of those sterile light handles for the surgeons to fiddle with the lighting independently. No self serve gas stations and no self serve overhead OR lights.; It worked out better the old fashioned way and it gave someone a useful job. Check out that gleaming green ceramic tile with visible grout lines in the upper right corner of the image. Don't even think about culturing those grout lines cuz we certainly never did. In Dr. Slambow's vernacular this was indeed the tiled temple. I don't see any electronic devices here (Hoo  Ray) especially the fact there are no computers. I just hope those surgeons have their perineal fallout prophylactic rubber bands in place around their ankles.

Sunday, April 17, 2016

A Surgical Switcheroo

Recently there were reports in the news of a patient concealing a miniature recoding device in her pony tail to record operating room personnel during her surgery. It's a good thing patients lacked the motivation or technology to surreptitiously record the goings on when my favorite surgeon, Dr. Slambow did a case.

Most surgeons like to engage their scrub nurses in the surgery. It makes the scrub nurse feel important and can be a real ego booster. Most surgeons keep it simple and ask things like. "Should we use 3-0 here?" Dr. Slambow took scrub nurse inclusion a step further. He would start by telling stories about how he worked as a "Mayo" nurse during his youth as a way to pay his way through medical school. For some reason he always referred to the scrub nurse as  a "Mayo nurse" and the circulating nurse as a "hustle nurse." His terminology did have a nice ring to it and sounded quaint and reassuring.

Whenever there was a routine cholecystectomy with a 4th year surgical resident scheduled, Dr. Slambow delighted in pulling his old switcheroo. He would start by telling the scrub nurse that he was going to gown and glove himself independently without our assistance. We all knew what was coming next. After self gowning and gloving he would say "Alright Nurse  Fool get down there opposite that young docster ( he referred a to all residents as docster), you are going to assist him perform the surgery while I perform as the scrub nurse. I anxiously complied even though my surgical skills were limited to cutting suture and providing retraction. I did eventually learn how to tie off a bleeder, but left the suturing to the resident because Dr. Slambow was very fussy about this. The sutures had to be perfectly equidistant and each suture line had to have perfectly aligned margins.

Dr. Slambow  just loved being the scrub nurse. He said that the "Mayo"  nurse had the best seat in the house and was in a position to control the tempo of the surgery. "The person handling the instruments is in charge of the case," according to Dr. Slambow. This was true when he was the scrub nurse as he provided a running commentary of the case. He reminded me of how Jack Brickhouse, a sports commentator on WGN called a baseball game. Dr. Slambow would yell out "HEY.....H.EY" just like Brickhouse did at high points in the case. As a nurse playing surgical assistant, I always thanked Dr. Slmbow at the close of the case just as he always did when he was the surgeon. He always replied. "The pleasure was all mine."

I sometimes wondered how the patient would have felt having known that the switcheroo had occurred. Back then what happened in the OR stayed in the OR. Thank heaven those mini voice recorders were decades in the future.

Wednesday, April 13, 2016

Nursing School Housemothers

A Trifecta of housemothers at the entrance to the nursing school and dorm.
Old time 3 year diploma nursing schools did not need sophisticated security systems or cameras because immediately after entering the front door you were face to face with a housemother or "house hags" as we fondly referred to them. We used to compare them to cancer; always present (24/7) and they could spread out anywhere in the  school or dorm without warning to induce fear and worry in a hapless nursing student. They controlled anyone and anything that entered the combination dorm and nursing school. There was only one way in and one way out and everyone that entered the building had to pass by the housemother's desk which was just past the student's mail boxes. The housemothers were also in charge of the mail.

They were the front line enforcement of every rule and regulation that governed the life of a student nurse. Nursing school rules determined when and under which conditions you could leave the dorm, what you could bring into the dorm (one suitcase), and who you could bring into the dorm. There were also mandated study and lights out hours closely monitored by housemothers.

If you were not studying during "study hour" which curiously spanned the hours between 7PM and 11PM you could get busted by the housemother  with a demerit. If you had a light on after 11PM you were busted. If you went home for a weekend and forgot to sign out at the housemother's desk,  you were busted again. That "friendly" housemother in the center of the illustration above is interrogating a student about some irregularity found in the signout card box. Things like this never ended well for the student nurse.

It must have been a serious transgression such as changing the sign in time to comply with the strict curfew hours or perhaps signing in for a roommate  because the hag on the far right in the illustration is already on the hotline to the school of nursing director's office. That hotline to the directors office probably caused us more angst than President Kennedy's nuclear armament phone did during the Cuban missile crisis. Sometimes students would try to sabotage it (the house hags phone, not the missile crisis) by unplugging it at the jack or even gluing the receiver to the phone base. Housemothers were very resourceful and always got the phone up and working again.

Another method to escape the housemother's scrutiny was the "Australian Crawl" technique. When 2 students came in past curfew one would distract the househag with claims of sobriety or sweet talk while the other crawled past below the threshold of the hag's window. At least only one student received a demerit with this deception.

On the opposite side of the lobby within the housemother's scrutiny  were 2 visitation rooms for non-conjugal visits with boyfriends. The rooms were slightly larger than a bathroom stall with partitions raised about 2 feet off the floor. There were benches on either side of the tiny room  with a small full length table in between. The rules were one boy and one girl on each bench with feet visible on the floor at all times. There was a complex work around for this rule that required stuffing each boy's pant leg with a shirt or whatever was available and then arranging the pseudo  stuffed leg into a shoe. It worked every time, and at the least provided some togetherness for the couple without having to negotiate around  the dividing table.

Don't be deceived by that veneer of a cute little old lady. That psedo-friendly  little smile could turn into a vicious grizzly bear of a snarl faster than you could come up with an excuse or confabulate a defense to an egregious offense such as  smuggling cafeteria food into the dorm. Housemothers could be a veritable cafeteria of emotions almost like a bipolar psych patient that neglected to take their Lithium. You never knew what to expect from them.

Appearances can be deceptive, don't let those granny glasses fool you, housemother's had the visual acuity of a hawk. Oh, and don't think those old one piece housedresses could slow a motivated housemother  down, these ladies could run faster than Michelle Griffith Joiner  and close in on a suspicious activity faster than a linebacker on steroids. They were definitely not people to be trifled with.

When patrolling the dorms at 11PM for lights out enforcement they could move about in absolute silence. There stealth was enough to instill a profound sense of paranoia. At times, it seemed like they could be in two places at once.

I have stuck in my memory an image of a distressed young student nurse which appeared in our yearbook with the caption, "I have come here to work and study for the next three years." She really looked as though she had been sentenced to death by firing squad, but I suspect she had just had a run in with one of the housemothers about being 5 minutes off in her sign-out time. Those housemothers were a really scary bunch.

Friday, April 8, 2016

Look Out Below

Florence Nightingale  envisioned hospitals as one story structures that had large windows for both lighting and ventilation. The fresh air was thought to have a healing benefit. Old hospitals had windows that easily opened and closed. There was no mechanical ventilation with a HVAC system and positive pressure rooms were in the distant future. Rooms were heated with radiators and windows were usually wide open in the Spring and Summer.

There were no high altitude flying insects in Chicago, so the windows above about the 4th floor lacked screens. There was nothing between the hospital interior and the good old outdoors.

This direct connection to the outside world presented a temptation too great for some nurses to resist. After working a harried evening shift with normal inhibitions dulled by being too tired and seeing too much misery the unthinkable suddenly seemed like a good idea.

The thought process went like this; "Hmm.... there are 8 Foley bags on this ward that need emptied.. I'm already behind schedule and it's 10:50PM...Over in the corner is a janitorial bucket with impressive capacity...Now lickety split I'll drain the urine bags into the bucket.. Now for the real stepsaver, DUMP THE BUCKET OUT THE WINDOW."

Now, I'm not saying that I've ever done this, but I know for a fact that it was practiced. One old nurse said the hospital planners even allowed for this practice. "Why do you think the sidewalks are located a good 40 feet from the building?" she asked. I don't know if this was true, but I made a mental note to keep a safe distance from any hospital building.

I noticed another tell-tale sign of the window urine dumping syndrome; the grass below selected ward windows was a dead brown color. The high nitrogen content of the urine had effectively killed the turf. I also noticed that upon venturing off the sidewalk (not a prudent thing to do without a raincoat) the unmistakable odor of urine was present. This smell could have wafted out the open windows, but it seemed to always be there which was further testimony of urine dumping.

Miss Bruiser, my favorite nursing school instructor, once asked the class for an explanation of gastric dumping syndrome which often occurred after a gastrectomy. One eager student quickly replied, "The dumping syndrome occurs on the detox wards when a patient vomits out a window." Miss Bruiser seemed puzzled by the student's response, but vomiting out an open window did indeed occur on the 6 bed detox ward.

I think it was a conditioned response with seasoned alcoholics to hurl their gastric contents out a window. The detox ward had that peculiar blend of olfactory insults as a result of the paraldehyde, stool, and emesis coexisting in a small area, so the windows were always open.
It is much easier to vomit out an open window than
trying to hit one of those tiny emesis basins. "When I
open the window, let it rip."
To a detoxing alcoholic the window looked like a perfect place to vomit.  The bed placement also encouraged this tactic. Two of the beds had the head of the bed aligned perfectly with the open windows.    As one old booze hound explained, "I've pucked out my car window many times, it's a lot easier to drive drunk, than clean vomit off the interior." I guess it's called projectile vomiting for a reason. This provided an added incentive to keep your distance from the hospital exterior. I don't know which would be worse to have dumped on someone, urine or emesis. They were both nasty.

There was no positive pressure ventilation in our old operating rooms and with our positioning on the 7th floor the windows were frequently open. Old time anesthesia machines were rather crude and sometimes leaked anesthetic agents. Even on cold days, Dr. Oddo would start hollering, "I'm getting sleepy, open the window."

Not much refuse was ever thrown out the OR windows as there were plenty of witnesses. Hospital window tossing of garbage or effluent  was usually a solitary act. The one exception would be an orthopedic case done in a regular general surgery room. This occasionally happened with a trauma patient and left the circulating nurse with a cleanup dilemma. The only sanctioned disposal location for casting plaster was way down the hall in the ortho room. The stuff could not be poured down a sink as it totally gummed up the plumbing.  After a long trauma case, the window could be a tempting place for plaster dumping. I always wondered what that stalagmite looking mass was on the ground below the general surgery OR. Now I knew, it was casting plaster, that stuff lasts forever.

With Lady Bird Johnson's keep America beautiful campaign in the late 1960's littering and dumping really had a pejorative connotation attached to it. I think most of this unsavory activity ceased. Of course if a nurse was working late at the close of a stressful shift, who knows what might happen. It's always prudent to maintain a safe distance from open hospital windows.

Tuesday, April 5, 2016

New Fangled Names for Old School Stuff

I wanted to come up with a fancy title for this post to impress people and started using words like "lexicon" and others I cannot even recall. Dr. Slambow my hero surgeon did not like complex medical terminology and had some interesting names for things that seemed off the wall at first but really did make sense after getting accustomed to his unique ways.

Instead of instructing a surgical resident to tie the distal 2/3 rds of the inferior  super duper vessel  off with an 18 inch  000 synthetic polyglomerualr tie, he would simply utter "meatball it." We all knew what he meant. Another term Dr. Slambow used all the time was a "good trauma." As a novice nurse this one really confused me; what could be good about a traumatic injury?  He would say things like to me things like "Get up here as fast as you can Fool, I've got a good trauma here." The translation was that he was dealing with a serious trauma that could be saved. We knew what he meant even though it sounded almost inappropriate..

I come across some new (to an old foolrn) terms that are really good, but I've never heard used in my many years of working as a nurse. I always think to myself "I wish that I could have thought of that one when I was a young fool."  Here are some of the best. Congratulations are in order to the whippersnappers that   came up with them.                           

Hemodynamically Unstable  A very descriptive term that is very useful in Triaging.
We never used either of these descriptive gems. Some old school military nurses probably used triage but we always said get the shock blocks under the head of the bed or watch that BP instead of that hemodynamic descriptive gem. Good job whippersnappers. It has a nice professional ring to it without sounding too snooty.

When instrument trafficking in the operating room always pass the needle driver loaded in the correct direction so it is ready to go.  I just love that descriptive instrument trafficking term. We just said when passing a needle holder make sure it's in the right direction. Needle driver  actually describes what the instrument does. Much cooler than an old surgeon mumbling "needle holder." That old school instrument passing term sounds bathroomish in comparison to instument trafficking..

Venous Access - Sounds much more elegant than "start an IV."

Metabolic syndrome - This descriptive term for a cluster of symptoms found in pre-diabetics and those prone to cardiovascular disasters has a nice ring to it. Descriptive, but again not too snooty, Dr. Slambow would have loved it.

Lap Chole - When I first heard this one, I thought it was doublespeak, of course you have to perform a laparotomy to remove a gall bladder. Then I realized that it was all about a minimally invasive technique to remove a gall bladder with a laparoscope. We did not have those back in the good old days(?) of open surgeries. Then I began to wonder, "What does a scrub nurse do while the surgeon is working with that new fangled scope thingee?" Back in the day scrub nurses were as busy as cats covering s----, loading sponge ring forceps, lobbing sponges into the kick basin, cleaning instruments, picking up instruments, there was always something to do.

State of the Art- I see this buzz-phrase all the time in medical advertising (I think medical ads are a waste of resources and should be banned.) Anyhow I thought medicine was to be science based today, so maybe this is not such a great phrase. I recall, not long ago, bone marrow transplants were thought to be curative for breast cancer and state of the art. Unfortunately the science did not support the procedure.

PBA - (pseudo bulbar affect) a drug company term for labile emotions such as cycling between laughing and crying. We used to simply call this emotional incontinence and it was usually self limiting and did not require expensive pharmacologic intervention. Most patients I cared for with this "problem" were not bothered by it.

I am certain there are many more new, clever terms, but I have had in mind a post about nursing school housemothers. Sometimes it takes me some time to organize my thoughts. It sounds paradoxical, but when I proof read my posts, they deteriorate. It must have something to do with my foolish cognitive deficits of which I'm sure are many. IF some of my posts end too abruptly, it's because I hit that Publish button inadvertently.

I noticed that a good number of people were reading my profile page and thought I could refer some of them to my foolish blog efforts by joining Google+  I am clueless what it means to be a follower, but I do appreciate that 20+ took the trouble to do this. If I don't respond back or do what I am supposed to do with followers, it's because I really don't know what I'm doing.  I really do appreciate those who indulge me in this foolishness.

Friday, April 1, 2016

April Fools 2016

I was having one of my usual brain freezes this April Fool's Day and decided to Google medical pranks and foolishness suitable for the day. The best trick that I found was to put Surgilube on stethoscope earpieces which I thought was kind of cute.

Here is an unintentional, but true prank that I was an unwitting victim of. In nursing school our uniform inspections were very detailed and Miss Bruiser, our instructor always found some fault to humiliate a lowly student. We were always supposed to have our clinic shoes buffed up to a gleaming shine, but sometimes the white laces were neglected. I can hear Miss Bruiser's shrill voice, "You forgot to bleach your shoe laces and have just earned yourself a demerit." Shoe laces could be bleached in dilute Clorox solution several times with acceptable results.

My roommate had been called on this issue and was carefully bleaching shoe laces in a plain old drinking glass. Someone saw the glass filed with dilute Clorox and white shoelaces, thought it was milk (we used to smuggle milk back from the cafeteria like this all the time using this method.) The proper place for a glass of milk was the refrigerator which is where it went.

I saw what I thought was a glass of milk in the refrigerator and being half-awake dumped it on my cereal the next morning. The bubbling and gurgling of the cornflakes in the cereal bowl should have been a tip off, but not this time. I stuffed a big spoonful into my mouth. My tongue started to sting and a smokey substance erupted from my nose. I suddenly realized that I had ingested a toxic substance and quickly spit it out. The "milk" was actually a  solution of  the shoelaces bleached clean of hospital grime . After a few aggressive rinses with Listerine, I was fine. I will never forget that noxious taste and always viewed Clinic shoelaces in a different light after that episode. Maybe it was actually a boon to my immune system because I never got sick in nursing school.