Friday, August 25, 2017

Skeptical Scalpel (on my blog roll) has an interesting post regarding the end result of connecting an oxygen tube to a Foley catheter. Even Oldfoolrns know there is very minimal gas exchange across the bladder wall.

Wednesday, August 23, 2017

Bridles Are for Horses - Not Patients

This post is about nursing interventions with nasogastric tubes from  many decades ago and filtered through my aging nervous system so don't count on relevance. It's foolishness of the highest order for entertainment purposes only. With the advent of PEG tubes and a more enlightened attitude, hopefully bridlers are extinct.

Nasogastric tubes (NG tubes) were handy little devices. They were used post operatively and connected to low intermittent suction to decompress and keep the operative area clear after gastric surgery. Another use involved feeding patients that were unwilling or unable to take nourishment and this is where the problems showed up.

NG tubes were dangerous devices in the hands of an inexperienced practitioner and complications related to wrongful placement were sometimes devastating. The most common misplacement was in the lung via the right main stem bronchus  (It's more perpendicular and bigger than the left bronchus) We always added a dash of methylene blue dye to feedings  and if your patient coughed up blue mucous, it was a sign of trouble. The pleural regions are not known for their ability to assimilate nutrients and likewise there is little gas exchange across the stomach wall. It's best to respect these barriers and that's the understatement of all time!

Skull fractures involving the cribiform plate invited the disaster of  the NG tube winding up in the brain as shown on the right.  Old time physicians hated to come clean with mistakes and I can just hear an old blow hard doc from the1960s coming up with a clever explanation that the NG tube in the  X-ray  could be used as a ventricular shunt, "after all it did course straight up the ventricle. Now we don't have to worry about complications like  hydrocephalus."

Blogger, Skeptical Scalpel has a fascinating post about an internal jugular vein cannulation by a misplaced NG tube. I think the person that accomplished this amazing feat  blunder would have to fess up to the mistake. Who in the world ever heard of  gaining vascular access via the nose? That phony excuse is just plain unbelievable.

Nurses commonly inserted NG feeding tubes and were responsible for keeping them in place. Post op patients were usually very cooperative as a result of vitamin "D" (Demerol) and did not tamper with their NG tubes. Placement of these NG tubes was also a short term affair of just a couple of days. It's much easier for a patient  to put up with a short term nuisance than a long term festering aggravation.

Having an NG in place for a couple of weeks is a miserable experience that I have had personal experience with. Occluding a nostril for the tube results in forced mouth breathing that makes your throat dry as the Sahara dessert. Dried mucous referred to as snot in less formal arenas dries up around the tube and picking it off results in red sore nares.

Tubes like Foleys are out of the patient's view. NG tubes of yesteryear were a bright red in color and were like the matador's red cape to a bull - always annoying and always in sight. It's no surprise that patient's liked to remove their NG tubes. I always figured these poor  old souls were trying to communicate something to us - they did not want tube feedings and their feelings should be respected. Leave the NG tube out and place a glass of water within reach.

Old nurses from the greatest generation had other ideas and I learned never to argue with these gallant geezers. All too often their interventions reflected their  rigid, authoritarian personality and not the reality of the situation. They did not tolerate fools like me and their answer to patient self removal of NG tubes was a brutal but effective trick called NG tube bridling. Somehow these determined oldster nurses  always prevailed when imposing their idea of therapeutic intervention.

Bridling involved inserting the NG tube via the right nostril until the tip of it was visible just below the uvuala (that funny thing hanging down between your tonsils.) I've been criticized for not writing clearly for non-medical folks, so that crude explanation is one of my lame attempts to be more broad based.

The old battle axe of a nurse then grabbed the NG tube from the back of the throat with a Magill forceps and gracefully pulled  yanked  the tube out the mouth. Some of these old Marquise de Sade nurses had tiny hands which meant they could skip the forceps and yank that bad boy NG  tube out with their fingers. Once pulled all the way out via the mouth the NG tube was looped around and reinserted in the left nostril into the stomach.

The end result was the NG tube anatomically anchored because the loop went completely around the ethmoid bone and maxillary sinuses before it's descent back to the stomach. Pulling on the end of  the NG tube resulted in excruciating pain which was an effective deterrent to removal. From my perspective, bridling was the stuff of nightmares with the poor patient yanking his nose and maxillary sinuses loose along with the offending NG tube.

I always tried to empathize with the patient. Dying patients just wanted peace and quiet on their lonely journey and before the hospice concept arrived this was rare. I always found a way out of the bridling NG tube business and only wish I could have had more influence on bridlers.

Friday, August 18, 2017

Side Rail Peference Separates the Bedside Nurses from the Office Sitters

Any bedside nurse can attest to the fact that the only safe side rail on a hospital bed is one that runs the full length of the mattress from head to foot in a single section. All old school hand cranked beds had full siderails that were raised and lowered guillotine style or hinged to swing out and below the bed when giving care. My favorite was the straight up and down style release because the swinging rail bed had to be moved out from the wall to drop a rail. When dealing with a patient determined to exit stage right it is sometimes helpful to butt the bed against a wall as a containment aid.

Old full length side rails engaged with a reassuring clunk that meant business -  similar to the feeling of a cycling shoe engaging with a clipless pedal - the patient is safe and I'm going to ride forever! At times it can be difficult to disengage from a bike pedal which always results in a fall for me, but I cannot recall any patient falls from an engaged full length side rail bed. Those old school side rails prized function over form which is the exact opposite of new fangled split side rails that are ubiquitous in today's hospital world..
The split rail special shown above is the office sitters dream bed and one big nightmare for the bedside practitioner. Sure it looks less intimidating and has better aesthetics than a full rail bed, but note the egress points between the foot of the bed and the bottom side rail. There is also an potential exit between the two rails that usually results in an extremity entrapment which is never pleasant. I've witnessed harried nurses lube up a patient's leg with Lubafax in a desperate attempt to slide it back to bed from under or between a siderail. Without the Lubafax those side rails are like Chinese handcuffs and the harder you yank on that leg, the more difficult it is to free.

Another fairly common exit strategy with this type of bed is often called the "flying buttress" for lack of a more technical name. The patient does a 45 degree rotation while prone and uses the bottom side rail to leverage his hips up and over the bed. It's prudent for a nurse to intervene while the buttress, so to speak, is still flying because the landing can be a real doozey when the patient impacts the floor. Thankfully most patients emit a verbal warning in the form of a shriek when they get stuck over the siderail and suspended in an uncomfortable, to say the least, position. At least the Surgilube or Lubafax is unnecessary with a flying buttress.

Today office sitting busy bodies are claiming that siderails are restraint devices which is pure balderdash to old nurses who like to think of them as freedom from falling incident devices. All an old nurse needs to keep just about any patient safe in bed is an extra sheet, a washcloth, and a roll of 3 inch gauze. The sheet is applied lengthwise across the patients chest and under the arms. The ends of the sheet are tied under the bed with the full length side rail up.

Mitts are applied by asking the patient to squeeze a rolled up wash cloth. The roll gauze is applied to the clenched fist from the wrist to fingertips creating a boxing gloved appearing hand. This also has the advantage of ceasing IV pulling or self adjustment of Foley catheters by the patient. I have seen motivated patients discontinue their NG tubes by clamping the tube between the mitts and yanking. This only happened once though because seasoned, old time nurses would bridle their NG tube by. OOPS never mind bridling - that's fodder for another post. Bridling of NG tubes is cruel and unusual punishment in my opinion and should never be done.

Egress minded patients are best kept far apart from each other. Semi private rooms become the devil's workshop if a couple of these bed bail out kings become buddies. Many times I have seen one patient perfect an exit strategy and then proceed to free his neighbor from bed. Once freed from the surly bonds of the hospital beds these folks just love to yank on Foleys, discontinue IVs and get into unimaginable mischief.

Full length side rails were highly functional and cost effective. Old hospital beds cost hundreds of dollars, not thousands like the beds of today. It's hard for me to fathom how something so highly functional could go by the wayside.

Thursday, August 17, 2017

If President Trump Tweeted About Disease

Cancer is bad, really bad, but so are oncologists. That chemo is equally bad as the disease they are curing. They are both equally to blame for the disease.

Wednesday, August 9, 2017

Montefiore Hospital Pittsburgh - A Unique Design

Architecture is not my area of expertise ( at my age about the only expertise left is shooting off my mouth) but I know a really special hospital building when I see it.  Pittsburgh's Montefiore Hospital was built into a hillside, ala, Pennsylvania bank barn style. The main entrance was located at the top of the hill which meant that a substantial portion of the hospital was below you as you entered. A subterranean wonderland of caring catacombs.
Montefiore Hospital, Pittsburgh, like a tree, it's supporting
roots were underground

The apex of the hill entrance floor was aptly named MAIN. There were three floors below main identified by letters."C" level on the very bottom  contained the operating rooms and recovery rooms, "B" level housed critical care units and "A" level contained the morgue and  cafeteria which served the best homemade bagels I have ever tasted. This was the only hospital I worked at that had the morgue so close to the cafeteria. This hospital made exclusive use of those double decker gurneys to transport bodies and morgue supplies were delivered in a cart that looked exactly like patient tray carriers so the general public was unaware of any morgue related activity near the dining area. Pretty clever.

Locating the OR on the very bottom of the hospital was a real switheroo for an older hospital as the most common locus was the very top floor. Explosive anesthetics were never used at Montefiore because a basement explosive mishap would have been catastrophic. There was little foot traffic on "C" level and this was a very quiet OR.

Montefiore's ER was underground on "B" level and accessed by ambulances entering a tunnel like opening from a side street. When recovering trauma patients related stories about near death experiences involving journeys through a tunnel, nurses set them straight by explaining that their near death experience was not all that ethereal. They were just entering the ER.

Having worked at Catholic, Protestant, and Jewish Montefiore, my nursing journey (I hate that journey business) has been an ecumenical experience. Of the three permutations, Montefiore was special. Some hospitals are focused on research, education, or making money but Montefiore was patient care oriented to the highest degree. Patient needs were the highest priority here.

There was never any of that "We will have to see if you are covered" or "That  treatment is unavailable because it's against church teaching."  Patients migrated to Montefiore like salmon swimming upstream knowing that once in the hospital, kindness and concern reigned even if their journey was one way. Dying patients never received a hospital bill.

The director of nursing even made rounds to the nursing units and never harangued or harassed a soul. She frequently inquired if we needed anything. If it was for a patient, we got it pronto.
Montefiore had its own 3 year nursing diploma school that was open from 1902-1974 and floors were staffed almost exclusively with RNs

In 1990 Montefiore was bought out by a giant healthcare corporate entity, UPMC. The first thing to go were the homemade bagels - they fired the baker. Next on the corporate agenda was renaming all the hospital floors; "C" became "1" and so forth. They even installed kitschy computer screens in subterranean rooms and connected them to an outside camera.

Maybe the renamed floor numbers made sense, but you cannot replace caring with virtual window  kitsch. Today a patient is lucky to find a pleasant nurse that is not umbilicated  to one of those computer on wheels monstrosities. It breaks my heart to return to Montefiore today. What is gone will never be replicated

Thanks for taking the time to peruse my foolishness. I have no idea how that stray line crept in at the conclusion, but I cannot seem to get rid of it!

could be wheeled from an ambulance to the ER without even having to open a door. si sized o

Friday, August 4, 2017

Emerging Nurse Leaders - What in Blue Blazes?

It doesn't take all that much to rankle my hackles these days. From nurse office sitters that don't know the basics of setting up a Mayo stand or how to cut a series of ligatures all the exact same length with just 2 snips of your Straight  Mayos. These are the same folks who dictate aseptic procedures while sneezing without a Kleenex. Regulatory and office sitting busy bodies regularly let loose with more crap than a chimp on laxatives and it's high time they stopped circling the bowl.

What the heck is an EMERGING nurse leader. It's high time they got off the pot and did something for a patient. Find someone to suction, milk a chest tube, load a Raney clip and by the way that Foley bag needs emptied. Emerge already and do something. Back away from that desk, arise out of that comfortable chair and for gosh sakes do something. While you were preoccupied with emerging other nurses were out there actually doing things for patients. Enough is enough!