Thursday, October 26, 2017

One Flew Over the Cuckoo's Nest comes to Roost at Downey VA Hospital

Cuckoo's Nest Nurse Ratched on the silver screen at Downey VA
Downey VA Hospital, the 1600 bed psychiatric warehouse hospital in North Chicago, Illinois had it's very own movie theater showing first run movies that had been carefully screened by an assortment of know-it-all, busy body administrators. Disney Movies, feel-good musicals  and an assortment of cartoons were the typical fodder. Someone must have been asleep at the switch in the movie review detail  because one afternoon the head nurse approached me with an agitated look about her. "Can you believe it..One Flew Over the Cuckoo's Nest is being shown this afternoon at the theater on base." Hmm..I began thinking it might be an adventure to escort a group of our locked ward patients over to view this movie.

One Flew Over the Cuckoo's Nest, based on a Ken Kesey novel, was a movie filmed on the back wards of an Oregon State  Hospital for the Insane.  It featured a down right despicable Nurse Ratched character that was domineering and abusive to her patients. She controlled everything on the ward from the TV to determining candidates for lobotomy. The scenes of the patients' on the ward was a spitting image of Building 66AB at Downey where I was working. Downey nurses, for the most part, were too burned out to dominate anyone. The modus operandi was just getting by until that Civil Service Retirement kicked in. There were no Nurse Ratcheds at Downey.

Downey had a rule that any closed ward group of  patients must be accompanied by an RN on outings. I made it my personal mission to get these guys off that smoke filled, depressing  ward as much as possible and organized walks, picnics, and even ball games. So when I heard about Cuckoos Nest  being shown on movie night, I figured, what the heck? These guys are just about living the movie and I was curious how they would respond. I strolled onto the ward after supper and called out, "Movie night, who wants to go?"

Two dozen or so of the patients stepped up and we walked over to the theater. Sometime movies elicited shouting and bouts of unrestrained laughter, but during Cuckoo's Nest there was a strange silence from the crowd. The experience of sitting in a long term psychiatric hospital watching a movie filmed in such a location reminded me of watching a war movie in the middle of an active battlefield. Today one of the most overused words that pops up in contemporary banter is surreal.

Watching Cuckoo's nest at Downey VA with a group of schizophrenics was way beyond surreal. It was one of the most unusual experiences I've had as a nurse except perhaps for the time a patient filled his prosthetic leg with urine and asked for help putting it on. When I placed his stump in the prosthesis urine splashed everywhere to the delight of the young amputee.

After the movie ended, about half of the patients had no reaction what so ever, because the long term use of drugs like Thorazine had wiped out any trace of individual personality. A chemical lobotomy of sorts. Another group of patients had trouble separating reality from the movie characters and asked me to speak with Nurse Ratched to "straighten her out."  The other small group identified with the characters and  was delighted that someone had made a movie about them.

On the commute home, I kept thinking that I'm going to write about  that Downey VA movie night experience down some day. I knew my lackluster writing skills would fail to communicate the bizarre nature of watching a movie imitating a mental hospital in a genuine metal hospital. At least I tried.

Thursday, October 19, 2017

Curved Surgical Instruments - What's the Deal?

One of the liberties of being "just a  scrub nurse" was the privilege of asking dumb, foolish questions. When there was a lull in surgical action such as waiting for a phone call from pathology or passing  time until an esoteric instrument was flashed,  the time was ripe to pose philosophical queries to the attending surgeon. Surgeons could come up with some convoluted answers to foolish  questions when they were caught off guard. Timing and delivery of the question was the key to obtaining an offbeat answer.

Here is a sampling of some questions I asked in a foolish attempt to resolve the greatest mysteries of the operating room; "Why do cloth shoe covers track blood on the floor a greater distance than new-fangled plastic disposable covers?...  How normal is 0.9 saline?... Can you sleep on a mattress suture?... and perhaps the ultimate question... "Why is the working end of many surgical instruments curved?"
Four lovely curved clamps in the foreground with the tips arching forward. A pair of straight Allis forceps, straight  hemostats, and a lone, proud Babcock sitting in the background. An obscure visual treasure of glimmering stainless steel enhanced with graceful arching curves, glowing in the brilliant overhead light of the tiled temple. The astounding beauty of those gracefully curved clamps surrounded by the deep sky blue surgical  towel is so easy to overlook while we live out our remaining days craving the cheap balm of a glowing screen. Hmm.. Maybe I could scrub for just one more case.😃

Here are some candid responses straight from the surgeon's masked mouth: "Instruments are curved to match the curve of the human hand....Because that is the way it's done Fool, now hand me a sponge stick and get back to work...There are no straight lines to be found in nature; that's why instruments are curved... Curved instruments have greater utility and are more useful."  That last answer probably made the most sense, but it's still not an elaborate rationale for instrument curves.

With the luxury of time to think about it and lots of experience watching curved instruments in action here is  my foolish explanation. When cutting with a straight bladed scissors the operators hand is directly in-line with the direction of the cut. This can obscure the view of the cutting activity. Curved scissors place the operating hand at a 30-45 degree angle (depending on the acuteness of the curve) to the area being cut, providing an unobscured view. Curved needle holders drivers as you whippersnapperrns call them, follow the same principle.

When using just about any hinged surgical instrument the opposable thumb is moved away from the index finger when spreading the jaws or blades, in the case of scissors.  It takes physical space to accommodate this thumb/index finger span. Curved instruments create an angle to move the hand above the area of work providing room for the necessary finger span. A long handled, curved instrument allows the surgeon to work in some very deep wounds such as encountered with obese patients.

Retractors have gracefully curved blades to distribute pressure over a wide area to minimize trauma. Wrapping those blades with saline soaked lap sponges helps too.  I believed that aggressive retraction caused as much trauma as any blade. Whenever a resident was pulling back so hard on a retractor that he assumed the position of a water skier, tissues were being stretched to the limit. Aggressive retraction always bugged me. Surgery should not resemble a taffy pull.

Old school nurses had the responsibility to ensure surgical instruments were in proper working order. If a surgeon encountered a  hemostat or needle driver with misaligned jaws, it was his prerogative to "fix" the offending instrument by opening it up and bending one arm up and the other down. Instruments that had been curved via this "repair" were rendered useless and thrown into the trash where they belonged. Curves, in this case, served to identify a non-functioning piece of equipment.

Friday, October 13, 2017

A Friday the 13th Foreign Body Mishap??

What does this X-ray reveal?  Looks like the scrub
nurse was preoccupied by counting sponges and over-
looked keeping track of the instruments. That looks
just like a straight Mayo scissors at waist level

Foreign body false alarm. That's just an x-ray of a student
nurse in uniform toting scissors in the standard location.
When a snip was needed, student nurses could pull those
scissors out faster than an outlaw cowboy could draw a
six shooter.

Tuesday, October 10, 2017

Thorazine - An Old Fashioned Cure-All

Thorazine was thought of as a revolutionary breakthrough medication similar to Penicillin when the FDA approved it's use in the early 1950's. It was the very first psychiatric medication useful in the treatment of schizophrenia. Before Thorazine,  institutions used leather restraints, alternating cold and hot body packs and of course crude psychosurgery such as lobotomy.

In a bizzare side note Freud never received the Nobel prize for his work, but the fellow with that ice pick brain surgery  got the call from Sweeden to come pick up his Nobel prize for lobotomy. Efforts to recall this Nobel have been unsuccessful.

Thorazine was discovered while searching for a cure for malaria and worked by blocking dopamine receptors  in the brain - a chemical lobotomy. After Thorazine disables the dopamine receptors all sorts of bad things happen. Blocking dopamine does blunt the psychosis, but fooling around with neurotransmitters never has a happy ending. Akathesia (constant uncontrolled restlessness,) sustained muscle sasms leading to a debilitating constant muscle activity called tardive dyskinesia. I always thought of Thorazine as the equivalent of weeding a garden with a hand grenade. Sure the psychosis was blunted, but so was everything else that made the person an individual. These people were mere shells of human beings. The reeks and wrecks found on the backward of any long term psych hospital were not there only for their psychosis. The institutionalization and side effects of long term phenothiazine therapy were at fault too.

Thorazine was supplied in a wide range of dosage forms including;  syrup,  concentrate, injectable vials and even suppositories.  On my first medication passing adventure at Downey VA I had a med card that indicated the patient was to receive 2000mg of Thorazine concentrate. I was taught the maximum dose was around 200 mg. How could a patient receive 2 grams of this potent tranquilizer and survive? I was told this was the correct dose and the patient acquired a tolerance over the decades and to go ahead and give it. The patient shuffled up to the med room, gulped it down and went about his business. Simply amazing.

Some of the long term Thorazine concentrate consumers requested the nasty tasting substance "straight."  This meant giving the drug in a small medicine cup diluted with just a splash of tap water. The concentrate turned a brilliant shade of pink when the water was added and this was long before the color was associated with cancer survivors. Thorazine concentrate was just plain nasty smelling. Cracking that big brown tinted bottle unleashed a scent not unlike the Testors glue that I used as a youngster to assemble plastic model kits. We usually diluted it in a thick sugary substance called simply "citric." I doubted this tactic made it any more palatable, but at least it knocked some of the unpleasant smell down.

There is ample truth to the old adage that when there are 3 or more treatments for the same condition, none of them are effective. The pharmacologic corollary- If one drug is used to treat multiple divergent illnesses; it's not an effective drug. Here is an interesting hodge-podge of ailments that Thorazine was purported to cure in 1950s ads. A foolish panacea if I do say so.

Hmm.. this might just work. Snow him on Thorazine and see if he makes it to the bar.

I wonder if her "serene detachment" persisted through the muscle spasms of tardive dyskinesia.

In my experience, Thorazine induced rapid, shallow respirations-not sure how well this would play out for asthmatics.

Thorazine was known for it's hypotensive actions. Throw in an old time general
anesthetic with a Thorazine pre-op and watch the B/P drop like a lead balloon.

Wow.. never realized Thorazine was such a miracle drug with an assortment of therapeutic applications. It did work well for nausea in small doses of 25mg, but patients never asked for a repeat dose. I always asked post-op patients if their nausea was relieved by the small dose of Thorazine and their reply was always something to the effect that it worked but made their mouth very dry and induced a profound malaise and general feeling of unwellness. "Don't give that to me again!" was a frequent request.

When drugs are touted as having so many uses I suspect it's because they don't work too well for anything. Of course this lesson has been well learned and would never happen today. HeHe.

Wednesday, October 4, 2017

Las Vegas Massacre

Despite a rigidly enforced news blackout in my household, the really bad events have a way of surfacing. When I heard hundreds of people were victims of gunshot wounds in Las Vegas  the logistics of treating this much trauma boggled my mind.

Three gunshot wounds were enough to wreak havoc in our busy Chicago OR. We used to mark preop X-rays with paper clips in a usually futile attempt to track trajectory. Projectiles can bounce or tumble after striking bone. The deflected path is difficult to assess. A box of paperclips lasted for years in the old time OR. I wonder if CT scans have eliminated the paper clip markers, but it's painful to think how many paper clips would be needed for hundreds of people.

The aftermath of mass shootings is becoming well scripted. The shooter is characterized as a psychotic madman which further unfairly stigmatizes the mentally ill. Politicians praise first responders and express sympathy for the victims. I heard one senator said it was to early in the investigation to consider legislative solutions. What more investigation is needed after learning the extent of the slaughter.

The gun rights folks will cite the second amendment which was crafted in an age of muzzle loaded weapons which took time to reload. I don't think our forefathers envisioned wide distribution of  rapid fire assault type weapons, but gun folks might allude to the notion that it's a price that must be paid for freedom.

I wish folks could see how powerful guns are when bullets meet human flesh. Tiny entrance wounds give way to shredded small bowel and lacerated livers. If shooters knew how tired hands get loading hundreds of needle drivers or counting pack after pack of  4X4s they might see things differently.

I am so sorry for the victims and cannot fathom how surgeons and nurses could treat so much trauma.