Friday, May 26, 2017

What is This Newfangeled Juxta Business?

Medical terminology is in a constant state of flux and I'm all for change if more concise or precise - hey it rhymes- information is provided by the new term. But what's this new fangled juxta prefix  applied to anything and everything all about?

We have juxtaglomerular, juxtacortical (brain or kidney?), juxtapyloric,  juxtavertebral, juxtachondral, and who knows what juxta  else. In the good old days we had prefixes like peri-,circum-, or in plain speak,  thereabouts. These old school terms worked very well but,perhaps lacked some of the cache of the newfangled juxta speak. However, I think the lingo from yesteryear was more straightforward and served it's purpose well.

Youngsters seem to have a preoccupation with inventing new  terms to replace old school terms that have withstood the test of time. On a recent visit to the Carnegie Museum it was a shock to find all the dinosaur names unrecognizable. A taxonomic smart aleck had pulled a switheroo with all the classic dinosaur nomenclature. The venerable T. Rex (I can't spell the full name) was renamed Tarbosaurus. I think that sounds like the name of a docile creature like some delicate avian species. It certainly does not jibe with a apex predator like the T rex.

All this terminology and taxonomy malarkey calls for some harsh correction from the Oldfoolrn  Institute for the Advancement of Medical Terminology. It's always nice to know the prognosis when various medical terminology terms ejaculate from the tongues of sophisticated medical  banterers. It's a simple matter to tack on a suffix to the medical term to indicate prognostications.

If a good outcome is anticipated the suffix is  -goodjuju which can be abbreviated GJJ. If  a  storm is brewing on the medical  horizon and the patient is juxtaing the drain-oops I mean circling the drain, the appropriate suffix is badjuju or simply BJJ. Here is a sample: Aortic dissection BJJ or erythematous skin lesion GJJ. My system is straight forward and fun. Feel free to use the next time you are typing in a diagnosis on the EMR. Maybe if enough folks use this system it will gain traction, just like that silly Juxta prefix.


Sunday, May 21, 2017

A Tale of Two Brain Lesions

It was near the end of a long shift and  after plodding along for 10 hours or so we would run the printer on each monitor to obtain a strip for the medical record. I always believed random and routine collections of patient data had limited usefulness, but that's what the bosses wanted so I happily complied.  Suddenly, something strange happened, as I looked up to the waveform on the monitor, it looked like there were 2 or even 3 waveforms plastered right on top of another where I knew only a single waveform could  be  present.  This caught me completely off guard and I began to attribute the multi-waveform  apparition to my end of shift fatigue or some sort of whacky monitor artefact-not likely- but it seemed like an easy explanation. That little voice in the back of my head spoke up and said, "Nothing serious..probably just a brain tumor..he..he."

 As I went about my care, I noticed the monitored patient was lying there  intently listening to a CBS news report and anchorman Dan Rather was in a somber mood relating the story of  Lee Atwater, the head of the Republican National Party. He collapsed  at a public appearance and was subsequently diagnosed with a brain tumor. He was receiving radiation implants and all the latest modern medicine had to offer for such an ailment at  the prestigious Montefiore Hospital in NYC. I made a mental observation to myself that rich people always get state of the art care. I  never used much in the way of healthcare services but doubted I would have access to Lee Atwater quality of care if I was sick. Some people have all the luck.

Lee Atwater was ahead of his time with various political spin jobs  and even fake news. After elucidating the fact that one of his opponents had mental health issues a story was spun that eletro shock therapy diminished his mental capacity. During his illness Atwater found God and joined the Catholic Church. He made frequent biblical references and later it was discovered his Bible was sealed in a presentation box and never opened. Atwater kept  making his pitches and spinning right through an illness that would likely  be a terminal event. Some habits are tough to break.

As time went on more strange things began happening to me. One day I found the back passenger floor of my Subaru littered with 7 or 8 cans of NEHI non carbonated lemonade. I was a Diet Coke person and it was a complete mystery how these empty lemonade cans got there. Maybe someone broke into my car and left their Lemonade cans behind. I didn't even like the stuff.

 Then late one night on the way home from work I had an epiphany while feeding quarters into a vending machine at an out of the way K-Mart in a not so nice part of town. It was me with the Nehi Lemonade consumption. I suddenly developed a craving for NEHI Lemonade, but had no memory of purchasing this  mythical beverage. At least  I discovered how those empty beverage cans found their way to the floor of my Subaru. Oh well..chalk it up to rotating shifts and too much stress. Life sure can be strange.

A couple of weeks later things got really crazy. I began having very vivid visual perceptual distortions. When I looked upward, it looked like I was in a blinding  snowstorm. A really bad blizzard like distorted vision that occurred primarily while driving. I gave myself a mental pat on the back and remember thinking; that's one good reason for leaving the snow tires on all year. This was taking place at the end of June in Pittsburgh. I knew I was in deep trouble because it does not snow in Pittsburgh in June. That thought about snow tires failed as a rationalization for my newly acquired blizzard vision.

Another symptom began driving me nuts (or nuttier than my foolish baseline) and that was itching like I had never experienced. I tried self medicating with Benadryl without much luck. Soon I was totally disoriented and had no idea where I was at.

I don't know how I wound up in the ER of a big academic trauma center. There was  no obvious trauma although there certainly could have been with me driving around in such a befuddled state. I owe a huge debt of gratitude to whoever delivered me to the hospital. I related my complaints about having blizzard vision to the youthful ER doc and soon I was having blood drawn for toxicology studies and promptly admitted to the inpatient psychiatric ward-they had a lot of beds in psych and probably needed the business. I remembered Dr. Slambow, my favorite surgeon always saying that I was a bit different from others, but that's what made me such a good scrub nurse. I guess he had a valid argument and I was coming home to roost.

The psych ward was very nice. I had a private room and the nurses were all pleasantly chatty with chipper attitudes-so different from my sourpuss co-workers in the OR. Just when it seemed like everything was going to be OK a profound sense of tiredness came over me. The cheerful  nurses quickly shed their perky demeanor and quickly  called one of the psych residents who  had an explanation, "The toxicology reports came back and he had a trace of Benadryl in his blood." No fooling! I was itching like someone in the middle of a poison ivy patch and admitted to taking Benadryl. It was more than 25mg. of Benadryl clouding my sensorium.

As my consciousness was  quickly sliding off to LaLa land I noticed an agitated figure standing at the foot of my bed. It was a neurology attending physician and he was not too pleased that I had been admitted to the psych ward.  He ordered a STAT CT scan to be followed by an MRI if the CT was negative. Back in the early days of MRI they called them NMRIs (the N standing for nuclear.) The  neurologist was now apparently in charge of my care. Just when I was beginning to appreciate the perks of a therapeutic milieu on the psych ward, I was slapped unto a Gurney and transferred to the not so pleasant  nuero/neurosurgery floor complete with overworked nurses and overly serious physicians. I liked the psych floor so much better.

The CT scan was normal, but a spinal tap showed traces of what was thought to be an old bleed. The neurologist wanted my head inside that NMRI machine pronto. My next recollection was being stuffed into that long skinny sewer pipe of an NMRI machine. This is certainly cozy I thought as my shoulders scraped the bore of the tube. If I happened to be any wider they would have needed some melted butter to slide me in. The various booming and banging noises reminded me of a motorcycle ride and the tight quarters were just like some of the caves I squeezed myself into as a youngster. The NMRI was turning into a fun little journey down memory lane.

The fun was turning out to be short lived as I was aware of a rush of people into the room. When people started rushing into the OR to see something, it was not a good sign. I figured the same principle applied to NMRI rooms. Here we go again, I thought. Trouble  on the horizon.

Sure enough I had an "impressive"  NMRI according to the down in the dumps neuroradiologist. I remember thinking, maybe you are impressed, but I'm depressed."  What seems to be the problem I inquired and he blurted out, "You have multiple areas of T2 signal intensity in the periventricular area of your right occipital lobe. It looks like a stroke or tumor." That little voice in the back of my head was getting real chatty. "I'm dead meat."  it kept repeating.

I was beginning to regain some of my cognitive abilities and started getting cold feet at this hospital. When they began talking about an open brain biopsy, I asked them if they had heard of stereotactic head frames. They indeed were up to speed but only had CT compatible head frames and my lesion would not image on CT. I pulled my ace in the hole out and informed them I was transferring my care to the internationally known father of Pittsburgh neurosurgery, Dr. Robert G. Selker.

I had worked with Dr. Selker and knew him personally. I did not care for his ultra conservative politics but he was the best in the business. Dr. Selker reviewed my care and just shook his head. "They had you on the psych ward?" he asked incredulously. "That's just plain stupid."

Attempts at a stereotactic biopsy were never successful and Dr. Selker thought the risk of hemorrhage was greater than any benefit. I remember telling him to go ahead and give the biopsy  a whirl because I had 9 lives just like a cat. He thought about it for some time and said, "If that's true what's that pile of dead cats doing under your bed?" The biopsy was off and Dr. Selker said he was certain the lesion was a low grade glioma. "If I were to biopsy the lesion, it's going to come back a low grade glioma and I would not know what to do with it."

I was to have an annual MRI to follow the progress of the mass. The first few years there were small changes. When I had 2 MRIs that showed no change about 7 years after the onset of symptoms, I decided to stop seeing Dr. Selker.

Lee Atwater died in 1990 and Dr. Selker died in 2010. I managed to outlive them both. I guess I was the lucky one and neuro gods really do look after fools like me.  Sometimes good fortune trumps medical intervention.

Wednesday, May 17, 2017

It's Payday

So many of you have been perusing my post, "Nursing Joins the Money World" that I thought you might be interested in an oldie but goodie post about nurse compensation. It takes a reckless fool to post paystubs online, but here they are. For the shocking details click on the link below.  I calculate that for a 3 hour trauma case in 1972  I took home the princely sum of 10 bucks. Doing just about anything solely for money takes all the fun out of it. Although my paycheck failed to show it, I felt very rich while at work in the OR  and paradoxically when the going got rough, I was most fulfilled and grateful.

Wednesday, May 10, 2017

Nursing Theory

Martha Rogers, esteemed nursing theoretician
exclaims, "Call the doctor! The patient is
deresonating his energy fields and his
helicy is dropping too fast."

Oh boy, subjects like  the theoretical basis of nursing really rub me the wrong way because they are waste  products of the nursing academic/administration/ office-sitter complex.  When my alma matter was fighting for it's life in the 1970s one of the survival strategies involved replacing operating room experience with a Martha Rogers nursing theory class. The rationale; "Anyone can learn how to be a scrub nurse, but few can master Martha's theories."  No fooling!

 If you want to drive yourself crazy check out this gem courtesy of the eminent Martha Rogers: "The integrainess of people and the environment that coordinate with a multidimensional universe of open systems points to a new paradigm of nursing:  energy fields, pattern, helicy, and resonance whereby man is always becoming."

Nursing theoreticians were in their heyday  several decades ago when diploma nuring schools were closing and nursing education was being shifted from the hospital to academic enetities. Nothing wrong with that, but educators needed a new curriculum to differentiate themselves  from diploma schools. Nursing theory and nursing research were what they came up with. One explanation of the relatedness of these two entities was that nursing research served to validate nursing theory.

I might be foolish, but I know when someone is trying to hoodwink me. Why do these highly educated academics term it "nursing research?"  If the research is to benefit patients it should be called clinical research and based on accepted fact, not unfounded theory. Facts are facts so why muddy the waters with nursing specific nomenclature. There is no such thing as pharmacist research or doctor research. Combining two entities that are not fact based or scientific does not increase their credibility. It's like stacking bafflegab on top of bolderdash which exponentially increases the inherent subjective content of any conclusions.

Conferring objective status to subjective findings never turns out well. It's how we came up with the old time surgeon's rationale for removing an organ that has no pathology. "I'm taking out his spleen based on empirical experience."  In contemporary times subjective matters like pain have been scientifcated  by pain scales. It's not doing anyone any favors to confuse subjective matters with scientific fact.

Probably the biggest failure of nursing theory was a failure to relate to clinical practice. This is facilitated by the fact that nurse theoriticians are office sitters of the highest order. My message to them is this.

Leverage yourself out of your comfortable chairs and remember it's not that difficult because once you get the largest body part moving, the rest is sure to follow. Find a sick person to help. Find a chest tube to milk, a Foley bag to empty, a trach to suction or learn how to load a sponge ring forceps with just one hand.  For crying out loud, find a patient to help! Don't just sit something.

BREAKING NEWS: Office sitting nurse theoretician studying
field gradient theory becomes flying nurse theoretician courtesy
of a friendly local MRI machine. Never fear, the OldfoolRN product
development institute is working on a nonferrous theoretician's chair.

Wednesday, May 3, 2017

Secrets from the Inner Sanctum - A Scrub Nurse's Internal Dialog

For some posts, I peruse my basement collection of old nursing documents which more honestly should be called a hodge-podge of dumb notes and  old papers that I saved. My wife says they are a fire hazard and should be thrown out. I suspect she is probably right as usual. This post is going to be different as I'm just going to relate some of the thoughts that passed through my youthful nervous system when in the OR and  scrubbed for surgery. It's amazing how clearly I can recollect events from 40 years ago but what I had for breakfast remains a mystery. Life sure can be strange.

Set up time...waiting for the surgeon inner dialog

Don't let me repeat any of my past sins and screw-ups. Are the patient's legs uncrossed?? Alice,, my beloved supervisor screamed at me for days after one of the patients went to sleep with his legs crossed. What are the 7 deadly  operating room nurse sins?  Hmm.. sloth, gluttony, lust, pride, wrath, greed, and letting a patient undergo surgery with legs crossed. Never again.

Oh phooey.. I should have taped the bridge of my glasses to my forehead so they don't slide down when I sweat. This one's going to be a  long, hot one. At least I have my pant cuff restricting rubber bands in place to curtail that dreaded perineal fallout.

I only have 1 (one) Metzenbaum scissors so why the  "s"  on the end of scissors. Maybe it should be Metzenbaum's scissor...Hmmm

I hate that new fangled Betadine prep..Yucky brown.  Zepharin and Phisihex is much prettier.

I hate it when drapes are physically attached to a patient's skin with penetrating towel clips. Unnecessary trauma is never a good thing. Towel clips penetrating skin is the Catherine's Wheel of surgery for me.

It's so cold in here that poor patient's blood will never clot. I hope those lights heat this room up in a hurry.

During the case...

I hate it when Dr. Slambow gives stock market tips in the middle of surgery...I 'm lucky if I have change to buy a tuna salad sandwich from the vending machine...let alone for investments.

I hate it when Bovie smoke gets in my eyes..I wonder if breathing it has adverse health consequences?

Why does Dr. Slambow ask for stuff he never uses. Oh well that ligature reel will make a nice toy for my favorite cat, Fritz.

It's getting hot in here. That sweat bubbling up on my forehead is getting absorbed by that 4X4 under my cap parlor trick, but I guess I will have to recycle that  nose sweat/snot combo sliding down my upper lip. That salty taste always reminds me of  a Pittsburgh steel worker chewing on salt tablets with a blast furnace roaring in the background.

Hmm..Dr. Slambow operating on an old man that looks just like him. Part of the circle of life

After the case...

Yes sir no thing left behind. Even number of hemostats and needle holders. Sponge count was correct so I guess I'll be back tomorrow. (Retained object or sponge=immediate firing of OR  nurses.)

Whoa, it's unbelievable that we started this case over 6 hours ago. when you are engaged in what you love time flies, but when unpropitious events hit the fan  it hits the afterburners.

No matter how messy the surgery, nothing looks more reassuring than a meticulously laid down skin suture line....each stich equidistant and cut with an exacting centimeter tail. Kinda reminds me of those "SANITIZED FOR YOUR PROTECTION"  paper bands on hotel toilets. Sure looks pretty from the outside but who knows what's brewing down below? I certainly hope we were more careful than the hotel maids who probably just slapped that reassuring band  over the toilet seat whether it was clean or not.

I know that in today's world you had a choice of foolishness to indulge yourself. Many thanks for choosing over things like today's political buffoonery.