Saturday, June 25, 2016

Name That Old School Object

These gizmos were few and far between but it was always good to find one.  If they ever clogged up, close the lid and flush away to your heart's content. Here are some possible answers. Just pick one of the answers or enlighten me with one of your own.

It's a science project gone awry. It was designed to be a tornado replicator. Just add some water and you can experience all the fury of a typhoon.

It's actually a horizontal hopper. Just invert the bedpan, close the  lid and let it work it's magic.

This is actually a distilling device for custom making irrigation fluid.

It's actually an old school public address system. The nurse just bellows into the megaphone like device and everyone on the floor can hear her. "I need help with a lift in 221 bed 1 or visiting hours are now over."

I promise to reveal the correct answer real soon.

Tuesday, June 21, 2016

Why Are Operating Rooms Always on the Top Floor of Old Hospitals?

Old hospitals were the source of many mysterious questions; What is that funny smell?.. How tight should a scultetus binder be applied?..How many hospital beds can you fit into a 600 square foot room?..Where is that blood curdling scream coming from?.. and finally, Why are the operating rooms always on the top floor of a hospital building?

In virtually any mid 20th century hospital patients were always being sent UP to surgery. The first time I heard that a patient was coming down to the operating room, I thought that either the ambient nitrous oxide in the room or sleep deprivation was getting the best of me. When I googled the question about operating rooms always being on the top floor of old hospitals very little came up. I just love obscure or overlooked questions that I can answer with my vast accumulation of foolishness so here I go again.

Cook County Hospital, Chicago, Illinois. Operating Rooms
on the top, morgue in the basement. Just like it should be.

I think that the notion of placing the OR on the top floor came about as an idea to isolate the area from the septic environment found on hospital wards. Nasty conditions like advanced syphilis, TB, pneumonia, and every contagious disease known to man was ever present in the hospital.  Setting up the OR and isolating it from general hospital traffic was a good idea. A sort of institutional inertia was set into motion and all hospitals adopted the notion of the top floor is where to place the OR.

There were other benefits to this top floor set up. Surgeons quickly learned that being on the top added another valuable tool to their pre-op evaluation armamentarium. The general surgery floor at our hospital was on the 6th floor directly below the OR. It was common hospital knowledge that the stairwell leading up to the OR was the perfect arena for pulmonary function testing. Instruct your patient that all he has to do to prove his lung capacity is to climb the flight of steps from the 6th floor to the 7th floor OR. Anesthesia residents would even write orders to hold the pre-op med until pulmonary function tests were completed. We all knew what that meant. It was not unusual to see a cachectic little old man wheezing and expectorating green mucous gobs while attempting his ascent. A resident holding his IV bottle and offering encouragement by pushing from behind was not unusual. I always remembered to watch out for slick, green spots when running up the operating room  stairs for an emergency call.

A couple of the older operating rooms actually had large skylights for natural lighting. Overhead lights had been added later in a modernization move, but those light rays beaming in were really a boon to surgery. Everyone really liked the naturally lit rooms and this was another good reason to locate the ORs on the top. After a heavy Chicago snow storm one of the first things to be cleared were the rooftop skylights.

Operating rooms on the top offered the opportunity to vent anesthetic agents which had the propensity to rise skyward when released. Today, I suspect all anesthesia is administered by a closed rebreathing circuit. In my time, it was not unusual to have an open system where exhaled gases from the patient were vented right out an open window via a clever device known as a "blow hose." Had the operating rooms been located on a lower floor of the hospital, the vented anesthetic agents could have anesthetized a captive audience, the patients on the wards. Whenever maintenance workers discovered deceased avian creatures on the roof we all suspected that it was the anesthetics.

The penthouse location of the operating rooms afforded some fantastic views of Chicago. We had several beautiful, huge, white ceramic scrub sinks located in an alcove with a splendid view of Lake Michigan. (If you would like to read what I think about  those rotten, no good, modern stainless steel scrub sinks, please see my scrub sinks post.)  Those new-fangled metal sinks look like they would be more suitable as livestock feeders and look out of place in a dignified OR. I despise them!  Ooops sorry about getting off topic.  It was a delight to watch the sailboats on the lake while scrubbing up for a difficult case. From time to time, surgeons would take a break from a case to refocus and gaze out the windows for a second or two.  Everyone appreciated the view from the top.

As a youngster, I always dashed up the stairs to reach the operating room suites. A bit of aerobic exercise served to clear the mind and the alternative was unpleasant. There was one old manually operated elevator to the surgical suites and it was manned by a cranky (that's putting it nicely) old man named Tony. He had an obvious, crippling orthopedic problem which he blamed on the entire medical world.  He must have had a series of orthopedic surgeries with a suboptimal outcome. When transporting attendings, he always kept his mouth zippered, but with nurses or residents he let the venom fly. He would begin by accelerating the elevator car up like a rocket and aggressively slamming on the brakes at the last minute leaving a gap to climb up to the 7th floor operating rooms. Upon arrival he would announce "butcher shop..everybody out."  I tried to avoid this at all cost. I suspect someone gave him the job out of kindness or because they felt sorry for his plight.

The other nice thing about being on the top floor was the relative peace and silence. Despite the posting of QUIET..HOSPITAL ZONE signs, the din of city traffic could always be heard on the lower hospital floors. I remember when James Taylor sang that old Drifters song "Up On the Roof." The lyrics "On the roof it's peaceful as can be. And the world below can't bother me."  It sounded to me he must have been singing about the location of the operating rooms.

Another feature of top floor operating rooms was a hybrid climate control system. Insects could not fly very well above about the 3rd floor so in the Spring and Summer we could open our windows. Winter meant that it was time to fire up the radiators and if they put out too much heat we could always open the windows. Whippersapperns think hybrid operating rooms are a new thing, but we had them back in the good old days of big open surgeries.

When our old penthouse operating rooms were finally retired, the area was redone at great expense to house the offices of our esteemed hospital director. What a great testimony to the value of the top floor location. Our brand new operating rooms were smack dab in the middle of a brand new building. Something always seemed like it was missing.

Sunday, June 12, 2016

Sleeping Pills: A Hypnotics History From 1960-1990

Sleeping pills always reminded me of the organized crime situation in Chicago; widespread, old players withdrawn (or jailed), new players or pills on the scene every decade, claims to be safe and acceptable, but very dangerous, and often fatal with long term use.

In the 1960's the big time hypnotic players were barbiturates such as the alluring red/pink Seconal. These little capsules were like a knock out punch in a medicine cup. After witnessing their power, I used to get sleepy just looking at the potent pill. Give one of these little 100mg capsules to a patient and it was guaranteed that in 30 minutes they would be sawing logs. I used to speculate that in a pinch these gems could be used for light anesthesia in minor cases.  I discovered that notion was not far from the truth. Dr. Bustoff, our plastic surgeon, used to order Seconal prior to performing local cases with Lidocaine. I vividly recall one case involving the excision of multiple sebaceous cysts where Dr. Bustoff  underestimated the length of the procedure and the patient began to arouse. "Tell him to stop screaming and give him 100mg of seconal STAT," was the order from the good doctor. Sure enough, 5 minutes later the patient was sound asleep and business went on as usual in the OR. Maybe open heart surgery could be done with a double dose!

Seconal was a drug that was carefully accounted for even before the Controlled Substances Act of 1970. The drug was sold by Eli Lilly and was packaged in small numbered cellophane ( a plastics precursor) packets that were reverse  numbered and rolled into strips and packaged 25 in a memorable green box with the Lilly logo plastered all over it. The company must have really been proud of this product. Nurses had a tremendous amount of respect for this powerful drug and I was never aware of diversion or abuse issues with nurses, although I have heard stories about health care workers becoming addicted. This drug was like penicillin in that fancy marketing campaigns and drug salesmen were unnecessary. The end results speak for themselves and did not really require promotions.

Occasionally, I research google something before I write (if you could call it that) about it. It was shocking to me that a pharmaceutical company recently acquired the right to market Seconal and was currently selling it for $3,000 per 100 capsules because the drug had been found useful in physician assisted suicides. Kind of sad, but then I realized that I must have handled over a million dollars worth of this drug.  It seemed like almost every hospital patient was on Seconal. As a nurse it always seemed like big money was flowing right through me or around me, but I can't complain, I've always had everything I could want with the wealth accumulated from being a scrub nurse. Life is good and most mornings I couldn't wait to get going in the OR which was probably a lot more important than the money. All of my old colleagues who have gone onto their great reward ran out of health long before they ran out of money.

Around 1970 or so, Seconal began to fall out of favor as it's addictive potential was recognized. A patient experiencing symptoms of barbiturate withdraw was not pleasant and the only way to combat the problem was with reintroducing the drug and tapering off it. Sometimes old school detox treatments were probably not too smart. Abbott labs actually made a D5W solution containing ethyl alcohol to prevent DTs while alcoholics underwent medical treatment. As a young nurse, I noticed a disproportionate number of alcoholics coming from suburbs around Ohare airport. I figured the jet noise must have driven them to the bottle.

In 1970 the shift to "safe" alternatives to Seconal was in full swing. The two I remember best were Doriden and Pacidyl. The most popular of these at our hospital was by far Placidyl. It came in 3 memorable doses; big, green jelly bean 750 mg cartoonish looking gelatin capsules, red gelatin jelly bean capsules which were 500mg and round gelatin 200mg capsules. The 200mg strength was intended to induce sleep if a patient aroused (not likely) from the heavy duty jelly bean capsules. Placidyl was not counted and there were huge stock bottles of it in every med room. Some nurses claimed the 500mg capsules were an effective way to deal with working an occasional night as a daytime sleep aid, but I never really wanted to try it after seeing what it did to patients.

One of the perks of being a senior student nurse was a class bus trip to Abbott Labs in North Chicago, Illinois. This drug company treated us like royalty (so different from our instructors.) We were treated to a really good lunch and a tour of the facility. The Placidyl production line was very memorable with 1000's of those red  Placidyl capsules and gelatin waste everywhere from molding the capsules. The excess gelatin was not really wasted, the drug company reused it as backing for the little paper memo tablets they gave away to medical personnel to promote their products. One of the tag lines printed on the Placidyl gelatin bound notepads was; "PLACIDYL...and softly,gentle slumber comes. Rest assured." When I saw this clever slogan the first thing that came to mind was "take one Placidyl too many and rest in peace." How different from the pharmaceutical industry of today that just raises prices to whatever level they please. I don't think that any drug company of today would worry about wasting gelatin or taking the trouble to use it as paper tablet binding material. It was very clever to convert a waste product (gelatin) into a marketing promotion for the product that created the waste. A profit circle of sorts.

Despite an alluring, peaceful sounding name there were big time problems with Placidyl. There was a very narrow margin between therapeutic and toxic levels of the drug which resulted in overdose. I did not have much experience with Doriden, but I think it was so addictive that the FDA banned the manufacture of it. Both Placidyl and Doriden were on the way out in the late 1970's and the new decade ushered in the benzodiazepine era.

Dalmane was a biggie and widely used sleeping pill in the 1980's. Patients used to complain of a funny taste in their mouth in the morning after awakening from a Dalmane induced sleep. To me, it did not seem to have the potent knockout ability of Seconal or Placidyl. In the mid 1980's there was some discussion that perhaps Dalmane had too long of a half life and a short acting benzodiazepine, Halcion was used. From my observation, this did not seem to be effective and there was much patient dissatisfaction. Lots of patients complained from feeling hung over the day after taking Dalmane.

I don't really know what came next in the hypnotic arena, but judging from the direct to consumer advertising, this must be a fertile market. Direct consumer advertising of toxic prescription drugs is one of the dumbest things that I have ever witnessed, but that's a contemporary issue and beyond the scope of my old time foolishness.

Foolishness and science are about as dangerous of a combination as guns and alcohol so don't take anything here as being factually accurate. There is probably enough misinformation in some of my posts to launch a Donald Trump speech. Oopsie, I should not have said that, but at least I have a good excuse. These are old memories sifted through an ancient nervous system.

Wednesday, June 1, 2016

Self Portrait

Although I am basically a dog person, when I lived in a Chicago apartment, Fritz the cat was one of my best friends. I was walking home from a late night January trauma call and Fritz approached me in the alley behind my apartment. He looked really cold and his eyes had a pleading look about them. Personality wise he was very friendly and when I picked him up he immediately began purring. I toted him into the apartment and fed him a can of sardines which has always been one of my favorite foods. Fritz found himself a home and we were the best of buddies for a really long time. Catgut suture material took on a new meaning for me and I found myself grinning ear to ear under my mask when loading a needle holder. Fritz made me happy whenever I thought of him. He never complained about me leaving for a case in the middle of the night or spending too much time reading Alexanders: Care of  the Patient in Surgery. Fritz did have a big ego and looked much like the feline artist above and embodied the same mentality. He was a really good buddy and I miss him dearly.