Monday, March 27, 2017

Nursing Career Choices - My Journey from the OR to Downey VA

It's so easy to get locked into one particular nursing specialty and latch unto for life. The problem is further exacerbated by seeking more education in that particular area which further encapsulates a career within one particular bubble. Stepping outside your current nursing  comfort zone and engaging in something completely different can bring a new perspective to a divergent specialty arena. Maybe if psych nurses ventured into the OR they could ratchet down some of the everpresent angst and emotional hub bub. Maybe if OR nurses tried psych, they could implement some useful interventions. Who knows? I figured it was worth a try.

I had a life long interest in OR nursing or  in the vernacular of you whippersnapperns "perioperative" nursing. I still like the old fashioned scrub nurse terminology, but then again, I'm an OldfoolRN. Psych nursing always seemed so very different. The long term custodial care of chronic schizophrenics seemed to be the exact opposite of slapping instruments into a surgeon's hand for an immediate solution to a health problem.

I thought that this  expertise, if you could call it that, could be applied to another nursing specialty like psych. Youngsters do indeed generate some foolish ideas when they are out to cure the world and I was no exception. I like dramatic quick fixes and doing something to really cure the underlying problem. Proven interventions that get sick people back on their feet and back into the business of life. Psych was to be my new alternate universe and I would somehow help those institutionalized souls with novel and pioneering interventions. I was probably as delusional as some of the patients!

Downey VA Hospital, just north of Chicago was to be my new stomping ground. I was hired and told to carefully review the employee orientation manual. They actually wanted me to start working on the very same day as my interview. Desperation does not make for clear, level headed thinking so I declined and agreed to report the next morning.

The nursing supervisor escorted to my new assignment, Building 66 ( AB  ward) in a VA facility that was indeed  providing long term custodial care to chronic schizophrenics with a smattering of manic depressives thrown in for variety. She opened the massive door which resembled a bank vault with heavy robust hinges   to "A" ward and as we stepped in, a pool ball thrown with the velocity of a Nolan Ryan fast ball whistled just over my head. In the far corner a patient was doubled over in pain after beintng "bayoneted" in the abdomen with the end of a pool cue. The blue pool chalk was mixing with a small amount of bright red blood. I remember thinking to patriotic his plain white t-shirt looked with a red and blue stain.

"Is this the therapeutic milieu  mentioned in the orientation manual?" I foolishly asked my orienting supervisor. "Not exactly," was her reply as she quickly wrestled the pool cue from the agitated patient who was brandishing it like a he was preparing for another vicious  strike to the body. The supervisor complained bitterly that she had ordered the pool equipment locked up and set about for an attendant to shoulder the blame.

After resolving that issue, she suggested that I remain on the ward to observe. There were 40 patients in the cavernous, exiguously furnished dayroom, most of them pacing to and fro muttering unintelligible ramblings. Everyone smoked and a thick blue cloud enveloped the entire scene. A huge ceiling mounted unit that whined and whistled like a 747 on a take-off roll was sucking up some of the cough inducing smoke. I asked one of the attendants about the strange device and was told that it was a "smoke eater." At least they are trying, I thought to myself.

There was no danger of anyone leaving this facility. The windows had heavy wrought iron bars that rivaled the entrance door in terms of shear mass. The place reminded me of a maximum security prison or a Fort Knox for people.

I concluded that I needed to do something physical to establish mutual trust and get the ball rolling with these guys. Attendants and other ward personnel were chatting with some of the patients, but from what I observed, this did nothing constructive. These guys had been talked to for years and it did not seem to do much for them

I noticed that they were all wearing scuffed, dirty, leather dress shoes that they had obtained from the hospital canteen. The ubiquitous athletic shoe of today's world had yet to be invented. In a supply closet there was a shoe shine set-up complete with a fancy gizmo to prop feet up at the optimal level for a seated operator to shine the footwear.

I had an epiphany. This is how I could engage some of the patients and develop some sort of therapeutic relationship with their tortured souls. I think it was called making therapeutic inroads or some other term firmly rooted in the rubric of psychobabble nonsense. Anyhow., I decided to give it a go and  when I returned the next day  I reported to the ward with some newly purchased tins of shoe polish and a couple of worn out scrub suits that I had collected from my previous nursing life. I knew from experience they were perfect for buffing shoes to a deep shine

"Shoe shine..Get your shoes buffed up to a nice shine," I shouted out toward the pandemonium emanating from the dayroom. Whenever a patient approached the door, I greeted him with a friendly smile and cheerfully offered my shoe shine services. Even some of the more withdrawn patients began accepting my services and this was a great way to learn their names. One of the attendants cautioned me to limit my shoe shine services to when the supervisor was off ward, but I did not worry about that too much. After all, I was doing a heck of a lot more than they were to help the patients.

It touched me deeply when after about a week of my shoe shines, a motley collection of disheveled patients approached me and asked to polish my shoes. I was really getting somewhere with these guys.

For my next Downey VA post, another OldfoolRN innovation: Teaching violent patients to request restraints to avert injury. Supervisors thought I was a nut, but the proof was in the pudding- It worked

Monday, March 20, 2017

A Young Jackanapes as a Scrub Nurse

Ahh.. It's Lent,  a historical time for introspection and coming clean with bad habits and misdeeds from the past. When more than one disinterested party brings attention to your personality flaws, it's time to pay attention, they probably have a legitimate grievance. One of the accusations tossed my way more than once was, "You are a blowhard." There I said it and allow me to explain.

Before a blowhard starts pontificating, it's wise to make sure your employment is secured by your job performance. I tried to be really good at what I was doing so the surgeons would need my services. Dr. Slambow used to request my services by calling the scheduler and demanding the services of that "jackanapes of a scrub nurse." Everyone knew who he was asking for. He used to describe me as the  most quiet scrub nurse he ever worked with. That was most likely another reason for my long term survival in the OR. Stress and long cases could initiate my assorted lame brain suggestions and tips for wise surgeons baloney.

For instance, one long case that dragged on for hours  involved a partial nephrectomy done by the chief of surgery. He was laboriously sewing tiny little BB sized pieces of abdominal fat to cover the excised surface of the kidney remnant. My fingers were aching,  loading one endless needle holder (or needle driver as you whppersnapperns call them,) after another. Suddenly I asked him, "Why don't you just suture one big giant fat ball onto that kidney and be done with it?" He did not miss a beat and said sardonically, "It doesn't work that way Fool!" I kept my mouth shut, but managed to walk away from my Mayo stand with a certain swagger as the circulator said with disbelief, "I can't believe you said that to the chief of surgery."

I was circulating on a portal caval shunt which is a high risk surgery especially with someone that has less than optimal clotting factors resulting from years of alcohol use. Suddenly the patient began bleeding very badly and it was my task to implore the blood bank that we needed everything they had for this patient. The technician began badgering me with endless questions about why we needed all that blood. Finally, tired of her interrogation, I said "We just really need the blood. The surgeon chopped too big of hole for the surgery." Later, I realized that everyone in the room heard my lame brained description of the surgery. But, hey we got the blood.

Bovie smoke really got to me and I had ways to minimize the damage. I frequently instructed the residents on how to use an ordinary suction to aspirate some of the smoke. I used to call these procedures "tips for wise resident surgeons" and most of the time they went along with my foolishness, but in hindsight it was just another blowhard manifestation.

At least aging has put some of a damper on my blowhard nature, I hope.

Friday, March 17, 2017

A Teeter Toter Surgeon

What goes up..Comes down..Hard
Play grounds from my youth could be very dangerous places with heavy moving objects,  very hard  unforgiving landing places, and young toughs on the prowl in search of  unsuspecting  victims to intimidate. Teeter toters were a favorite playground  implement for bullies to ply their trade. A hard wooden plank moving up and down with a  fulcrum in the middle was too much to ignore for those with devilment on their mind.

The bully's pitch went like this, "You wanna have some real fun, lets go play on the teeter toter. I'll even let you get on first." The unsuspecting victim was seduced by the bully's jubilant grin and happy go lucky demeanor.

Once the hapless victim was in position on the end of the teeter toter, the corpulent bully promptly planted his overstuffed backside on the opposing seat. The victim was suddenly thrust high into the air with amazing force. If he was strong enough to hold on, the finishing  move was about to present itself. The victim would be held captive on the elevated end of the teeter toter as the bully began his verbal torture.

"You sucker, now you are really going to get it," the bully taunted. As the victim screamed and cried the bully suddenly hopped off the depressed end of the teeter toter sending his high- flying victim crashing to the ground with a sickening thud/crash/cry cacophony.

We had an aging, well  past his prime, ENT surgeon that everyone  referred to as the teeter toter surgeon. His well earned nick name was indicative of his smooth preop pep talk followed by a harrowing experience once the patient was situated in the operating room proper.

His life long obsession was rhinoplasy and he even invented specialized surgical instruments that carried his surname. Whenever Dr. Cuddle asked his scrubnurse for an instrument, he made a point of accentuating the "Cuddle" in it's nomenclature. "I'd like the cuddle speculum followed by the cuddle elevator." was a typical command issued in his carefully modulated, stilted speech pattern. "Yes Dr. Cuddle," was the canned scrub nurse's reply.

He could convince just. about anyone with a nose that they were a candidate for rhinoplasty. His sppech, like the playground bully, was filled with false promises and fantastic benefits. I remember how he extolled the vitality benefits of his nose jobs because they increased the oxygen carrying capacity of the blood. Then he went on and on about how beautiful their new nose would look. Hollywood would soon be calling. That beautiful new look and rejuvenated persona would be too much for a movie producer to resist. Better days were as close as a lateral osteotomy fracturing the nasal bone structure to smithereens all the while an awake patient teetered at the maximum elevation of the teeter toter OR table.

For those who question my comparison of  Dr. Cuddle to the playground bully, understand this: The positioning of both victims is identical when receiving their punitory ministrations. The play ground victim receives his coccyx shattering impact sitting bolt upright and Dr. Cuddle performs his proboscis punishment with the victim  patient in the identical configuration. The OR table is positioned with a break in the middle and the back of the table raised at a 90 degree angle.

Dr. Cuddle was one step ahead of the playground bully who was content with letting his crying victim to quickly vamoose from the scene of the crime after receiving his butt busting punishment. There was to be none of that flight or fight syndrome business for Dr. Cuddle's patient who was physically restrained to the table with an airplane type belt around the waist. This served the dual purpose of arresting the patient's departure and also prevented him from throwing blows in the direction of  Dr.  Cuddle. The ankles were also tacked down with another robust belt to avert kicking. The coup d grace' was an elastic bandage wrapped  around the forehead  and secured behind the table for stabilization.

Once he had the patient in the OR, he had that same look in his eye as the playground bully. Someone was about to experience torture on the same level as the teeter toter victim. Dr. Cuddle performed all his procedures under local anethsia if you could call it that. That look on a wide awake patient's face  as they surveyed the Mayo stand directly in front of them loaded with a multitude of glimmering sharp steel instruments was eerily similar to that of the teeter toter victim.

Their was a reason for his making sure the patient was restrained on the table. Even if the local anesthetic was effective, that sound of a mallet impacting with an osteotome and fracturing your nose has to be worse than the crash/cry after a playground victim's  teeter toter free fall. The stuff real nightmares are made of.

Whenever I was anywhere near Dr. Cuddle, my nose was covered with a surgical mask. I did not want to give him any ideas about "fixing" my nose. As a youngster, I was the victim of that teeter toter free fall prank and I did not want to repeat the performance at Dr. Cuddle's crafty hands.

Wednesday, March 8, 2017

Buidling A Culture of Life - One Wound Infection at a Time

The young surgeon in this advertisement is purportedly "building a culture of life."  I would like to add one caveat based on her inappropriate OR attire. Building a culture of life - one gram positive wound culture at a time.

This ad really rankles my hackles and I don't know where to start with my diatribe. The self-righteous pronouncement of  life promotion is quenched by a paradoxical illustration of sepsis inducing operative attire. Her gloved hands are elevated way past the zone of accepted gown sterility. If she can avert contaminating them on the inferior margin of her mask, contact with her exposed scrub top will surely infest them with a host of eager microorganisms just itching to infect an open surgical wound. Could that gown even be called a gown? You can see through it and I suspect that  blood would run through it like water through a Keurig. Instant contamination. Her skin is visible on the left wrist below the glove. She must have put her aseptic consciousness on hold while busy building her culture of life.

And those wrinkled gloves are just waiting to get snagged on just about any  ratcheted instrument. Initially, I thought the gloves were an issue of improper  fitting, but on closer inspection, they appear to be crude exam gloves perhaps suitable for a surgeon's  Halloween costume. I'm all for hospital cost cutting, but it's just plain wrong headed thinking to skimp on surgical gloves. Despite the high-minded tone of the add copy, the  illustration would insult the intelligence of an amoeba.

My favorite OR supervisor, that red headed whirling dervish named Alice,  had a way of dealing with characters like this. The improperly gloved hands would have been smacked with a sponge ring forceps so hard an ortho consult for the practioner would be in order. The ridiculous "costume" of a gown would require more serious remediation.

This practioner of sepsis would be sequestered in the utility room with the task of scraping dried blood from every nook and craney of the sponge racks with a periosteal elevator that had been retired from service decades ago.  Just when she thought the unpleasant task was finished, Alice would roll in another sponge rack encrusted with enough dried blood that it could be used as a prop in a  Halloween house of horrors. When her clean up duties were finally  completed she would have spent an entire career in the cysto room hanging bottle after endless bottle of bladder irrigation fluid. At least when she retired her arms would rival the muscle definition of a weight lifter after elevating all those heavy glass bottles. "That'll learn ya,"  as Alice would shout with glee when one of her victims nurses had completed their penance.