Friday, July 28, 2017

The Souttar Craniotome

Every surgical specialty has a memorable instrument from the past that inspires trepidation in modern folks; urology had the Kollman dilator, OB had the cephalotribe,  and neurosurgery had a host of ghastly  tools to fashion approaches to the brain.

The dicey part about accessing the brain is that it's covered in a very durable, hard, boney box-like structure, the skull. The dura which covers the brain lies directly beneath the skull. The trick is to get through the bone without harming the underlying dura. Just like fashioning a small round opening in a boiled egg without touching the white.

Modern pneumatic craniotomes  in use since the mid 1960's do a great job of this. There is a blunt foot on the end of that whirling dervish of a  cutiing blade that leaves the dura unscathed. It was invented  by John Nash who ironically became one of the first customers to utilize his invention. He required a craniotomy for a brain abscess shortly after marketing his device.

My favorite neurosurgeon, Dr. Oddo, just loved antique neurosurgical  instruments and had them proudly displayed in his office. I was fascinated by an unusual device for cutting thorough that bony barrier, the skull. The Souttar crainitome  consisted of   a solid 6X1 inch stainless steel post with an adjustable expanding  base, a pivoting arm that moved around the post, and a cutting wheel that resembled a plumbers pipe cutter.

Dr. Oddo was more than delighted to explain the operation of the Souttar craniotome which was invented in the early 1930's. It was designed to cut a perfect circle in the skull in whatever diameter the surgeon desired. Asking dumb questions was one of my signature moves so I asked Dr. Oddo what's wrong with a square or rectangular opening into the skull. "Intersecting lines never work in neuro surgery. If there is pressure building up under a square opening there will be greater pressure in the corners. An oval or round opening heals best and permits pressure equilibrium beneath the bone flap."  Thanks for the enlightenment Dr. Oddo, but can bone wax be used to polish a surgical instrument? Can ambulatory patients receive care at Chicago's Lying In Hospital? How normal is normal saline? Do blood gases smell funny?  Oops, those dumb questions never cease when Oldfoolrn is on the case. It's time to get back on task.

Henry souttar was an engineer before he took up medicine so maybe his skull opener was inspired by circle cutting devices from other discplines. To the left is an arts and crafts circle cutting device that is a dead ringer for the Souttar craniotome.

In Souttars version a burr hole was manually drilled in the center of the intended skull opening. Burr holes were drilled using a device that resembled a boring brace and the bit was attached to a clutch mechanism that ceased the rotation of the bit when it was through the bone.

The next step involved inserting a stainless steel post in the burr hole. The post was rigidly secured in the burr hole with a set- screw activated expanding base which was identical to the manner a bicycle stem is secured in the top of the fork.

Once the pivot post was secured in the burr hole, an arm with a cutting wheel was attached. The size of the circular skull opening could be varied by sliding the cutting wheel on the arm. As the cutting wheel was moved out the radius of the circle increased making a larger opening. The pressure of the cutting wheel on the bony skull could be increased by tightening a screw atop the wheel. When Dr. Oddo demonstrated the device in action he compared it to children frolicking around a Maypole. The action was similar, but the analogy gave me the creeps. What in the world do innocent children have to do with chopping a hole in someone's skull?

The old school neurosurgeon stopped frolicking  the  cutting action just before the skull was cut through to protect the underlying dura. The final removal of the bone flap was done with a mallet and chisel.

You can count on Oldfoolrn Blog to bring you the latest in little known, esoteric, meaningless information. I Googled, Binged, and Medscaped "Souttar Craniotome" and came up dry. This post is based on memories sifted through an aging nervous system so reader beware.

Thursday, July 27, 2017

Skeptical scalpel has information regarding the possible ultimate solution for that unsavory perineal fallout issue. There is a link to his blog on my blog roll.

Friday, July 21, 2017

A Vintage Operating Room - Circa 1930

When I started this blog I envisioned it as a  museum of nursing history with an emphasis on life in the OR. After reviewing some of my previous posts,  I came to the realization that my endogenous foolishness has resulted in a blog that more accurately resembles a carnival side show. It's time to put the foolishness on the back burner and restore some credibility with a straightforward post.

So here it is; a guided tour of a 1930's operating room. Prominent in this overhead view is the unique shadowless lighting system. A very rare, explosion proof resistant black Operay. That black Sputnik-like orb contains the light sources and lenses to focus the beams of light on the reflecting mirrors arranged around the periphery. The goal: shadowless lighting.  Here is the link to an old Operay post.

This old photo  illustrates one of the problems with Operay surgical  illumination.  Shadowless lighting failed to live up to it's hype and the folks in this OR augmented it with a floor stand pedestal spotlight which is visible in the upper left hand corner. Unlike contemporary operating rooms that are filled to the hilt with electronic equipment, Old ORs had plenty of floor space for pedestal lights that could be moved about on wheeled platforms. If a light bulb element went kaput in the middle of a case, no problem, just wheel it to the corner and bring in another light.  Pedestal mounted lights were very versatile and  tons of  fun until you stubbed your toe on that unyielding massive pedestal. OUCH.

One of the mysteries in this photo is the use of the black explosion resistant Operay in a room that could never be used with flammable anesthetics. Cyclopropane gas anesthesia was in vogue back in the 1930s, but despite the correct Operay for an explosive environment, that beautiful  ceramic tile floor could never be condutive so as to minimize static electricity. No Cyclo allowed in this room.  Ether and chloroform were popular agents and you can see the agents being delivered by mask on the laterally positioned patient. Intubation was yet to come.

Old school hospitals were very cost conscious and you can see the scrub nurses using an old wooden pallet to gain some necessary elevation. It would have been considered fiscal recklessness to splurge on a fancy metal platform when old wooden pallets could be had for nothing. Function trumps form anyday in this acient OR.

The twin scrub nurses suggest a training situation. As an eager  youngster learning the trade, I had the opportunity to scrub with a veteran nurse only once and  then I was thrown to the lions surgeons. I spent many happy evenings perusing Alexander's Care of the Patient in Surgery and mentally planning my cases for the next day, praying that I wouldn't get yelled at or forced to duck a thrown instrument.

Where is the back table in this old time OR? My favorite OR supervisor, Alice, loves yammering on about this feature of vintage  operating rooms. "We used one massive curved back table that was stocked with all of the supplies and instruments for a full day's caseload. The curve facilitated corner placement of the table with maximum usable surface area," she explained.

"Old school nurses were motivated and did not sashay in and out of the rooms like you youngsters are so fond of doing. Once that back table was stocked, we stayed put in the room until the day's caseload was finished. Between cases the circulator carefully covered the back table after the scrub nurse fetched her instruments. It was considered bad form for the scrub nurse to need an item from the back table once a case started, so we had to use our head's for something other than a hat rack."

Alice was an OCD nut and insisted her charges prepare for and conduct cases in a  Kabuki Theater like style. Everything had to be planned for and conducted exactly according to her rigid authoritarian rules which was fine until something unexpected happened. There was only one way to open an instrument set or thread a suture needle in old school ORs. The scrub nurse in the photo has her left hand under the Mayo stand. A  definite according to Alice and grounds for getting a knuckle slap with a sponge ring forceps. That'll learn ya to keep both hands above the Mayo stand.

What's missing in this old OR? There are no electronic monitoring devices or piped in medical gasses. Anesthetists monitored vital signs using a precordial weighted stethoscope that was taped to the chest. An earpiece connected to a stop cock enabled toggling back and forth between the stethoscope and blood pressure cuff. Anesthesia sans any type of electronic monitoring.

These old time ORs were places to have something removed and every case was an -ectomy of one type or another far removed from the repair and replace surgery of today.

Thursday, July 13, 2017

Paper Medical Records

A paper medical records trifecta; med cards, kardex
and paper chart. Med cards and anything recorded in
Kardex was tossed after their purpose was served.

The importance of the medical record cannot be overstated. Communication of patient information in a usable format has been a priority for many eons. Where else can you find a blow by blow account of surgical treatment, response to drugs, and basic diagnostic information. Whippersnapperrns complain endlessly about electronic medical records and older practicing nurses often  dream of a return to paper records.
Paper records had a certain charm and ease of use, but there were problems with divergent formats, inaccurate data, and unauthorized access, which in some ways, mimics problems with electronic records. At least with paper records nurses were not distracted by a wheeled monster of a computer that followed them everywhere. I don't think there is anything more frustrating than communicating with a person distracted by a  computer screen.

 Most private and charity hospitals were writing progress notes and physicians orders on standard 8 1/2 X 11 size paper. Federal agencies such as the VA medical system had a very unique paper size which was 8 X 10 1/2. This was another example of that infamous VA tag line, "The right way, the wrong way, and the VA way." President Reagan established a government Committee for the Simplification of paper sizes in 1980 and the VA switched to the 8 1/2 X 11 standard.

 When a VA patient was admitted to a private hospital the combination paper sizes were difficult to stack (VA patients always had voluminous records) and the end result was a leaning tower of medical records. How acute the lean angle became was dependent on the volume of the record and the sequence of the odd sized paper. Old nurses always characterized the medical record lean orientation as port or starboard. For some obscure reason port side canted records usually foretold a very difficult patient care situation.

Everyone approached patients with leaning  paper medical records with due caution. These were complex, time consuming patients. One nurse summed it up nicely with this little ditty. "Those patients have every case but a suitcase." It was amusing until one of these patient care conundrums actually brought their suitcase with them to the hospital. It could have been much more morbid. When a patient was not expected to recover one family sent along a three piece suit. "Make sure one of the nurses gives that suit to the undertaker when he comes for Gramps," was the instruction.

Today nurses must be concerned with hacks and computer glitches upsetting the delicate order and sequence of recorded medical data. Paper was not immune from unpredictable  disorder. Old time hospitals were never air conditioned except perhaps for the director's office. This meant that nursing stations were equipped with gigantic fans capable of moving as much air as a Piper Navajo on take off roll. That prop wash at the nursing stations was capable of sending any and all stacks of paper flying off into the wild blue yonder.

I vividly recall one sweltering August afternoon  at Downey VA  Hospital when a stack of newly minted physician's orders was placed on the ward secretary's desk for transcription. Unlike patient care areas where the windows had security screens, administrative zones like nursing stations  went screenless. The massive floor fan actually blew the new orders directly out the open  window. I quipped that the records were "gone with the wind." The head nurse, Lois, had the last laugh and ordered me out of the building for order chasing duty.

Another problem presented by paper  pages was how to organize them into a format for ease of perusal by health care workers. There were clipboards and spring loaded metal chart jackets that worked the best. Later ringed  notebooks came into favor, but there were compatability problems with 2 hole or 3 hole. The VA Health system actually  came up with a  novel and unique system of punching 2 holes into the top of the record and affixing it to the chart with a metal hasp.

Data security is a big deal today with HIPPA this and HIPPA that frequently cited. Paper records did not require mixed character passwords to protect. In hospitals there was someone present by the chart rack 24/7 and physician's offices made a ritual of keeping records under lock and key. When a chart was sent with a patient for a procedure or diagnostic test, the chart was encased in a canvas bag with a locking zipper. Data security at it's finest.

Finally. since paper records were always physically close to the patient they communicated a sense of presence. Nothing tells the story of a harried trauma surgery like an anesthesia record splattered with blood or prep solution. The physical appearance tells the story better than the data recorded. Nurses frequently did their charting while taking a break for a Coke and a smoke. It was common to be ceremoniously greeted by a cascade of cigarette ashes when opening the chart to the last nursing note.
Sometimes the "presence" of paper medical records resulted in a messy situation.

Thursday, July 6, 2017

Crash Cart - Circa 1921

Inventory of ancient crash cart: Tracheotomy set, solutions of H2O2, adrenalin, tannic acid, and gallic acid. Equipment to administer a stimulating enema and if that failed, how about some smelling salts?  Sterile supplies with the notation, "If carefully done up, these will not need to be frequently sterilized."

I should probably publish  this post without pontificating about crash carts, but like the oldfoolrn that I am, here I go shooting off my old wrinkled up mouth. Mouth flapping and jaw jacking at it's finest about a subject I have no current experience with.

There is something almost talismanic, I think, about having an assemblage of lifesaving equipment and pharmaceuticals gathered together in a  mobile crash cart or trolley. The individual components assume a far greater reverence and respect than they would on their own and the ability to move them throughout the hospital is indeed  magical.  If a patient is circling the drain, it's always prudent to park that crash cart right outside the door to chase away that bad juju.

Whippersnapperns were quick to admonish oldfoolrns like me for failing to respect the supernatural  powers  of  collective resuscitation equipment, "Hey you need to have the crash cart at the bedside when you do that," was their frequent outburst. They were just shocked, and awed by my magical power to convert tachy arrhythmias to normal sinus by slight of hand vagal tricks  like applying gentle ocular pressure, a trick old nurses learned from watching the 3 stooges. There were no crash carts in the stooge era and I never converted anyone into cardiac stand still, but the youngsters had a good point and I became more concerned about access to a crash cart later in my nursing life..

Whippersnapperrns were always flabbergasted to learn there were no crash carts in the OR and we never called a code for a patient that was on the table. The rationale for this practice was the notion that anesthesia was on the ready with all  equipment at hand for resuscitation. I was explaining this in my usual blowhard, know-it-all tone of voice to a young whippersnappern and she piped up with the question, "Where is the defibrillator, fool?"  I did not have an answer as all that we had available were defibrillators with  internal paddles. "Well..I guess we could run over to ICU and borrow their defibrillatoer," was my lame reply.

Old nurses knew and practiced resuscitation without new fangled devices like ambu bags using mouth to mouth. I once performed mouth to mouth on a chap with about a weeks worth of whiskers and it felt like trying to blow up a water ballon studded with porcupine quills. Ambu bags were one of the greatest inventions for lips-off resuscitation.

This cart is so important that a nurse is obligated to check on it every shift. I knew a nurse that accrued big time trouble because an amp of bicarb was a month out of date and her initials were last on the checklist when a supervisor went through a crash cart. Nurses can get into trouble for the most inconsequential of misdeeds. It never paid to worry about supervisor admonishments because trouble always accrued from something totally unforeseen. Don't happy and carefully check that crash cart was always good advice.