Thursday, June 29, 2017

The Metrecal For Lunch Bunch

Old time surgeries could last for a very long time as a result of their complexity, a lackadaisical attitude about anesthesia time, or unforeseen pathology. After 6 hours of standing on your feet (never, ever lock those knees) a sense of fatigue would settle in and it was tough to be at your hypervigilant  best. I always knew I was in trouble when my head started to feel heavy or my hands began to shake. I devised some strategies to deal with hand tremors and they are O.R.  tested. You can find these tips at this link. It's a common problem with some straightforward  solutions that worked well for me.

For that generalized malaise and heavy headedness feeling there was only one remedy and that was intraoperative nourishment. You can't eat a Big Mac in the midst of surgery although I did witness an attempt to ingest a hot dog which  was accompanied by an assortment of gastronomic complications. Those tube steaks are hard to slip under a surgical mask and difficult to properly masticate with mask ties impeding jaw movement.

Philadelphia Eagles quarterback, Mark Sanchez knows all too well the down side of eating hot dogs on the job because of the trouble he got into eating a tube steak  on the sidelines. It did not work well in the OR either. The consistency of a traditional hot dog makes it an aspiration hazard if eaten quickly. The diameter of the hot dog is the perfect size  to occlude a trachea or if further down the line, a main stem bronchus. At least in the OR, a Magill forceps is close at hand to extricate that wiener plug from an airway. For hot dogs to work in a surgical setting, the contents of the meat in the casing would have to be similar to toothpaste. Just have the circulator inset an end of the hot dog under the mask and once the scrub nurse chews the end off, squeeze the meat paste into her mouth. The Surgi Dog is born.

This illustration of Hawkeye of MASH eminence shows some of the challenges with intraoperative nutrition. The circulator, Hotlips, just contaminated the front of the surgeons gown with her nutririve ministrations. Solid food which requires sacrificing the surgical mask coverage is not prudent. The ideal mid surgical procedure meal is a liquid, nutrient dense, and shelf stable. The name of that miracle surgical sustenance was an old time product that was one of the very first diet products, Metracal.

The longing for a svelte body is not a new phenomenon. Mead Johnson came up with the diet drink, Metracal, which soon became a pop culture icon in the 1960's. Each can which required the use of a genuine can opener, delivered 225 calories derived primarily from soy protein. The consistency was a miserable watery, pasty slurry that often contained tiny lumpy glops of congealed soy protein. To disguise the unpleasant taste, novel flavors like Danish coffee and egg nog delight were offered.

Ad copy from the mid 1960s touted, "Join the Metracal for lunch bunch on a new kind of treasure hunt. Discover Metracal which tastes just like a milk shake." The ad suggested that 4 cans per day of this diet drink would trim off the pounds in nothing flat. It was a popular product and sold for 12 cents a can at your local grocery store even though it tasted nothing like a milkshake.

We discovered that Metracl was a near perfect nourishment for intraoperative sustenance. In the OR can openers were readily available for popping the tops off multi-dose vials and also  worked great to open the Metracal cans. The next step was to obtain a straight catheter (18 Fr. worked just perfect) and insert the business end into a can of Metracal. The flared distal end of the catheter was carefully threaded through the side of the anxiously awaiting scrub nurse's mask  and it was lunch time while the surgeon searched for that last persistent bleeder.

There is nothing quite like savoring the gastronomic delight of a Danish coffee Metracal while inhaling putrid Bovie smoke. That combination of gustatory delights is bound to induce an anorexia syndrome that practically guarantees weight loss. Maybe Mead Johnson should have figured out how to can and sell Bovie smoke.

Since Metracal was mainly protein, we would add a 20ml ampule of D50 ( concentrated Dextrose)after about half the can of Metracal was consumed. I just loved the loud snap-crack noise those big ampules made when they were cracked open with bare hands. The scrub nurse knew that a pick me up was close at hand when that crack thundered throughout the room. Metracal and  D50 really did enhance vigilance when lassitude settled in during a lengthy case. My all time favorite flavor was called Thahitian treat - a taste of coconut delight from the islands while sweating it out in a Chicago operating room. Life  was good.

Thursday, June 15, 2017

Whatever Happened to Sluice Rooms?

It's a conditioned response. Whenever I observe a Whippersnappern wearing gloves for routine patient care or  worse, comingling sheets soiled with scatatolgical resideue and run-of-the-mill dirty linen my anxiety mounts to intolerable levels. Someone is going to be raked over the coals for these misdeeds. Hospitals of yesteryear had unique protocols for these unpleasant circumstances.

Any sheet soiled with solid matter-what a euphemism-required a sluicing in the dirty utility room. A lovely, white 6 foot porcelain slab lined one of the walls of the dirty utility room. It was not for napping. At the elevated end of the sluice there was a massive faucet capable of unleashing a Niagra Falls torrent of water flow. The depressed end of the slab terminated at a slop sink which had a massive drain. This drain could accommodate a bolus biomass of stool the size of a bowling ball. Don't ask how I came to know that  little factoid. Someone had the foresight to install a trap on this sink which seemed to me comparable to the diameter of a subway tunnel. At least once the fetid fecal foosball facsimiles were beyond the trap they were gone for good and you could breath again.

To properly sluice a sheet place the origin of the offending substance at the lowest point of the sluice nearest the slop sink. If you enjoy inhaling aerosolized particulate matter simply reverse this procedure. Now for the fun part; turn that mighty faucet to full blast and watch that mass of olfactory offensive material sliding away on it's merry way to the waiting slop sink. Some types of residue affectionately referred to as smears, mucilaginous masses messes,  or pasty blobs require some encouragement from the intrepid sluicer and for this unsavory task a squeegee borrowed from housekeeping acted s a pusher. I always found it strange that the housekeeping personnel never asked for nursing to return their squeeges.

Suddenly, like a bolt out of the blue in the very early 1970s a memo from the nursing director came out stating that sluicing was no longer required due to improvements in the hospital laundry system and we could simply toss soiled sheets into the hamper. Sluicing like the lobotomy was gone for good and nurses were ecstatic.

This really piqued my curiosity and called for a personal visit to one of my favorite places which was our on site laundry operation. The Hispanic staff working the laundry were among the most content of all hospital staff despite working in a place that reminded me of Dante's inferno. This place was hotter than a brick oven, louder than a Pittsburgh steel mill and to top it off, smelled funny and that's putting it nicely. These folks made $2.20 an hour and were overjoyed with their pay (minimum wage was $1.65 an hour.) They were some of the nicest people in the hospital and even helped me with my lackluster Spanish skills.

When I asked about the new sluice free linen policy they happily showed me their brand new washers that had a built in sluice cycle. The washers had huge outlets that opened before the start of the wash cycle that permitted a huge flow of water through the batch of linen before the wash was initiated.

I was invited to observe a mechanical sluice cycle and it was very impressive. The mighty roar of the water being injected through the linen sounded like a 747 on take off roll in the midst of a rain storm. These giant sluice/washing machines had to be one of the greatest engineering accomplishments in healthcare history-and you thought anesthesia was an impressive invention. An open drip ether drip mask is nothing compared to these sluicing behemoths.

A few years ago nurses from my alma matter were invited to a homecoming. Changes made in the use of space at the hospital were depressing. The old OR suite, home to much drama and lifesaving (I hate that "L" word with a passion.) had been remuddled remodeled to fancy administrative offices. The beautiful terrazzo floors had been covered with Karastan carpet and pretty pictures hung on the walls. The sluice room on one ward had been converted to a data processing room filled with computer doo dads with blinking LED lights.

Crude rooms that were vital and offered maximum utility for patients  were converted to an office sitters paradise and an electronic wasteland. A depressing commentary on contemporary healthcare.

Wednesday, June 7, 2017

Operating Room Superstitions

 Old time operating rooms were fertile ground for the proliferation of  superstitions. Surgeries performed with equal technical excellence can have profoundly divergent outcomes causing thoughts of supernatural powers. Unexpected complications can occur without reason or explanation. Practices and behaviors that accompany good outcomes can be elevated to cause and effect status even when there is no supporting science. A Cartesian circle of the highest order develops. (I tossed that Cartesian word in there to try and sound smart..I'll be darned if I know what it really means.)

Superstitions have one thing  in common with science, they gain real traction with repetition. Thoughts like "Hey..the patient always does well when I use that scrub sink near the door." Pretty soon another nurse notices the same phenomenon and a "lucky" scrub sink is born. If a superstition does boost confidence it becomes much like a positive affirmation. Thinking positively was not one of my strong qualities and some superstitious actions do serve to boost confidence in nervous Nellies like me. If there is no danger to the patient and superstitions boost staff confidence a positive aspect of such non - science backed behavior becomes apparent. Without further ado, I present the magic superstitions I have encountered over the years and there is not a single full moon or "Q" word among them. No nurse would dare tempt fate by uttering the "Q" word especially when the moon is full.

Intracranial aneurysm surgery is a high stakes and nerve wracking procedure. Dr. Oddo, my favorite neurosurgeon had a couple of unusual habits for aneurysm clippings. Rule #1, No talking during the surgery and now comes the mystical  photon diminution exsanguination challenge. After the offending aneurysm is clipped, the overhead and ceiling lights in the OR are turned OFF for one full timed minute. The bone flap cannot be wired into position until the lights out test is completed and assurances of a dry field confirmed. I asked Dr. Oddo if the rationale for this test was the fact that it would be dark in a closed skull and he admonished me for overthinking the matter. "I do it because it's effective," he muttered.

Surgeons love to brag about their "bucket time." This refers to the interval from incision to when the diseased organ is ceremoniously tossed into the kick bucket. Every circulating nurse worth their salt  knows the sooner that pathology infested gall bladder or ripe appendix is bagged up and out of the room the better. If a resident wants to fool around with the specimen looking for stones or what not-do it in a scrub sink outside the room. Get that thing outta here-It's bad JuJu of the highest order! Skin approximation at closing time is so much easier when that specimen is gone and the anesthetist will thank you too when it's emergence time. Everything is just...better.

This lucky maneuver was brought to my attention by a very bright Filipino surgeon. In his native country, the surgeons would place a huge leaf from a tropical plant under their  scrub caps as an aid for cooling. Serendipitously, it was discovered that surgical outcomes improved with the tropical leaf  undercap maneuver. We don't have tropical forests in Chicago unless you count that flower shop on Belmont St. in July, but we have cabbage leaves readily available in the hospital kitchen. This green vegetable worked just fine and there was usually a head (of cabbage) in the OR refrigerator. Just look under all those blood bags-yep we comingled food, blood, and (get em outta here) specimens in the same refrigerator. Our overseers were safely hidden away in their offices and dared not even approach the double doors to the OR.

Here is an oldie but goodie that every old nurse has probably practiced. The idea of transferring this maneuver from the bedside to the OR was a stroke of sheer genius. When a patient is declining rapidly old school nurses would tie a knot in a corner of the bottom sheet usually at the foot of the bed. It's best not to question superstition practitioners, but the explanation had something to do with binding the soul to the body. If a problem developed during surgery some circulators would duck under the table under the guise of adjusting a Bovie pedal and knot the sheet covering the OR table.

If sheet knotting is such a great thing I thought maybe we should just knot the sheet before each case prior to draping. An old nurse was quick to admonish me, "It doesn't work that way Fool. The knot has to be secured after the patient begins that downward slide. You should have learned that in nursing school."  I stand corrected.

Thanks for indulging in my foolishness. My blog always experiences a marked decline in readership after the traditional school year ends. Somehow, I did not think foolishness and academics mixed, but I must have been wrong.

Thursday, June 1, 2017

Let's Stop Using These BS Terms

Calling a doctor's office an INSITUTE such as Two rivers Orthopedic Institute. When a doctor hangs out his shingle he can't be the founding father of an institute. The term "institute" refers to an entity that combines clinical practice, research, and academic endeavors under one umbrella (another BS term if I've ever heard one.)  I better be more careful.

Clever spellings of terms like orthopAedics, just to sound like a bigshot. It's orthopedics unless you happen to live in England. I interviewed  asked an orthopedic man the rationale for this nonsense and he said it was being used a  nod to the history of the specialty. That's piling BS on top of BS if you ask me.

Calling patients "consumers."  This was tried in the past by calling patients "clients." It did not work back then and won't work now because it depersonalizes sick people seeking help. History is on the side of calling sick people patients, so let's not mess with it.

Let's stop calling dense urban centers with lot's of health issues "medically underserved."  There are lots of medical folks in your nearby hospital. The problem is horrendous, intractable social problems not a lack of medicine or medical personnel.

Doctors who refer to the number patients cared for as a "patient panel." I'm not sure where this one came from, but suspect it has something to do with remuneration. How do you determine the size of your "panel?"  Maybe the number of patients you see per day times  the number of days you see patients. Patients have highly variable levels of acuity. Maybe it would be easier to categorize by acuity before assembling a panel or just say how many people can give you a phone call and be seen by a provider. Yikes, provider sounds like another BS term and that's stacking BS on top of BS. I'm getting into some really bad habits here.

Free pharmaceutical samples from your local, friendly Doc that are not free or samples. UPMC the dominant domineering health system here in Pittsburgh hands out bottles of cheap generic drugs plastered with advertisements for their brand of health insurance. It's enough to make me sick!

Physicians that promote themselves by proclaiming they are a Harvard educated medical specialist. From my experience an Ivy league education does not promise a good outcome. That sounds like a misguided superiority complex to me.

 Two BS terms for the price of one - "experience" and "journey."  Your weight loss journey begins with a surgical experience with our Harvard educated (oops) bariatric surgeon.  Weight loss is not a journey and having your gut rearranged is not an experience.

Here is a real gem. "Work needed to undergrid  healthcare  reform involves a new paradigm in perception." That "paradigm" word has been around forever. Dr. Slambow, my favorite person to scrub with, said that whenever you here that paradigm word it's someone attempting to sound smart when they don't know what they are talking about. Maybe I need to come up with a new paradigm with this foolish blog.