Sunday, July 31, 2016

Sacral Perirenal Oxygen Insufflation - An Embarassing Gas Problem

A uroseptic patient positioned  with his derriere kissing the ceiling. A 3 inch spinal needle. Gas under pressure injected to the tune of over a liter. A young resident with the reassuring words, "Don't worry I've done this once before..."  What could go wrong?
I cannot imagine a more unpleasant imaging experience than this one from the 1960's. Just imagine feeling as sick as a dog and having someone position you with your buttocks as the highest point of your body and then ram rodding a 3 inch spinal needle into your coccyx. The best is yet to come as over a liter of oxygen is pumped into a place that it certainly does not belong. If you think expelling air post-colonoscopy is uncomfortable, you aint seen nothing yet. The only way to get rid of gas from this procedure is to hope that it absorbs before you suffer a fatal emboli.

All this for an X-ray that might define the morphology of a diseased kidney.

Thank god for CT scans.

Tuesday, July 26, 2016

It's a Bird!..It's a Plane!..No, It's a Patient!

Hospitals tend to elicit the fight or flight syndrome in some patients. This is a contemporary image but you better believe the problem is timeless. I have had to contend with birds like this decades ago.

When assessing patients for flight risk here is a helpful pneumonic mnemonic  device from The OldfoolRN Institute for Enlightenment. It's elegantly termed APE because all primates love to climb and it's easy for old fools like me to remember. Now if I could only recall what I ate for breakfast!

A -  represents alcohol which causes patients to do all kinds of silly things.  If your patient has imbibed welcome to the world of unpredictable events. I know you whippersnapperns are fond of algorithms and computers to predict the outcome of events, but if alcohol is involved you are on your own when figuring out when your patient may take to the skies.   From my experience in the OR with trauma patients, alcohol causes more pain and suffering than cancer or heart disease. Trouble in a bottle.

Drugs are also capable of altering consciousness to the extent that elevation events are possible. Amphetamines, cocaine, and even heavy marijuana use can be the wind beneath the wings of contemporary ascenders. It is prudent to limit the opportunity for patients to climb, but a determined and drug intoxicated patient can always find a way to the ceiling. Onward and upward.

P is for psychosis. It's really sad that someone would comply with voices telling them to do dangerous activities. When I worked at Downey VA hospital there were two water towers and each of them was surrounded by security fencing. I remember one patient that tunneled under the fence (ground hog style) and proceeded to ascend the ladder on the tower. Luckily, he was easily lured back down with the promise of a pack of cigarettes. When we asked him the rationale for his climb, he provided the  mountain climbers mantra, "Because it was there."

E is for elevation opportunity. This can be tricky to assess, but anything overhead could be climbable. Here in Pittsburgh, many of the old industrial jobs required climbing. I've cared for many steelworkers and they are some of my most memorable and treasured patients. A dozen steel workers would be more fun to care for than a single stock broker, but that's a story for another post.

One time I walked into a patient's room and found him on top of the traction frame. He had been incontinent and was carefully positioning little compacted spheres of stool down on the dangling trapeze.  When I asked him what he was doing the indignant response was, "I am mixing cement." The elevated positon made clean up much easier and a Posey belt tethered him to the bed. Anything overhead can be used for elevation.

I never had to worry about legal implications or litigation, but times have certainly changed. Just about any untoward event could be fodder for litigation. No matter how careful a nurse is , bad things can happen and the nurse in the above illustration has a clever risk management strategy. It's called going dark. Whip off that nametag and slap on a mask.

One final tip. Avoid going vertical after the patient. It only encourages them onward and upward.

Tuesday, July 19, 2016

The Operay - A 1930's Operating Room Light

As a scrub nurse, I have had many memorable surgical experiences: there was the trauma patient hemorrhaging so fast that you could hear it, bubbling chest wounds,  loading 2 Raney clips simultaneously with the same hand,  and  that strange extraterrestrial-like object hanging from the ceiling in our oldest and unused operating room.

The old abandoned  operating room at the end of the hall contained some interesting bits of surgical history. There was an observation gallery that was accessed by climbing an old wooden ladder. It was so well used that the rungs were worn down by the footsteps of budding  young surgeons learning their trade. If I had been around back then, I might have waited until they were all situated and surreptitiously removed it.

What really got  my attention was that extraterrestrial appearing object suspended from the ceiling and hovering above that old operating table. It was surrounded by 4 mirrors and I deduced that their purpose was to frighten alien visitors back to the solar system they came from. When they emerged from that Sputnik like device in the center, one look in the mirrors would frighten them so badly that they would return to their place of origin.

My next thought was that the mirrors were to give the budding surgeons in the observation gallery a better view of the surgical procedure. Maybe they could reflect a view from deep inside a wound. The sight lines were a bit off so I quickly dismissed that theory.
A bit later, I learned that Dr.  Slambow, my general surgeon hero, had actually performed surgery in the 1940's using this mysterious object for illumination. It was an Operay surgical light manufactured by The Ohio Chemical and Manufacturing company in the mid 1930's. This company is still in business as Ohio Air which manufactures suction and flow meter equipment.

Old time operating theaters or galleries such as the amphitheater at the Pennsylvania Hospital or the Ether Dome in Boston were illuminated solely by soft, available light delivered via skylights. This greatly limited the times suitable for surgery. When the sun went down, the surgeon was out of luck. This soft, diffuse natural light was thought to be the ideal illumination for surgery. The Operay was designed to be a shadowless light source to replicate the natural lighting in old operating theaters.

The Operay was a very complex device for delivering this shadowless light. The most fascinating part of this system was the central sputnik-like light source. This component of the Operay was referred to as an orb, sphere, Christmas ornament or light ball. It contained two incandescent light bulbs each drawing 200 watts. There were 6 concave mirrors reflecting the light through 6 or 7 convex lenses on the periphery of the orb. Later models of the Operay replaced the lens on the top of the sphere with another light bulb in attempt to produce more light. The light was then reflected off the four remote mirrors and finally reached the operative field. I don't recall that much from high school physics, but I do remember the inverse square law regarding light. Double the distance the light travels and  you reduce the intensity big time. The Operay was really a fancy way to reduce lighting intensity. Not a good thing in the operating room.

There was a knob extending down from the Operay between the counterweight and the light ball that was connected to a gearbox controlling the rotation of the orb. This served to focus and direct the shadowless light to the operative field. This orb control knob was fascinating. The gears were as smooth as silk and it was a thrill to see those rays of light do their dance with such little twisting of the control knob. It made me feel like a cat with a big ball of yarn. Whenever  I had time between cases, that old abandonded operating room and the spectacular Operay beckoned me with their siren call. At least Dr. Slambow always knew where to find me.

From a patient's perspective lying on the table, an Operay was probably a haunting sight. Those old time anesthetics were famous for their emergence reactions and I suspect the Operay hovering overhead added fuel to the fire. That orb looked like it was straight from Dr. Frankenstein's laboratory. Imagine lying on the table gazing up at that orb surrounded by those ominous mirrors and the anesthetist lowering an ether frame over your nose and mouth. The instrument nurse brandishing flesh shearing instruments and lurking in the background did little to reassure the hapless patient. Those heavy duty restraint belts on old operating tables were there for a good reason.

A patient's view of the Operay as viewed from the table. Image
courtesy of (Thanks Steve)

I doubt they had sterile light handles for the surgeon to make his own adjustments to the Operay. I would have loved to hear the old time surgeon's light directing commands to the hapless circulating nurse or hustle nurse in the vernacular of the day. "Move that 2nd mirror so it shines some light on the gall bladder not the liver... I said gall bladder you idiot." The adjusting knob is visible just to the left of  the solid copper counterweight on the far right.
A really nice overall view of the Operay. Pedestal mount units were also available. I suspect that counterweight
caused much head trauma when it impacted with a careless circulating nurse.

Despite the complexity and intricate nature of the Operay, the .end result was disappointing. Surgeons quickly learned that shadowless lighting was not all it was cracked up to be. Shadows are necessary for depth perception and delineation of textures in different tissues. It is also more important to have the lighting illuminate deep into wounds rather than worry about shadows. The Operay did not put out much light and even adding an additional bulb to the top of the sphere did not help. By the end of  WWII the Operay was obsolete.

The mechanical complexity, specialized use, and rarity of  Operay lights spark an acquisition urge in some and inspire collectability. I have seen Operays listed on Ebay for $3000 or more. Somewhere amongst my nursing junk pile archives I managed to save a burned out lightbulb from our old Operay. It was unusual because it was not frosted and had a visible filament. There was no wattage listed on the bulb, but it was mysteriously  labeled a 212 light bulb.

There were a number of complex solutions to medical problems that did not work out. I'm thinking of those complex gyne instruments for external pelvic measurements to assess pregnancies or the use of hyperbaric chambers for heart surgeries. Lutheran General Hospital in Park Ridge, Illinois designed a hydraulically driven heart lung machine for use in their hyperbaric chamber. Another widespread use of a complex device was the IPPB for all decade of the 1970's.  Complexity does not always translate to improvement.

Friday, July 15, 2016

A Fine Art Operating Room

This is the plastic surgery OR at Barnes Hospital in St. Louis MO circa mid 1930's. I have worked with many plastic surgeons and they were a zany lot. This surgeon even commissioned an artist named Gisella Loefler to decorate his room.

A number of sights grabbed my attention here. Why are there 2 scrub nurses? I suspect one must be a student. That instrument trolley is actually a precursor to what is a modern Mayo stand. Modern that is to Old Fools like me. In the 1930's operating rooms had a common back table which was loaded up with instruments for a full day of cases. The nurse selected instruments for the current case from the common supply on the back table. The back table was always covered between cases. Nurses and surgeons stayed put in the room until the day's caseload was done. None of that traipsing in and out of the room between cases like you whippersnapperns are so accustomed to. This eliminated extensive room turnover times and there was minimal delay between cases.

One of the scrub nurses has committed one of the 7 deadly sins of OR nursing; her gloved hands have been dropped below the waist band of her gown. For punishment, may I suggest damp dusting that overhead Operay multibeam shadowless light. This was difficult to do with traditional lighting, but imagine the fun in cleaning the nooks and crannies in that Operay

I have always been fascinated with OR lighting devices and I immediately recognized that Operay shadowless lighting system. Our very old unused (except for Dr. Slambow's office) operating room had one of these devices. I spent many happy hours fooling around with it and will post about it soon.

Friday, July 8, 2016

Oldfoolrn"s Guide to Cost Cutting in Healthcare

The cost and financial end of healthcare today takes my breath away. The skies the limit with expenses and it seems like any price can be justified. We were constantly reminded to limit our use of expensive commodities like gloves and to reuse just about anything and everything. We used the containers of big piston syringes as props to hold heavy single hung windows open. Empty cardboard boxes were stuffed with trash and hauled off to the incinerator. If any hospital purchasing agents are interested, here are some money saving tips.

Hospital equipment is grossly overpriced. A Hoyer patient lift can cost as much as $3000. If you would like to save $2800, skip those over priced medical supply joints and hustle on over to your local, friendly Harbor Freight Tool store. You can purchase a $189 engine hoist that can easily double as a Hoyer and save thousands. Maybe you could give the nurses a raise. One caveat, both engines and patients can be prone to fluid leaks at the most inopportune times. Engines leak oil and coolant. There is something about the herkey-jerkey action of patient lifts that stimulate peristalsis. Blue chux pads are in order for patients and absorbing granules should be scattered on the garage floor. If you are a free spirit try the absorbent material for the patient and stick a blue pad under that oil belching engine.
Sometimes the new-fangled replacement for time tested equipment is a joke. We used the 3 bottle set up for closed chest drainage. I did not look this up and I can tell you exactly how a 3 glass (of course) bottle set up is configured: bottle 3 is the suction control. bottle 2 is the water seal and bottle 1 is the collection bottle.  When plastic pleurevacs came on the scene in the early 1970's we figured they would never come into widespread use. They were NOISEY. All that plastic amplified the bubbling sound to the degree that it sounded like we were working inside one of the fish tanks at Shed Aquarium. These fancy noisemakers were not cheap. Glass bottles were readily available at no cost from the pharmacy, pleurevacs were a hundred bucks or so. Bring back the trusty glass bottles and save money and wear and tear on your eardrums.
A no cost, quiet, effective chest tube drainage set-up
The expensive, noisy, alternative

I will let you in on a little secret. All animals on earth are carbon based lifeforms. Homo sapiens have only been around for 200,000 years or so. Inflammation, infection, and disease processes are similar in humans and animals. I think religious entities are to blame for spreading that baloney about humans being superior and having domain over animals. People and animals are more alike than most homo sapiens would admit.

When I took my best friend to the veterinarian she only charged $35 to remove a huge sebaceous cyst from  his back. They say pet owners are much like their pets and in my case this was true, but when I inquired of the veterinarian about removing the cysts on my back she looked at me like I was nuts. Something about licensing laws and such. Think of the money that could be saved by letting veterinarians perform surgery on humans. That would really be something to bark about.

Any type of specialized equipment is likely to be overpriced. A good example is evacuation chairs and I'm not talking about bedside commodes. There is actually a special device for moving patients down a flight of stairs in a disaster. These gizmos probably work but cost several thousand dollars and how do you keep one of these overpriced wonder seats available for disaster use. Ordinary chairs  and wheelchairs are everywhere in a hospital while evacuation chairs are few and far between. With practice a wheelchair can be used to evacuate patients down a flight of stairs. Just go down backwards with the big wheels first. Two people can carry a patient downstairs in a standard chair if you restrain the patient to the chair with a Posey belt. We used to actually practice this with drills.

With the influx of big business types and the corporatization of hospitals real money wasting is as common as infections in pre-Lister days. One of the most costly trends is when business types attempt to quantify completely subjective matters. I'm thinking of those pain rating scales where patients have 10 increments to rate their pain. Whenever I've been in pain, it hurt too much to figure out the difference between a 6 and 7.  When the cost of addiction and all the related pain and suffering is factored in, this has to be a very expensive endeavor.

I'm thinking of starting  a new feature called "caresucker of the month" for the most wasteful use of healthcare resources.  This month the award goes to those who seek to quantify subjective experiences. I suspect they are the same characters that would spend 3 thousand dollars for an evacuation chair.

Friday, July 1, 2016

Bedside Nurses In Action

I came across these mid 1960's images of bedside nurses and thought they really illustrated old time diploma school nurses in their glory days. These were the times before nurse theoreticians, nurse informatics, computer  nurses, pharmaceutical sales nurses, and other permutations of their ilk. Bedside nursing was a calling and the bedside was the alter where it was practiced. We used to feel deep sorrow for any nurse that couldn't cut it at the bedside. They were holed up in places like central supply or doctor's offices and we viewed them as a sorry lot. The entire nurse academic establishment was yet to come but I am certain they would have been viewed in a pejorative light. Nurses, after all, were trained - not educated.