Thursday, January 26, 2017

From the Anals of Anesthesia History

This photo was snapped in 1909 and immediately piqued my curiosity. At first glance, I guessed that this must be an old school exercise device, perhaps an inversion table or tilt table, but further investigation revealed that it's a set up for the rectal administration of ether anesthetics. This sounds like a high risk technique bordering on medical misadventure based on the flammability and mucosal irritating nature of ether. Here is what some of the physicians of the time had to say about colonic ether.

"The fact that the intestinal mucosa is especially efficient in transfer of gases to and fro from the blood, prompted the colonic administration of ether. The head of the operating table is depressed after the patient is placed on the table. The afferent rectal tube is inserted past the bulb and efferent tube. The anesthetist then opens the efferent tube to allowing bowel contents, if any to escape. The etherization should then commence by forcing the ether mixture into the bowel by pressing on the bulb until an intracolonic pressure of 20 mm Hg is obtained. Every 15 minutes the efferent tube should be opened and the cycle repeated. The colon should be inflated with oxygen after venting the superfluous ether at the conclusion of the procedure."

The prep for this anesthesia was brutal. NPO for 24 hours prior to surgery. Cleansing enemas the evening before and again in the AM prior to surgery. I was trying to deduce the rationale for the Trendelenberg (head down position) of the OR table and came up with a couple of guesses. Ether was notorious for inducing cardiac arrhythmias. An old school trick for converting arrhythmias was to place the patient in Trendelenberg and tell them to hold their breath or possibly the position helped in the retention of the ether. Who knows?

I was curious as to the nature of the ether used and learned that an ether generator was used. This was a crude vaporizer that created etherization by passing room air or oxygen through the liquid ether. Who knows what they did with the ether vapor that was vented off via the "efferent tube" but somehow I suspect that it was just vented out a window. This was a common practice many years ago and one of the reasons ORs were always on the top floor of old  hospitals.

One of the early axioms in medicine was the more primitive the procedure, the more sophisticated the lingo describing the action. That must be how the "afferent" and "efferent" rectal tubes came about. The clever old docs hijacked a term describing the autonomic nervous system and applied it to their backside buffoonery.

I don't think their notion that the intestinal mucosa is an effective means of gas exchange is accurate. "The patient is desaturating...get that rectal tube hooked up to oxygen said no one!" There is very little gas exchange along the GI tract as anyone who has erroneously intubated the esophagus knows all too well.

Although butts and gas go together like tweedle dee and tweedle dumb this procedure was inherently dangerous because ether was so flammable. Another complication was (surprise) rectal bleeding. This procedure looks more like a colitis simulator than an anesthesia agent.

Anyhow, the next time I have surgery it's going to be a spinal or regional.

Sunday, January 22, 2017

We've Only Just Begun

My affinity for medical devices was shattered to the core when this glimmering silver coffin-like
machine with all  it's doo dads, dials, roller pumps, and bubble machine up top was wheeled into a room. Someone even had the audacity to attach an anesthesia dispensing Halothane vaporizer into one of the circuits. It hung off the end of this beast with all of the grace of a man who had an encounter with cowboy justice. Unconsciousness was the modus operandi of this device - no anesthesia augmentation necessary. Waking up was the real challenge.

Dr. Nutsy, our one and only heart surgeon was in charge of this splendid piece of medical equipment and did he ever have clout with the purse string controlling, office sitting bigshots. The hospital had just spent $835 to have his baby air freighted fron Ohare in Chicago to Texas to install a state of the art entertainment system that consisted of an 8 track tape deck. Two speakers one on each end amplified the tunes. I shudder to think what he paid for the installation for this state of the art audio device. We were too blown away by the air freight charge to even think about installation fees. This was a surgeon who got what he wanted. Few hospitals did open heart surgery  and retaining Dr. Nutsy was essential to maintaining bragging rights.

Early open heart surgery was not pretty. Dr. Nutsy once lost 8 patients in a row and the nurses that lost  big money betting on number 9 were consoled by the fact the young patient was only 7 years old and had an easily repaired septal defect. I remember how delighted we all were when his young patient did so well that she walked out of the hospital a week later. Even a surgeon with borderline surgical skills gets lucky now and then.

The heart room had a dedicated team so I never had the pleasure of working with Dr. Nutsy. His shovel like lunch.hooks hands wielding sharp metal objects, some them under pneumatic power near a beating human heart looked like something out of a horror movie. All that blood coursing about to and fro in clear tubing added to the creepy ambience. Dr. Nutsy had mutton chop like bushy  sideburns and it used to creep me out watching dandruff particles flake off and lazily float like snowflakes into the surgical site. His patients survivors did have low infection rates so this must have been aseptic dandruff if there is such a thing.

I remember one of the early myocardial revascularization techniques involved dusting the heart with talcum powder in hopes that the irritation would stimulate new circulation. Maybe Dr. Nutsy and his shedding of intraoperative dandruff was unto something.

Sometimes uninvolved and disinterested observers have a different perspective that initiates questions that the so called experts never consider. I intuitively thought that medical devices that mimicked the way human organs functioned were best. After all, early ventilators had a sigh mode where the device delivered a deep breath from time to time. That rock steady non pulsating output of a heart lung machine was nothing like the squirt - squirt output of an actual heart. Blood flowed from a heart lung machine like soft ice cream from a soft serve machine. The heart provided intermittent squirts of blood  that a trauma nurse knows all  too well from observing an arterial bleeder. How could this be?

When I asked Dr. Nasty about this, he claimed that he never thought of it and mumbled something about capillary perfusion. I was always afraid to even speak to him with his belittling demeanor.

His love of music was limited to an early 1970s pop group, The Carpenters. I clearly reollect the lovely contralto tones of Karen Carpenter flowing from the side speakers on the heart lung machine.
"We've only just begun.. We've only just begun to live, so much of life ahead... A kiss for luck and we are on our way." Unforunately the lovely music was often interrupted by lengthy bitter diatribes and outbursts from Dr. Nasty because so many times while the beat of the 8 track tape player in the perfusion machine went on, the patients heart beat did not..

I never could stand listening to the Carpenters after spending time in Dr. Nasty's heart room. When the Carpenters tunes were played I felt instant waves of fear pass through my body and visions of that 8 track tape sitting on top of that heart lung pump as the patient was wheeled out danced in my head.

Some images really stick with you.

Monday, January 16, 2017

When Air Becomes Breath - A Historical Perspective

"After 8 more arm raise cycles, It's time to check her ABGs"
A 1910's critical care nurse has just found her patient apneic and beginning to turn that dreaded inky, cyanotic color. All is not lost. It's time to initiate artificial respiration. Of course before all the heroic measures start, it's always prudent to check the upper airway for an obstruction. Every old nurse knows the time honored mouth opening trick of placing a thumb on the mandibular arch and the index finger positioned above on the maxilla and then rapidly crisscrossing her fingers. The other hand  finger is free to probe the oropharynx for obstructions. If you encounter a hot dog segment, Brazil nut, or hunk of steak all you have to do is yank it out and  hope for the return of spontaneous breathing.

If the chest has ceased that comforting sight of rising and falling, it's time for artificial respiration. Pull your supine patient to the very  head of the cart, table, or bed and get a gorilla grip on her forearms. To initiate expiration, pull her arms down and adducted into her chest with her fists at the base of her lungs. Now for the fun part. Rapidly pull her arms overhead and below her body for inspiration. One caveat: just as modern CPR can crack ribs, this old school method can wreak havoc with elbows dislocations. Just how do you explain that to the family? This complication is also not favorable to Press Ganey Satisfaction Surveys so be careful lest those pesky patient relationship builder consultants  appear on the scene. (As an Oldfoolrn, I give thanks everyday that I never had to deal with that!) Hats off to you bright, whippersnapperns that are forced to submit to this nonsense.

There was one other old school artificial respiration trick  procedure done with the patient prone. The nurse jumps up into the bed or litter and straddles the patient. The patients arms are flexed at the elbows with forearms at a right angle to the body. For expiration the nurse pushes down and forward at the base of the lungs and inspiration involves grabbing the flexed elbows and pulling them toward and into the head. This was the popular Red Cross method taught to 1960's lifeguards. These techniques probably moved just enough air to clear the dead space in the pharynx, larynx, and trachea.

Unfortunately these techniques ignored one of the most basic anatomic characteristics of the chest which except for some intercostal movement during respiration is a very rigid, unyielding  cage like structure. When the diaphragm moves down the volume of the chest increases, lowering the intrathoracic pressure causing inspiration. A very clear example of what happens with a non rigid chest occurs with traumatic injury breaking ribs causing a flail chest. Not a pretty picture when the chest wall is mobile and it's really time to head to the OR.

An Engstorm in action. Who needs piped in
Oxygen with those handy dandy "J' cylinders?
Moving them around was like wrestling a
Sumo Wrestler.

A lifesaving (oh, how I hate that term) innovation for critically ill patients was the introduction of  volume respirators such as the mid 1960's Engstroms. These precision machines from the Karolinska Institute in Sweeden cost $8,000 USD in 1960 and had the capability of expanding the lungs at the alveolar level. This was the birth of PEEP (positive end expiratory pressure.)

These early ventilators were impressive looking machines. The control panel looked like something from an airplane cockpit and was ingeniously tilted to prevent nurses from stacking anything on top of it. I can tell you from personal experience this was no place to temporarily set down that Albumin bottle.Cleaning up the sticky substance laced with glass shards is a lesson that sticks with you.

As much as Oldfoolrns love old, familiar analog medical machines, they could have some truly vexing and potentially fatal problems. Being a 100% mechanical device the Engstrom had zilch in the way of electronic alarms. A nurse could be lulled into a false sense of security by that reassuring whoosh/whoosh as the macines bellows appeared to inflate the patient's lungs. Without a continuous monitoring of pressure in the breathing circuit, a patient's trach tube could disconnect from the ventilator tubing without an audible warning. Nurses really had to be right at the bedside watching for the rise and fall of the patient's chest.

I cannot resist the segue to a foolish tale from yesteryear. Ventilator supported patients in the times before oximeters and capnography required frequent arterial blood sampling (ABGs)  to monitor respiratory status. If the patient had an arterial line in place this was no problem. Without an arterial line nurses had to tap a radial or femoral artery for a sample inflicting pain and trauma. We hated doing these on a frequent basis and if the critical care fellow ordered ABG's too often we threatened to put a plastic trash can liner over his head and draw his blood gases in 30 minutes. The young physicians were conditioned so that whenever a nurse began removing a  plastic trash can liner from the waste basket, it was time to rethink the blood gas order.

Tuesday, January 10, 2017

The Disappearance of Darkness

Before PACUs there were recovery rooms and yes they were nocturnally
illuminated by 15 watt nightlights and nurses penlights

Over countless millennia,  human behavior has been influenced by the 24 hour cycle of sunlight and darkness. Evolution has imprinted our nervous systems with the notion that daylight is for vigilance and night is for peaceful rest. Fooling around with nature's rhythms produces an unpleasant emotional response. Just ask any night nurse how they feel leaving the hospital when all the daylight personnel file in all bright eyed and bushy tailed. I used to feel nauseated after working nights and the bright sun provoked a throbbing headache. Hospital patients don't feel well to begin with and keeping them up all night with bright lights adds fuel to their emotional distress.

Modern hospitals are brilliantly illuminated inside and out at night. The brightness of the helipad can be seen from miles away. Florescent lights bombard halls and patient rooms with artificial daylight 24/7. This photon bombardment is definitely NOT patient centered.

One local hospital here in Pittsburgh actually had signage (don't get me started on hospital signs) offering eye masks to patients. Just ask your local friendly nurse for one if the bright lights prevent you from sleeping. Maybe they should be also be in the ear plug dispensing business. There is certainly minimal resources contributed to promoting restful sleep. I guess this is one more attempt to force patient participation in their care. "No.. we cannot dim the lights at night so here is an eye mask to cover your face with." said the caring nurse.

From personal experience, I can tell you hospitals do not promote restful nights for their patients. I don't know which was worse, the bright overhead lights or the nurses clip clopping around in their noise producing clog footwear. I believe they are called Danskos, but a more accurate name would be Decibels for all the racket they produce. Old nurses valued quiet footwear. There  was nothing like a well broken in pair of Clinic nursing shoes for stealthy moving around at night.

Old school hospitals were serious about patients getting their rest. Sleep was actually recognized as an important element for the patient's recovery. At night the hall lights were dimmed by a switch at the nurse's station so they were barely on. All areas occupied by patients contained one tiny night light that was louvered and close to the floor. Nursing personnel all carried flashlights or tiny penlights and these were only switched on at the bedside when providing care. There was a cache of tiny 15 watt bulbs at every nursing station. Darkness was an important commodity.

I have been attempting to write about something other than operating room tales, but it's difficult to shift gears at my age. So here I go again with a story about lights out in the OR.

There was an unusual, but very good vascular neurosurgeon that I occasionally worked with. After clipping and removing a potentially life threatening aneurysm from cerebral circulation his routine orders were for the circulator to turn off all overhead lighting for a full 2 minutes. He asked the nurse to carefully time the lights out interval, but by instinct, he could tell exactly when 2 minutes were up.

His explanation for this practice was that the brain was housed in the light tight cranium. He wanted assurance that there would be no occult bleeding in the dark intracranial cavity after he closed everything up. If anyone questioned this practice he always said in a haughty, judgmental voice that he was doing this based on empirical evidence. I guess his point was that this trick seemed to work, but there was no science to back it up.

I always thought that after having a brief lights out interval, the surgeon's eyesight was more acute and sensitive to any bleeding after the lights were fired back on. Anyhow, his trick seemed to work. Nurses see some whacky things!

Thanks for reading my foolishness.

Sunday, January 1, 2017

Not on My Back Table!!

Don't even think about lobbing that ovarian cystic teratoma on my back table.

Old school scrub nurses work from 2 horizontal surfaces, a Mayo stand which is positioned just South of the surgical site and a back table that sits at the patient's feet at a right angle to the patient. Every scrub nurse likes to keep an organized Mayo stand with a minimal amount of instruments. When it's time to close all I kept on the Mayo stand was a pick-ups, needle holder, suture  and straight Mayo scissors. This can lead to the back table assuming the role of a dumping ground which got me  angry as a surgeon with a non-functioning suction. Here are some things to keep away from my back table or I will pinch your keister  with a sponge ring forceps. I am experienced with doing this without breaking sterile technique, so beware! I know from personal experience that sponge ring forceps can leave one heck of  a mark and the pain can give you something to really think about.

I don't like basins of water or solutions sloshing around on my back table. This is an OR, not a trout farm. Whatever happened to ring stands for basins of water? When I see photos of contemporary ORs the ring stands have disappeared. Where does all that unused OR  equipment wind up? Probably in the same place as sponge racks and table-side light stands. Bring back the ring stands and get that aquarium sized basin of water of your back table. It's a hazard every time you move or bump the back table. A wet back table is a contaminated back table.

Another thing I hate on my back table is oversize specimens. Trying to land a huge pandus or teratoma on my back table is like landing a 747 jumbo jetliner on an aircraft carrier. Don't do it. Big hunks or globs of tissue should be handed off to the circulator. If the circulator is busy and the surgeon insists on lobbing that Big Tuna of a specimen your way, just drop it in the kick basin. The crash/splat noise it makes when it hits the target will remind everyone not to pull this trick again. Think of that sound as resembling a church bell ringing in a slaughter house as that big side of beef is placed on a cutting table. It's a  very memorable sound like a newborn's first cry or the rales and rhonchi of a patient on his death bed; an acoustic experience that really sticks with you.

Kudos to the person who invented sterile operating room light handles. Surgeons are like patients in that the more they can meet their own needs, the better for all parties concerned. Savvy scrub nurses do not keep sterile light handle adjusters on their back table. Before you set out an instrument, take a couple of seconds to thread those sterile light handles in place. Get them off the back table.  When a surgeon bellows to the circulator for a lighting adjustment you can curtly reply, "The adjustment handles for the lights are sterile, monkey around with them at your leisure." Multiple adjustments of lighting on the same surgical site can be indicative of a poor prognosis. I wrote a post about unusual signs of a bad prognosis, I think it could be located by typing "Prognosis" in the search box. In the new year, I promise to figure out links!

Anything that has the potential to dangle over the edge of the back table does not belong there. Only the very top of any table is considered sterile. Get rid of that suction tubing and potential dangler early in the game to be on the safe side.

Here is something that I have had some painful encounters with. Loaded needle holders on the back table are a real danger to hurried hands. They will stab you right through that glove.  Why do bright, young whippersnapperns wear gloves when handling needles? Gloves provide no defense when it comes to needle sticks and dull tactile sensations. It is hard for oldsters like myself to make sense of healthcare today.

Enough of my foolishness. Thanks so much for indulging in my silliness and I hope the New Year brings you peace and fulfillment in all that you do.