Sunday, December 9, 2018

Is Surgery A Spectator Sport?

Observers in a sanctioned overhead viewing site 
advancing their surgical acumen. Serendipitous 
snoopers were another story.
Vintage hospitals went to great lengths to provide surgeon and/or nurse wannabes the opportunity to observe surgeries. European hospitals even referred to their operating rooms as "theaters."  I once worked with a charming British surgeon that affectionately  referred to  us "theater nurses." This soft spoken man actually  thanked  us personally after a case was finished even if our performance was not up to snuff.  A different breed of surgeon compared to his American colleagues.

Surgical spectators were all different and the most interesting  involved the serendipitous observer who happened to be in the right wrong place at the time of the surgical experience.  Don't get me started on those whippersnapperrns who freely use that confounded "experience" word to describe a planned operative  anatomical alteration, but I figure if you can't beat 'em, join 'em. Who says you can't teach an old dog new tricks?

The operating rooms where I toiled were on the very top floor of the hospital and offered a beautiful view of Lake Michigan which was 8 blocks due East. Large picture windows offered surgeons and nurses the opportunity to feast their  weary eyeballs on a  tranquil visual treat of sailboats and sparkling blue water far off in the distance. A welcome reprieve from eyeball stinging Bovie smoke and squnting to thread fine needles with 8-0 white silk while a surgeon hollered at you in the background for being too slow for his speedy needle plunges.

Everything was fine and dandy until the esteemed members of the hospital board decided to erect a high rise employee housing palace  next to the hospital. Nurses were agitated because these were luxury apartments and unaffordable for all but the most privleged office sitters. We were stuck in our 3rd floor walk ups where heat was a rarity even on the coldest winter nights.

Various members of Chicago's building trades toiled on the construction crews erecting this palace for the medical center moguls. They were a cast of colorful characters to say the least. Ironworkers in particular were a flamboyant, in your face sort of personality. I think it had something to do with their performing hazardous work at elevations where one false move meant falling many stories to a colorful  death.

As the building began to rise, we eagerly watched the progress while standing at the scrub sink which was probably less than 50 feet away from the ascending steel I-beams. You  could hear the ironworkers incessant babble before you could see them.   We joked with the surgeons that the ironworkers must be afficionados of expensive German automobiles just like them because they bantered constantly about "beamers" while guiding the gigantic steel beams into place.

The merriment came to an abrupt halt when the ironworkers ascended to the level of the operating room windows. This rag tag bunch of haggard workers acted as though they found a visual paradise. They glared and made contorted expressions as they avidly observed the goings on in the operating rooms. If they found the proceedings in one room not to their liking a short stroll along the steel beam provided a different procedure to observe. Legitimate surgical observers were limited to viewing the proceedings in just one room while the ironworkers enjoyed a virtual cafeteria of surgical sightseeing.

Their ringleader with his distinctive orange striped  hardhat led his merry men along a steel beam parallel to the OR windows until they found a procedure to their liking. The cysto room was the least popular after a worker nearly stumbled off a beam while observing a meatotomy. That procedure shivered my timbers too, so I could empathize with their revulsion.

The most popular room for these happenstance journeymen observers was the orthopedic room. A hammer is a hammer whether the one doing the hammering is a surgeon or an ironworker. The orthopedic surgeons were kept busy reducing and stabilizing bones just as the tradesmen were with steel beams. Both used lag screws and plates in their work. A brotherhood of sorts was established.

The surgeons took little notice of these nosey nitwits, but nurses thought the activities bordered on voyeurism and should be halted. Plan "A" was to scare them off. Sponge racks were crude, nasty looking devices ostensibly designed to facilitate counts, but really served to provide the surgeon of a visual reminder of blood loss. These morbid contraptions were wheeled, so positioning loaded sponge racks dripping with blood  in front of the windows worked to frighten off the men of steel. Some nurses took to displaying suction bottles full of blood on the window sills, but gradually the men of steel acclimated to our repulsive displays.

Alice, our beloved supervisor came up with the ultimate solution to the problem. Being an ultimate Killjoy, she used autoclave tape to suspend surgical drapes over the windows. some problems work themselves out with benign neglect. The observation opportunity ended with our move to the new operating rooms in the Stone Pavilion. Windowless operating rooms were very popular in the mid 1970s and put an abrupt halt to all the fun.



Thursday, November 29, 2018

Retention Sutrures

Old school surgeons had a tendency to overdo just about everything from meticulously double tying simple bleeders to throwing in heavy duty retention sutures for added insurance against impending complications. A patient with wound dehiscence or more bluntly a burst abdomen was like a graphic, negative advertisement of surgical ineptitude. Something  to be avoided at all cost.  The  illustration above shows a wound that is beginning to "dehis" on the right side, but the retention sutures are averting a catastrophic blow out.

There was little science in deciding when to deploy torturous retention sutures and empirical notions ruled the roost. The end result was almost every obese surgical patient suffered the excruciation of miserable retention sutures which were applied in wide suture bites through skin, abdominal fat pad, and firmly anchored in the muscular abdominal wall. The dimpling of the  delicate skin before it yielded to the vicious thrust of a gigantic cutting needle pulling heavy suture was a chilling sight. A surgeon strafing a delicate abdomen with retention sutures shivered my timbers like nothing else. Orthopedic surgery with all it's bone crunching sawing and drilling was small potatoes compared to the forcible  application of retention sutures.

These gargantuan  sutures were usually left in place for about 2 weeks of abdominal throbbing madness for the hapless patient. Removal  was the most painful part of the surgical experience. ( I just love that new fangled vernacular where just about everything in modern healthcare is an experience or journey.) How about that, I can write like a whippersnapper if I try really hard!

The suture extraction process was very painful as a result of tissue adherence during the healing process. Sutures were practically cemented in place.  The fact that the abdominal wall was richly innervated exacerbated the situation. Considerable traction was necessary to pull the unyielding suture free from it's tenacious cementation in the underlying tissue. The sordid suture removal   affair reminded me of pulling cold taffy accompanied by loud screams and anguished howls. The task was almost always relegated to the least senior resident. Thank heaven, nurses never removed retention sutures.

One aspect of retention sutures always reminded me of an executioner applying a hood to the condemned before the act final was completed. This action was ostensibly done to make it easier on the prisoner, but the only real beneficiary was the executioner who could not see condemned man's suffering. For patient "comfort" the retention sutures were cushioned with short lengths of latex tubing where they contacted the skin. These bolsters or bumpers as they were called were custom made by the scrub nurse trimming a length of tubing as the sutures were placed. Any "comfort" from these little gems existed solely in the mind of the surgeon.  Retention sutures fueled post-op pain like pouring gasoline on a fire whether bolsters were in place or not.

More recent knowledge suggests that alteration  in the integrity of connective tissue is responsible for wound dehiscence and not necessarily obesity. The retention suture for all obese patients was not appropriate. Hopefully laproscopic procedures and improved techniques have made retention sutures extinct.

Thursday, November 22, 2018

Giving Thanks

Maybe it's my advanced age or the Sinemet I'm taking  for uncontrolled spasms, but I have this recurring dream. I'm called in to scrub on a messy trauma case. When I show up in the tiled temple with overhead lights ablaze, everyone is glad to see me. Dr. Slambow greets me with that subtle grin and says, "Boy am I glad to see you,  we have a real doozy here. Open up a thoracotomy set with your usual general surgery  paraphernalia. I suspect we're going to need it." Trouble was always around the corner with this request because Dr. Slambow was a general surgeon and the administration determined that he did not have privileges for chest procedures. I always thought that my job was to do what's best for the poor soul lying there bleeding out on the cold table. Office sitters be damned.

About this time I wake up and realize it's all a dream. I'm just an oldster huddling under the covers with knees aching so bad that I would be lucky to crawl out of bed, much less stand at a Mayo stand for hours on end.

OR nursing was difficult to say the least, but I had people who really appreciated my efforts and made me feel important. Maybe a bit too important for my own good.  The difficulties made everything seem more worthwhile. At least I was trying to help someone and was grateful for the opportunity. I don't know what I would have done without it.

I'm grateful for a different sort of life now. I never thought I would outlive so many of my contemporaries who were more fit and much healthier than my foolish self. I was marveling at my longevity with my internist and he summed it up by saying, "Well you never know when your time is up." How true, and I'm  thankful for all these years whether I deserved them or not.

Thankfulness has opened up my soul to humility and the realization that it's not necessary to work in the OR to have a purpose-driven life. I'm grateful for a day unburdened by obligations with freedom from time constraints. The ability to reflect on all my foibles and foolishness. It's difficult for me to believe so many folks read my foolhardy reflections and memories. I am especially thankful that so many of you read my blogging foolishness. Gratitude brings about an all encompassing feeling of peace and satisfaction and I will always be thankful to those who indulge in my foolishness by perusing this blog.

HAPPY  THANKSGIVING.

Sunday, November 11, 2018

When The KARDEX Was King of Communication


Glen from Texas emailed me with a suggestion to write about my experiences with the nursing KARDEX which he advised is disappearing. I had no idea. How could something with so much utility just up and disappear?

Christians have their Bible, Jews have the Torah,  and nurses from a bygone era had their KARDEX. Named after a company that specialized in using index cards for data storage, KARDEXES  were the center piece of any nursing station. Patient charts come and go with whoever snatches them up, but the KARDEX is always front and center at any gathering of nurses. Change of shift report without this wonderful collection of data would be impossible.

The front and back of  a vintage KARDEX was a solid sheet of gunmetal grey steel with a piano hinge through the midsection. When you opened this hefty collection of vital information an audible, metallic  CLUNK would echo around the room. That harmonious sound reminded me of a church bell announcing that something important was about to happen. The flipping through the KARDEX index cards  made a gentle rustling sound like the wind blowing through a Midwest cornfield just before the combine moved in for harvest. What a contrast to the contemporary clicking, bleeping, and clacking of a computer keyboard. I loved this bit of KARDEX  acoustic candy because it was an auditory sign that my shift was over and more peaceful, restful times were ahead.

What information was included in the KARDEX?  Everything a nurse needed to know when providing patient care: demographics, treatments, medications, allergies, consults, code status,
 urine reductions, diet, surgery, I&Os, IVs, and  IM injection rotation sites (everyone received these painful ministrations and rotating the  sites distributed the pain over a larger area).  The patient's name and physician was written in ink, but everything else was written in pencil and unlike the medical record, subject to erasure. The Kardex was not a formal document and when the patient was discharged, the cards were ceremoniously tossed in the circular file. No HIPPA - No shredding.  Identity theft was unheard of.

From my blogging foolishness, I can attest to the fact that people say different things under the cloak of anonymity and the KARDEX was no different. I was a quiet and reserved scrub nurse and just look at the blowhard  I've become  with an anonymous blog.  Notations in the Kardex were not signed and nurses perfected a generic form of printing to avert handwriting analysis. This cloak of secrecy  promoted blunt and sometimes crude KARDEX entries.  KARDEX notations often liberated many a nurse's free spirit and foolishness was not too far away.

Nurses who came  before me often had to administer painful and unpleasant (to say the least) treatments and never took "no" for an answer. Rather than write that it was necessary to restrain or hold a patient to the bed for a treatment, code words were used. "Patient needs assistance maintaining proper position for enemas," sounds better than "restrain his arms to prevent fighting to dislodge  enema tube."  In pediatrics the youngsters often needed "help" to receive painful injections or treatments. Those old school nurses were a force to be reckoned with and their KARDEX entries sometimes bordered on fiction. I vowed to never cultivate a mean, sadistic nature present in these hard core care givers.

As I was thinking about the KARDEX, a stream of odd ball and memorable entries returned to my obtunded consciousness. Every student nurse remembers their very first patient. Mine happened to be a pleasant, young Hispanic man recovering from a heroin overdose. Prominently displayed on his index card was a very good suggestion: No heroin on discharge.

Downey VA could be a very dangerous place to work and assaults were an unfortunate occurrence. A night  nurse pulled from the medical side of the facility left an ominous warning taped to the front of the KARDEX: Unsafe to be in attendance here  at ant time. DO NOT ask me to cover this ward again. I heartily concurred but could not do much about my situation. Building 66 was my permanent assignment.

Folks addicted to drugs had a very difficult time in vintage hospitals and old school nurses seemed to delight in social engineering to make their stay as miserable as possible. The old "That'll learn ya" attitude on steroids. A frequent entry on a drug addicted patient's Kardex was: Known drug abuser-no pain meds of any kind.

Floor is slippery. Patient expectorating giant phlegm globs.  Enough said.

If patient is experiencing difficulty voiding, have him blow through a drinking straw. Along with running the sink, this trick really worked.

On the post-partum unit: Remind patient to pull inverted nipples out. Ouch..as if the delivery experience wasn't bad enough.

A patient, Dudley, that I cared for as a student nurse smelled of urine no matter how carefully I bathed him. A perusal of the KARDEX offered an unusual explanation of the pungent odor.  Remove patient's prosthetic leg  from the room on PM shift. He awakens at night and fills it with urine.

Have footwear at bedside for AM pulmonary function testing. We all knew what this entailed.  PFTs were conducted in the stairwell at the end of the hall. If a patient could ascend  2 flights of steps with a  resident encouraging him from behind, he was deemed an acceptable surgical risk. Just be careful not to slip on the giant pools of phlegm/mucous left behind on the steps.

Some patient families are prepared for just about any contingency. I remember well the family that brought a 3 piece suit to the hospital with a dying patient. The KARDEX notation:  Make sure the suit in the clean utility room goes with the undertaker when he comes for the body. Yikes!

KARDEXES were the hospital equivalent of a jungle telegraph and revealed information that you were afraid to ask about or never knew existed. I think rigid and permanent forms of medical record keeping, electronic or paper, can block nursing inventiveness that drive holistic care. The old KARDEX unleashed the nursing free spirit by delineating what really worked for the patient.
                                                                                                                                                                                                                                               

Sunday, October 28, 2018

Le Mesurier's Hammock - An Early Scoliosis Treatment

Kids have unique gifts and abilities; some are smart, others have artistic ability, and last but certainly not least, some  are preternaturally athletic. I could not lay claim to any of these wonderful  attributes, but I did posses the gift, if you could call it that, of unusual joint flexibility. I could take my heel and twist it at an acute angle and tuck it behind my head. My favorite move was performed from a seated position and involved taking my right foot and lifting it above my straightened left leg while pulling it toward my body. Why did I enjoy such foolishness? I guess the answer was similar to the reason climbers give when they ascend Mount Everest - "Because it's there."

My Mom, a long suffering nurse from the Greatest Generation  did not appreciate my skills as a junior contortionist. Just when I had finished twisting myself up like a pretzel, she would holler, "Stop that tomfoolery before I take you to the hospital and string you up in a Le Mesurier's  Hammock. Do you want curvature of the spine?"  Her admonishment did little to curtail my extremity entanglement and circumvolition  activities, but it did whet my curiousity about that hammock thing threat. "How bad can that be?"  Le Mesurier's Hammock conjured up restful, peaceful experience. My next order of business was an investigation into the how and whys of the hammock threat. This could prove interesting.

Like me, my Mom retained her old nursing school textbooks and class notes which were carefully archived  heaped in a basement corner. One day while perusing the hodge-podge collection of nursing texts a serious looking black bound tome called out to me.  Nursing of Children  was the no-nonsense title and the table of contents listed topics like Diseases of the Glands, Spasmophilia, Hordeolum of the Eye, and Early Correction and Fusion in the Treatment of Scoliosis.

During my quest for hammock enlightenment I happened upon a chapter  about bedsores. This little tidbit of medical horror instilled a sleep disorder that persisted well into adolescence. In a mood of wonderment and sheer terror my eyes popped at the images of patients with oozing gaping wounds on their lateral hips and shoulders sustained by simply lying in bed. How could this be?  I made a note to myself to awaken q2 hours to check myself for these loathsome lesions. A peaceful night's sleep was gone forever because visions of bedsores danced in my head. Some things never change, now it's a pain in the prostate that awakens me q2 hours for that lonely journey to the can.

Finally a chapter in the orthopedic section about a condition known as spinal scoliosis revealed the LeMesurier's Hammock treatment. This was another one of those medical misadventures treatments that involve harnessing the spinning earth's gravitational pull. Weighted speculums that are ram rodded in various orifices to gain exposure during surgery are a twisted, devious use of gravity  but the LeMesurier's hammock use of this force  was far more grotesque.

When one views the history of treatment of pathological spinal curvature it is apparent that crude and brutal measures rule the roost. Lemesurier's Hammock involved placing the patient in an orthopedic bed that had risers on each corner connected via an overhead frame matching the dimensions  of the bed. These steel framed monstrosities were frightening in their own right but add traction pulleys and assorted doodads for limb fixation and they resembled medieval racks that could dish out unthinkable tortures. YIKES and double YIKES.

A scoliosis patient in position just prior to application of the hammock.
The victim's scoliosis patient's ankles  wrists were liberally padded and heavy leather cuffs are applied and connected by traction cord to pulleys on the corners of the ortho bed. The extremities begin their audacious ascent until the patient is suspended so the apex of the spinal curve is straightened. After a couple of days hanging around over the net, a body cast is applied and a large window cut to expose the operative site. A surgical spinal fusion is the final step in this uplifting treatment.

Helpful tips from this vintage nursing text advise that the leather cuffs can be sourced from the psychiatric ward and the hammock portion can be constructed from ordinary fishnet. The reference to the psychiatric ward  probably foretold impending problems. Patients subjected to 4 point suspension over a surplus fishing net are likely to sustain psychotic ego fragmentation and the nursing staff subject to PTSD. Perhaps a package deal is in order with the whole the whole kit and caboodle; patient, nurses, and leather restraint cuffs  winding up back on the psych floor.

Nurses are stuck in the quicksand of existing knowledge and looking back it's shocking to realize the barbarity of period treatments like LeMesurier's Hammock. It's amazing what patient's will submit to when the treatment is ordered by paternalistic  physicians attired in immaculate white lab coats uttering trite expressions such as, "It's all for your own good." Old school nurses in there all white uniforms and caps were a commanding presence too. It would have been tough to say "no" to authority figures like that and probably wouldn't have stopped their ministrations if you did.



Wednesday, October 10, 2018

Drinking Bile

No, that's not bile in a T-tube drainage bag. It's a bilious beverage 
just waiting to wet your whistle. Bottoms up!

Waste not / want not was the mantra in epoch hospitals. This philosophy led to events like performing sterile procedures with 2 fingercots and overly judicious rationing of utilities. There were almost no lights on after dark so night nurses always had a flashlight on hand. Recycling and reuse were common with "disposable"  equipment having an almost infinite life span.

Recycling was not limited to medical equipment. Gall bladder surgery was a brutal and miserable experience  with a huge subcostal incision in close proximity to the diaphragm so every breath exacerbated post-op pain. A T-tube was usually placed in the common bile duct during surgery and drained the greenish yellow unsavory goo in a nearby bag.

Bile is a vital component in the digestive process and works to emulsify and break down fat. A deficit of this greenish gooey fluid results in an unpleasant condition known as steatorrhea whereby fat passes through the intestines undigested. An unusually putrid scented diarrhea is the end result.

To avert steatorrhea old school surgeons had a very direct and straightforward solution.  They ordered the night nurse to save the contents of the biliary drainage bag and serve a glass of this gruesome green goop to the patient prior to breakfast. Hospital breakfasts were notorious for their high fat content. Just about every meal was a permutation of that All American staple, bacon and eggs which was a steatorrhea stimulator of the highest order.

The disgusting bile beverage was best served in an opaque vessel such as a coffee cup so as to obscure that yucky green visual stimulation. Minimal explanation was also important. The nurse never drained the bile into the serving container in view of the patient. Optimal bile bag emptying was done with the patient sound asleep and unaware of the impending tortuous tipple. Old school nurses were masters of deception and were even known to ask patients to turn over for a temperature check. While they were prone a painful and totally unexpected intramuscular injection was hastily administered.

The bile drinking gambit  was not much different than the stealthily plunge of the 18 gauge needle during the temperature diversion injection. Either experience was misery of the highest order no matter how it was presented. Bile had a unique earthy/nasty scent to it that could not be masked and the bitter salty taste was cringe worthy. Oh..And be sure to offer mouth care after bile consumption. It promoted dental decay.

Did bile recycling help patients? That's a tough question. Perhaps the diversion of consuming the vile liquid distracted them from their symptoms. It's always prudent to maintain a high level of suspicion when offered just about any beverage from an old nurse. Better safe than sorry.

Wednesday, October 3, 2018

High Tech Hemorrhoid Surgery Meets Old School Positioning Techiques

The advances in modern surgical technique always amaze me. I recently found myself fascinated by a  newfangled hemorrhoidectomy procedure. The surgeon was working with a high tech laser device and magically zapping the 'rhoids into submission while an assistant struggled to manually pry the buttocks apart with the patient flat on the table. High tech meets low tech in the totally unnecessary and difficult manual retraction for operative site exposure. Leave it to OFRNs like me to offer tips to improve the bottom line.

Old school hemorrhoid surgery was a backward, crude sort of affair. A surgical assistant grabbed the offending hemorrhoid with a Babcock and pulled it skyward. At this point Dr. Salmbow would give the command, "Meatball it!" The stretched pile was quickly tied off with a ligature and cut free with a Metzenbaum scissors. Then it was on to the next 'rhoid. At the conclusion of the case some wise guy was sure to proclaim, "We really Wrecked EM." Nurses were always advised to chuckle at a surgeon's attempts at jocularity.

Proper positioning was key to this procedure and there was none of that  struggling or manual prying of the offending, shielding nature of the site occluding  buttocks. Old school OR nurses were adept at exposing just about any body part with the use of sandbags, rolled washcloths or towels, airplane belts,  and  3 inch J&J adhesive tape. The secret ingredient was tincture of benzoin which was the old time equivalent of modern super glue.
Hemorrhoid surgery began by placing the patient in the jack knife position as shown above. The buttocks were then liberally painted with tincture of benzoin which usually brought out the Picasso in me although  I suspect he never had a palette like this. The benzoin served to affix the adhesive tape aggressively to the skin. Next a 3 inch by 2 foot section of adhesive tape was applied to the buttock and then pulled laterally like a piece of taffy. When the "pull" was sufficient the opposite end was wrapped around the under table rails of the OR table. An additional strip of tape could be applied at a right angle to  this main "spreader" for oversize patients. The end result; a perfectly exposed operative site.

Abrupt removal of tincture of benzoin secured adhesive tape frequently enhanced a patient's emergence from general anesthesia. That stuff was a real challenge to separate from the skin in a civilized manner.

I often thought that the Preparation H folks should advertise by showing snippets of forcible hemorrhoid removal. Hemorrhoid surgeries were enough to convince me of the value of topical treatments.



Monday, September 24, 2018

Fun With Operating Room Kick Buckets


My recent visit to Pennsylvania Dutch Country rebooted a long dormant memory of an unfortunate incident  with that wheeled dervish, an operating room kick bucket. The Amish eschew internal combustion engine powered transportation devices in favor of things like foot powered scooters. One foot remains firmly planted on the scooter platform while the opposite lower extremity propels the device with intermittent kicking motions. As we shall see, that mode of propulsion is not exclusive to Amish scooters.

Kick buckets in the OR are similar to Amish scooters in that they share the ability to move through space on wheels and are about the same size. My tale begins as another long case comes to a conclusion and I am involved in the usual post-op prattle with Janess, the exhausted scrub nurse. As she descended from the artfully OFRN designed scrub nurse  platform her foot landed smack dab in the middle of a carelessly positioned  kick bucket. The wide opening at the bucket top guided her foot into the much smaller base firmly entrapping and immobilizing her leg in the contraption. Luckily the bloody sponges had been removed from the kick bucket or the situation could have been rather messy.

The ensuing commotion soon aroused the attention of our hypervigilant supervisor, Alice, who added to the cacophony with one of her bitter diatribes. "Look what you've done now you clumsy little goofus. I've got a mind to teach you a lesson that you won't soon forget," shrieked Alice.

Janess was now a hostage of her sympathetic nervous system which activated the flight or fight instinct. Alice was a contentious character with a military background so the only viable option was flight without further ado. With one foot entrapped in the confining but mobile kick bucket, Janees used her free extremity to propel herself through the open door with all the skill of an Amish scooter driver. Alice was not up to speed with her arthritic knees so Janess was able to open up a substantial lead and soon disappeared into the locker room. The ensuing laughter soon took the wind from Alice's sails and we all lived happily ever after...sort of. Folks that work together in stressful environments like operating rooms often transforms themselves into one big dysfunctional family. It did not seem like much fun at the time but in a strange way, these were some of the best years of my life.

Sunday, September 16, 2018

I'm unplugging ( Tee Hee - as if Oldfoolrns  like me can be plugged in) and heading to PA Dutch country for a week or so. I just love being around the Amish and maybe I can think of some new posts worth reading.

Thursday, September 6, 2018

Ring Stand Challenge Racing

An official makes last minute preparations to the race course.
Old school operating rooms were brimming with an assortment of unsavory, unpleasant and downright dangerous tasks; from unclogging floor drains occluded with who knows what to running test firings on  hissing and sputtering behemoths that passed as autoclaves. Who cleans up the room after a trauma case and who tends to the patient?  We used to draw straws with discarded suture for the equitable assignment of these nasty tasks. For the athletically inclined, the alternative to games of chance like the drawing of straws  was ring stand races with the winner awarded the undesirable  task of their choice.

Ring stands were a piece of operating room furniture designed to hold large basins of solutions used during the case. Before the advent of modern  disposable surgical gloves ring stands were used to rinse talc off reusable gloves. This ubiquitous piece of equipment was a favorite plaything for old school OR nurses. Contests of skill involving the tossing of various objects through the ring stand gradually evolved to attempts involving the passing of  an entire nurse's entire body up from the base of the stand and out of the elevated dastardly top disc that served as the finish line. The contest obviously favored the petite, lithe, thin contestant. Since I met none of these criteria, I was an almost certain loser and frequently found my self with a ring stand stuck on my ample waistline. My buffoonery quickly transitioned to outright embarrassment as the laughing of my colleagues crescendoed .

An official race began with 2 nurses facing the race course ring stand. On the "GO" command the nurses slid down to the floor like a limbo dancer and contorted their way up through the opening in the ring stand. The next stage of the contest was the hard part and involved slithering your body all the way through the ring stand with the victor emerging free of that confining circle. Older nurses always positioned the ring stand parallel to the OR table and leaned against it for assistance. Lithe youngsters could use their upper arm strength to rise above the confining circle. Victory was sweet with the winner having a justified sense of power knowing the choice of unsavory tasks was their choice.

For my next post, I'm thinking about another piece of OR furniture that could be more fun than a barrel of monkeys - the kick bucket.

Monday, August 27, 2018

Caring For Amputated Limbs

The brave new world of modern healthcare culture continues to dumbfound, agitate, and get stuck  in my old foolish, wrinkled up craw. The latest outrage?  I was reading an expert's answer  on Quora that amputated limbs are treated as "medical waste" and are disposed of by encasing them in a red sealed plastic bag marked with a biohazard symbol and sent on their merry  way to a landfill or incineration.

Self respect starts with caring for others in a dignified fashion.
Don't even think about tossing this in the trash!

Since everything in healthcare is governed by money, I suppose this is the cheapest  most cost effective means of limb disposable. Preoccupation with money when it comes to caring for people leads many in the wrong direction. Patients are never clients or accounts and caring for them is not an "industry."  That amputated limb was once a part of someone who is going to have a tough time, to say the least, of dealing with a new body image and learning a new lifestyle. An amputated limb is not an inflamed appendix or a gall bladder full of stones to be tossed in a kick bucket and tossed aside, it was part of someone and their identity. Who knows? Maybe an integral component of the patient's spirit was living in that limb. Treat body parts with the respect they deserve.

Alice, my favorite OR supervisor taught me how to care for an amputated limb many years ago. Alice could be a mean, cantankerous taskmaster, but I agree with her wholeheartedly about showing care and respect for an amputated body part. Despite their harsh appearances, old school nurses had and an innate sensitivity and were determined do-gooders.

When it came time to care for my first amputation patient in the OR, Alice was on hand for direction. "The first order of business is to line up 2 carts just outside the OR. One cart is for patient transport ant the other is used to transfer the amputated leg to the morgue. I don't ever want to see one of my nurses toting a large specimen through the halls like it was a suitcase. You will reap enough negative Karma to burden you forever with that trick." That last line said with Alice's all-knowing conviction made me shiver in my OR shoe coverings as I imagined an amputated limb coming back to haunt me. You better believe I conducted myself with dignity when showing respect to that amputated leg.

I carefully placed the amputated leg smack dab in the middle of the cart and carefully covered it with a white sheet. The trip to pathology was uneventful until I nudged open the door to the morgue and found the pathologist in the midst of an autopsy. He had just plopped a liver on the overhead scale when he noticed me and nonchalantly asked, "what can I do for you?" I stuttered and stammered that I was here with a large surgical specimen. He called  over to  a resident and advised , "Take aerobic and anaerobic cultures and some tissue for microscopy then show the nurse how to put the leg at rest."

One of the hospital  board members was a funeral director and donated a very nice metal casket to the hospital for one specific purpose; the dignified burial of amputated limbs. After the path resident obtained his specimens the amputated leg was wheeled over to the elevated casket in the back corner of the cooler. I gently raised the substantial lid of the coffin and gently nested the  severed limb inside. There were a number of other limbs resting comfortably in the ice cold  casket and when I was finished with the transfer I covered them all back up with a hand knitted shawl lovingly crocheted  by a dedicated member of the Ladies Auxiliary. The limbs were at peace.

The hospital purchased plots at a nearby cemetery where the limbs were carefully buried when the casket was full. I was curious how often burials occurred and was advised it was an annual event complete with a religious official and a few of the path personnel to show their respects.

Years ago I entertained myself with notions of working again as a nurse, but as I thought of the money grubbing corporations running the show my mind did an abrupt 180. My values come from a different place in time and although I failed many, I think my heart was in the right place. I plain just don't believe in nursing the way it's practiced today and the image of treating limbs like trash haunts me.

Tuesday, August 14, 2018

What Was the Official Cigarette of Your Diploma Nursing School?

There were so many diploma schools of nursing in the 1960s that each class adopted their own unique motto, school colors, and slogans. There was no formal mention of the fact that each class had their own preferred brand of cigarette. Brand loyalty was the byword and everyone wanted to feel part of the same "club," so there was minimal deviation from the standard brand of smokes.

I dug out my old nursing yearbook from my basement  junkpile archives and refreshed my memory. Our class colors were light blue and navy blue, class flower was a white rose, class moto was A journey of a thousand miles begins with a single step, and the class philosophy was "I have no yesterdays ,tomorrow may not be--but I have today." Last, but not least the class cigarette was KENT. Student nurses tended to mark their territory and Kent cigarette butts were virtually everywhere. Favorite ashtrays included the orthopedic beds with big gaping holes for attaching traction bars and even unused suction bottles on the Gomcos used for demonstration.

Cook County School of Nursing students lived up to their hardcore image by smoking disgusting unfiltered Phillip Morris Commanders. You could always identify a Cook County Nurse by her nicotine stained brown fingers.

Ravenswood hospital was bicultural when it came to cigarette usage. Both Kools and Winstons were in vogue here. I guess the nurses could not come up with a consensus which was a frequent problem in nursing when critical decision making was required.

When I relocated to Pittsburgh the official cigatrette custom was in full force. At Montefiore Hospital all the nurses smoked Salem Light 100s. I think the 100mm length was a thoughtful choice because it served as a break extender.
I betcha Nurse Bonnies classmates were Red
Apple Smokers. An apple a day keeps the Dr. Away??

Thursday, August 9, 2018

"Don't Worry, I Was an ARMY Ranger"

My obsession with surgical instruments and fondness of  esoteric operating room tales are not appreciated by everyone, so it's time for something completely different - a true story from that long term VA  psychiatric hospital, Downey.

It was nearing time for my annual proficiency review and I was beginning to feel nervous with an impending sense of doom. One of the key metrics in the evaluation other than restraint hours was avoiding patient elopements. The restraint hours could be managed with some clever slight of hand when filing reports and records. Maybe that's why all the nurses winked and called records of locked restraint hours the "funny papers." The favorite maneuver was to apply locked restraints and leave one of the locks open.  They were just as effective but technically not full locked leathers.

Mr. Dunkfeather who had been recently upgraded from head attendant to nursing assistant looked grim as he approached the nursing station. He had just completed the 2200 hour  patient count and came up one man short. "Fool, Hughes is not on the ward for patient count," he related. My first reaction was denial,  reasoning that it was impossible to elope from a locked ward. There were 3 sets of locked doors between patients and the outside world. Things like this never happened.

I quickly did a search of all the hiding places; shower curtains, under beds, and even inside lockers. Hughes had simply vanished. Next on the agenda was a review of the records. Whew..at least he was a voluntary patient. If a committed patient was lost, the notification process was quite onerous and time consuming and involved official notification to administration and law enforcement personnel. All that was required of a voluntary elopement was the completion of a 10-2633 form which was reviewed the next day at a treatment team meeting.

When I unlocked the heavily grated main entrance door to leave at the end of my shift a surprise greeted me. It was Hughes bounding up the front steps with an ear to ear grin. I must have looked like I had seen a ghost. "How in the world did you get out of there?" I stammered in disbelief.

"Don't worry, I was an ARMY Ranger and was trained how to jump. There is a gap in the bars covering the back bathroom window so I squeezed out and jumped. I was just repeating an old Ranger training exercise. Now that I know my skills are intact everything is going to be OK."

Hughes was obviously uninjured but the window he jumped from was on the second floor  of Building 66 which was the equivalent to a 3rd floor level because the basement was elevated on that side of the building. He showed me the gap between the iron bars  and further explained some of the techniques used when landing from a jump. He seemed amused by my interest and added that he would be happy to teach me some of his jumping skills. Not tonight I muttered before stopping at the nurse's station and discarding my elopement reports. No harm..No foul.

Thursday, August 2, 2018

The Grooved Director Surgical Instrument Mystery Explained

The function of a surgical instrument is usually obvious; retractors retract, clamps clamp, cutting instruments cut and forceps hold things. I made a comment about a lovely grooved director instrument on Instagram and was asked, "What is that thing used for?"  When I was a novice scrub nurse grooved directors were widely called for and  used for a hodge-podge of probing, directing of suture and guides for  cutting tasks. As I approached retirement they  remained in the instrument tray on the back table and finally disappeared forever.

Grooved directors always reminded me of Mickey Mouse. The end of the instrument with the ears was called the spoon or saddle. Dr. Slambow, my favorite general surgeon liked to sing Home on the Range while working so I took a  liking to the "saddle" reference. The curved shaft extending from the saddle was called the shank.

 Surgeons are big fans of devices that restrict their view to the work at hand and use drapes and devices like grooved directors to frame their field just like a movie director with  a view finder.  The tiny, circular opening in the saddle was often centered over the opening of a duct or anything else that might require exploring with a probe. The grooved director was positioned at a right angle to the wound or duct and served as a fulcrum for manipulating the probing. Imaging techniques were few and far between in days past. Probes  were a crude but effective tool for exploring. When ducts and wound tracts could be evaluated without probes grooved directors fell out of use as guides for probes.

Grooved directors could also be used as protective shielding tools. The shaft had a horseshoe or curved profile and could be placed over nerves, arteries or anything else that should not be cut. The rare illustration of a grooved director in action shows it placed over a tendon while cutting from above. The surgeon must be an early specialist as general surgeons almost never hold a scalpel like a pencil. He must really be an old-timer. Is he actually performing surgery bare handed? That lovely scalpel is way before my time. BD disposable scalpel blades have been in use since the 1950s.
Surgical residents are very familiar with 3 rules of survival:  eat when you can, sleep when you can, and don't monkey with the pancreas. Grooved directors were frequently used to guide suture away from the pancreas when working on the duodenum. They functioned much like a clothes line prop with the suture strand guided by the groove in the spoon away from the friable pancreas. If left alone, suture assumes a caternary  curve and the grooved director straightened things out.

I managed to put my blowhard nature on the back burner and seek outside input for grooved director information. When I Googled the instrument  I discovered uses like a pediatric tongue depressor or elevator during surgery on the frenulum. That's a new one on me.

I emailed Dr. Sid Schwab from Surgeonsblog fame and he exclaimed, "That's a trip down memory lane!" He used the instrument once or twice on pancreatic duct procedures. Dr. Skeptical Scalpel (on my blog roll) almost never used a grooved director.

Grooved directors fell from disuse like open drop ether anesthesia and Operay lighting systems. Almost everything has a shelf life and I often what modern devices will be extinct in 30 years. Maybe the grossly overpriced, unproven surgical robots?

Thursday, July 26, 2018

A Dubious Award for Bovie Smoke Control

There is a cornucopia of awards for modern day nurses. I've previously blogged about this trend which seems to have proliferated to the point of ridiculousness. An organization supposedly representing operating room nurses is now offering an award for an expensive system that attempts to contain the smoke liberated by the cauterization of human tissue. They  have "partnered" with a commercial entity that manufactures these devices. The coveted award is called "Go Clear," and there are gold, silver, and bronze permutations. I can visualize the winners standing on a podium resembling an OR table in their AORN approved bouffant head coverings looking more like chumps than champs.  Any nurse that had the unmitigated gall to seek personal enrichment by huckstering anything by enticing folks with awards would have been shown the door in a vintage hospital.

After a cursory review of the literature, I found there is little in the way of hard science to prove Bovie smoke is harmful and no published randomized trials. Sure it contains some nasty substances and most folks find it unpleasant but old OR nurses would laugh in the face of someone selling an expensive toy to "go clear." If Bovie smoke is one of the worse things you smell as a nurse you must be spending too much time sitting in an office and please, don't get me started on nurse office sitters.

OR nurses were so acclimated to Bovie smoke they could correctly identify the type of tissue being cauterized by the scent of cautery smoke and regarded this ability as a badge of honor. Remember that old TV game show, "Name That Tune"  where contestants said they could identify the song in 3 notes or less?  Vintage scrub nurses played a variation of that game by playing "Name That Tissue Smoke."  Pleura was the easy one for me and I could name that tissue in 1 whiff because of the characteristic sweet/sour smell released by the smoke plume.

There are cost effective ways to mitigate Bovie smoke that do not involve the unsavory element of money changing hands. We were conditioned to believe nurses were meant to be poor and efforts toward personal remuneration were sinful. My what a different world today where patients check in and check out of medical office  visits with all the dignity of a Wal Mart Trip. Nurses have more money today but something has been lost in the process. Proud, caring professionals have been rendered mercenary automatons by corporate healthcare.

One of the most efficient Bovie smoke minimization  strategies has presidential overtones and it's appropriately called  the Clinton strategy; don't inhale. Just wait until that perilous  plume dissipates to resume normal respiratory activity. Works every time and doesn't cost a cent.  If you don't inhale it can't hurt you or cause adverse political consequences. Bill was unto something.

Surgical masks are designed to implement a barrier that prevent endogenous operator  bacteria from reaching the surgical site. Masks function both ways and  are also effective filters to block inhalation of Bovie smoke. As proof  I offer the post operative sniff test which involves reversing the mask and thrusting your proboscis dead center into the mask after a long case. Guess what? It smells just like Bovie smoke that's in the mask and not your lungs.

Oldster nurses were frugal by nature and trained to use existing resources to the maximum. If  you are interested in saving your hospital big  money there is post on my blog that explains how to perform a sterile procedure with finger cots. Gloves are not cheap. There is suction available on surgical cases so if you don't care for Bovie smoke just suction away with what you have. Be prepared to be belittled because tolerance of Bovie smoke was an expected virtue and self serving actions like this were seen as a public declaration of your lack of commitment to patient care. Nurses were expected to put themselves in uncomfortable  and self endangering situations. It was all part of being a nurse. A hospital is not Disneyland!

Tuesday, July 17, 2018

Hospitals Before Air Conditioning

Vintage Hospitals had very little in the way of mechanical climate control and patient care areas on the wards often became sweltering brick ovens. High ceilings and transoms over the door of each room helped some, but hot is hot and working in an overheated enviroment was accepted as part of the deal of being a nurse. Wide open  wooden double hung windows helped a bit and as an added thrill there were no screens above the third floor. The theory that there are few high flying insects might have been true but pidgeons did not follow this rule. We used to coral them in a corner with a draw cloth and send them back on their merry way via the open window.
 
We all agree. It's too hot in here.

Staff nurses frequently draped towels  soaked in ice water around their necks, but such luxuries were not permitted for student nurses. Misery and suffering were vital elements in the quasi-religious initiation into the nursing world and belly achers soon found themselves on the outside.
I had it much easier than the female students who wore a heavy apron over their blue dresses. A common problem was sweat running down legs and pooling in fluid containment  vessels like Clinic shoes. A memorable sight was a student in the break room removing her shoes to drain the sweat. I had a different problem because my primary sweat generator was my back. The perspiration would slide down my back and soak my underwear and seat of my pants. I stopped one day to purchase a Chicago Tribune from the corner news stand and after producing a dollar from my hip pocket the vendor commented, "Hey..This dollar bill is soaking wet." I kept my mouth shut and just smiled rather than explaining the embarrassing source of the moisture.

Patients were the ones who really suffered in the heat. Working on the ortho floor meant dealing with a particularly uncomfortable bunch of patients. The casts often exacerbated the sweating which almost always produced itching in remote areas of the casted extremity. Clever nurses produced under cast scratching devices by taking an ordinary coat hanger and straightening it out. The business end of the scratching device was twisted into a tight loop which could be threaded down to the area of itch. They were crude but effective anti-itch devices.

The hospital director's office and operating rooms were air conditioned and clever nursing personnel learned to take advantage of an occasional whoosh of cold air. The ORs were accessed by a manually operated elevator that moved cold air down the shaft like a giant piston. An oasis of cool air greeted anyone standing near the old elevator doors when the device was on a downward plunge. We concocted a variety of excuses to linger by those doors. My favorite excuse was awaiting the arrival of a fresh post-op patient.

Hospitals were not early adopters of air conditioning. For the first couple of hundred years after it's invention, the wheel was only used for making pottery. Nobody could figure out how to make wheeled carts as effective as sleds on runners. The same situation applied to hospitals and AC. The roof of a hospital was not designed to support refrigeration units and there were no ducts in radiator heated hospitals, besides nurses and patients were meant to suffer. It was just the way the world worked.

Wednesday, July 4, 2018

Axillary Fallout a Pitfall in the Operating room


Axillary fallout abatement in action.
Tucked scrub top and containment 
garment under scrub top.


One of my most popular posts is from a couple of years ago and it was about the perils of perineal fallout and measures used to control such a menace in the OR. So as a sequel, I would like to present an equally dangerous infection generating body part, the armpits of OR personnel full of hair, sweat, and bacteria. They smell funny for a reason and attempts to camouflage the odor with topical deodorant only exacerbate  the situation.

Asepsis is one of the foundations of successful surgery and begins with the aggressive scrubbing of the operative site. This "prep" is usually conducted by the circulating nurse or a resident. The rub-a-dub-dub of scrubing  the patient's skin produces a copious (we always got brownee points for using that "c"  word in our care plans-old habits are tough to break) amount of to and fro arm movement. Some preppers even resembled marathon runners with their violent herkey-jerkey arm movements. This violent arm oscillation from a fixed point creates lots of friction in one of the most bacteria infested parts of the body, the armpit, second only to the aforementioned disease producing perineums.

My favorite OR supervisor, Alice, paid special notice to the arm swinging preppers and developed one of her famous theories. Hard scientific theory can become boring, but applied sciences like nursing is where the fun begins. Alice believed the armpits shed micrococci and who knows what else when the friction of the arm swinging liberated them from their hairy denizens in the armpit. The patient was especially vulnerable during the prepping procedure because the drapes were yet to be applied.

Alice just love finding fault with men especially those of a lower caste. Male  nurses were the perfect fodder for her "interventions." Alice had been verbally abused by an assortment of surgeons over the years and this created a revenge oriented mind set. Someone had the temerity to ask Alice why she singled out men for her perineal and axillary fallout ministrations and she knowingly replied, "because that's where all the hair is. It's the friction from rubbing two hairy skin planes together that unleashes bacteria."

Putting the brakes on axillary fallout begins with tucked in scrub tops and as I mentioned in my last post, Alice was an aggressive scrub top tucker inner. After ramrodding the top into the pants, Alice always administered a rough skyward yank of the pants which often changed the timbre of the victims voice and marked the laundry of those with poor hygiene.

When disposable gowns came on the scene in the early 1970s a large cache of cloth gowns was dedicated to the pre-operative skin prep. The old cloth gown served as a perfect containment vessel for corralling free falling axillary micrococci thus averting one of the pitfalls of skin preps.

Sunday, June 24, 2018

Teaching Student Nurses - That'll Learn Ya

"The next time Miss Bruiser gives me the
business, I'm gonna let her have it."
Crime and Punishment was more than a great Russian work of literature. To a lowly diploma school nursing student it was an integral component of the educational  training process. Mishaps, oversights and downright mistakes were all dealt with by mean spirited instructors out to teach a lesson that usually incorporated humiliation and the infliction of discomfort if not outright pain.

A bulletin board in the lobby of our nursing school was referred to as the wailing wall or the wall of shame. It publicly proclaimed the scores on NLN proficiency exams with the less than stellar results underlined in red and accompanied by cryptic notations to see Miss Bruiser for further review or report to so and so for remediation. The "reviews" were not pleasant and "remedial" usually meant painful and/or humiliating of the highest order.

My scores in obstetric nursing were not up to snuff and as a shy, 19 year old male I was ordered to teach a post partum mother's class. "Fool," Miss Bruiser intoned in her most somber voice, "I've got something special in mind just for you. You  are going to teach new mothers how to care for their infants." It was as if Bozo the Clown had been put in charge of a manned spaceflight to Mars.  I had to demonstrate with a baby doll how to bathe and care for a new born infant. My "students" were all experienced multigravadas that did more laughing and chuckling at my ham fisted, clumsy attempts than an audience at the Comedy Club. I think it was probably the most embarrassing episode in my entire life and I have a special knack for putting myself in embarrassing situations.

My procedure pal Janess was very busy with passing meds and was late turning one of her patients. Miss Bruiser caught her in the act of being 20 minutes behind the turn schedule and had that look in her eye that shivered our timbers to the core. We knew something was up the next day when a bed from the nursing practice lab had been wheeled front and center in the nursing school  auditorium. Before the day's lectures began, Miss Bruiser ordered Janess to hop into the bed and with her usual brusque mannerisms proceeded to "position" Janess with the entire class as a captive audience. When all the bending and twisting of extremities was completed, Janess found herself in a side lying knee-chest position with her head canted at such an acute angle that  her mandible was parallel to her clavicle. "You will remain in that position for the duration of today's lectures," barked Miss Bruiser as she ram-rodded  the siderail up with enough force to elevate the entire bed. The entire class witnessed Janess's contortionist like  punishment  that went on for nearly 4 hours. When she was released from the surly bonds of the bed she could barely walk and all she ever wanted out of life was to be a nurse.

Thankfully, the operating rooms were out of bounds for Miss Bruiser, but Alice, my favorite nursing supervisor was a perfect stand in with a bag of punishments  honed over decades of service. She had a real obsession with finger nail length and would approach nurses at the scrub sink with her millimeter ruler at the ready. One millimeter was the specified nail length and any deviations were treated with a subungal curettage with the business end of a mosquito hemostat. I learned the hard way that the subungal space is highly innervated when Alice began carving away on me while I was a novice OR nurse. I learned how to shave  my nails to half a millimeter length  for an extra margin of safety.

Alice had a thing about tucked in scrub shirts because she claimed leaving them out provided an escape for sub-axillary micrcocci which she affectionately termed "pit fallout" not to be confused with perineal fallout. She  also claimed that lose dangling scrub tops were at risk for inadvertently contacting a sterile field. Alice's cure for untucked scrub tops was an aggressive manual tuck in followed by a practiced upward yank of the scrub pants. I believe the street name for such a maneuver is a "wedgie" and it was something to be avoided at all cost.  I always carefully tucked in my scrub top to avoid this pitfall..

Getting caught wearing gloves for anything but a sterile procedure was a serious deviation from accepted hospital practice. The punishment for wearing gloves was usually a cleaning assignment that involved hospital beds encrusted with a variety of dried on excrements and don't even think about donning gloves.

In the old days things were done in a different way. Nurses scraping by on a subsistent wage faced a wild, chaotic hospital work environment where there were few cures for some very dark illnesses. In this entropy rich culture rigid rules and their subsequent enforcement provided a twisted sense of security to hardened old nurses. Of course, things are different today...I hope.

Thursday, June 14, 2018

Time Out - I Contaminated my Gown

President Trump now seems to be buddies with his old North Korean nemesis and  most likely has surrendered his "dotard" title. So.... I've been thinking about changing my handle from OldfoolRN to OlddotardRN because there  is just so much about modern operating rooms that fall beyond my level of comprehension.

What happened to the sacred tiled temples that were once ORs?  Modern ORs have sacrificed  their penthouse location to practically anywhere in the hospital and worse yet resemble a waiting room at the Greyhound station. Valued work areas have been converted to electronic warehouses with enough computerized  doo dads to land a 747 in a whiteout.

The above illustration is the latest  iteration in a long line of befuddling situations. When I initially laid eyes on this young, scrubbed  whippersnappern I had that weird feeling that totally smacked my gob, (see, I can talk like a youngster if I try real hard.) She just contaminated her right hand by elevating it well out of the accepted zone of sterility. Everyone knows that the sterile part of a gown is restricted to below the armpits and above the waist tie-NO EXCEPTIONS.  If Alice, my favorite OR supervisor were on the scene she would be swinging her sponge stick like a baseball bat at this poor nurse's knuckles. Breaks in sterile technique earned the most severe knuckle bashing and I can almost see  Alice winding up like Mickey Mantle at the plate.

I educated myself about the situation and learned this nurse is calling for a "time out," which probably means she recognized the error in her ways and wants a sleeve and a new glove from the circulator. Asking for a sleeve to cover the contaminated section of a gown was a humbling experience because it required the assistance from a sterile member of the surgical team.  A surgeon helping a scrub nurse provided ample fodder for endless jokes. Dr. Slambow, my general surgeon hero usually made the nurse step away from her Mayo stand and assist with the surgery while he assumed scrub nurse duties to demonstrate the correct way of doing things.

There are a couple of other issues with the way this nurse is conducting her duties, but I think I'll let my esteemed readers point them out.

Sunday, June 3, 2018

Illness Stories for Profit

The local healthcare giants have discovered a new advertising strategy that must be lining their corporate coffers with gold. I was sitting in a crowded waiting room awaiting my next "experience" to begin a new health "journey" when the giant flat screen  flickered to life with an engaging story of  a profound, deep illness tale and subsequent recovery thanks to the miracle workers at the corporate hospital giant. I don't have one of those magical flat screens  in my little hovel; my 150#  Baby Huey tube TV brings in more nonsense than I can stand and all I use to get a signal is an ancient rabbit's ear antenna.

These corporate generated gems follow a predictable script and typically involve a respected member of the community such as a minister or retired kindergarten teacher sustaining a life threatening illness or injury but with treatment at "Big Bucks Hospital," is now back as a functioning member of society. Here is a sample.

Reverend Bagley was singing a hymn to the congregation with his lovely wife of 53 years accompanying him on the recently restored pipe organ. He suddenly clutched his chest and fell over backwards impacting his head on the altar rail. BBH  cardiothoracic surgeons performed a triple coronary artery bypass and repaired a septal defect that was found incidentally. Neurosurgeons promptly averted a life-threatening subdural by performing an occipital craniotomy. Now the good Reverend is back to singing in church with his grateful wife at his side. Remember -  choose your healthcare as if your life depended on it.

Old time nurses like to tell stories too but I don't think they would serve BBH's marketing needs. These stories are usually of complications (surgical are  the most profound,) that change someone's life forever. The purpose of these grim tales is to alert others of the mechanism of action so the event never happens again. Here is a sampler.

Officer Friendly was helping a stranded elderly lady change the tire on her old Ford and felt a sudden surge of disabling dizziness. He was transported to BBH where an MRI of the brain revealed a rather large juxta cortical area of increased signal uptake that could be neoplastic, encephalopathic , or vascular. A brain biopsy was recommended but the stereotactic head frame was ferrous and could be only used with CT. The lesion failed to visualize under normal CT protocols so two large bore IVs were established and contrast media was infused as rapidly as possible in a futile attempt to visualize the lesion. The fluid overload prompted a hypertensive crisis that ruptured the intracranial lesion which on autopsy was found to be a fragile arteriovenous malformation.

Somehow, I recall the later tale much more vividly than the feel good corporate fairy tale stories. Must be my age.

Thursday, May 24, 2018

I'm Going to Give You something to Think About! YEOWW

I stumbled upon this old image and it made my knees feel weak and my knuckles throb. It's a spitting image of my old time OR supervisor, Alice, who could wield a sponge stick with all the force of a burly cop swinging a billy club. This photo shows her assessing the severity of the infraction which will determine the location of the fulcrum to swing her weapon sponge stick from when it impacts the knuckles of her hapless victim. Swinging the sponge stick from the distal tip would inflict the most pain.

It looks like she is about to wail away with the fulcrum in mid position near the instrument's hinge. This was for relatively minor offenses  like passing an instrument to a resident rather than the attending surgeon, even though the resident was in the proper position to deal with the problem. Rules were rules-always provide the attending surgeon first.

The most brutal knuckle cracks were for any offense, real or imagined. that broke aseptic technique. Alice was an equal opportunity knuckle basher and residents were fodder for her cruel ministrations as well as nurses. She caught a young resident with his nostrils protruding over his mask and he received a double punishment, Cracked knuckles and a set of dental rolls plugging his nose. I think there might be an old post about that Aliceism somewhere amidst my foolishness.


Saturday, May 19, 2018

What Was the Most Useless Old School Diagnostic Test?

 The first notion that popped into my foolish mind was the "spit test" for digitalis toxicity. The patient was asked to produce about 5 cc  of pure saliva which was tested for potassium levels. The notion being that a high level of potassium excreted in the saliva was indicative of toxicity. Everyone had a different threshold to spill potassium in their saliva and hypokalemic patients could be digitalis toxic and have a "normal" potassium level on their test. This procedure was relatively benign in that it seldom led to further testing and had it's lighter side involving nurses providing graphic descriptions to befuddled patients about the difference between saliva and sputum.

The Histamine stimulation test for determination of gastric acid output was one of the chief  villains when it came to useless or even downright harmful diagnostic tests. The test was widespread in that just about anyone experiencing epigastric pain was a candidate and it frequently got the patient placed on the medical hamster wheel of cascading invasive tests all of which led to virtually ineffective treatment.

The underlying principle of peptic ulcer  treatment was the Schwartz dictum (no acid-no-ulcer.) This was accomplished by the Sippee diet which consisted of hourly swigs of 1/2 and 1/2 which was kept iced in a bath basin at he bedside. Copious consumption of antacids was also encouraged. This treatment did not provide a long term cure, but for some provided symptomatic short term relief. Peptic ulcer treatment improved dramatically when Australian researchers showed the root cause of the disease was bacterial. This insight was the gateway to effective treatment for peptic ulcers.

The test was sheer misery for patients. Step "A" involved inserting a naso-gastric tube regardless of the difficulty passing it. Miss Bruiser, my favorite nursing instructor, "assisted" novice nursing students perform this procedure by forcing the hapless patient to  take sips of water from a glass as she forced  the liquid past their  lips all the while barking, "SWALLOW..SWALLOW."  She often explained to the student nurse that inserting an NG tube was just like fishing; just wait until you get a  bite  swallow and ram rod that slippery cylindrical hose home to the patients eagerly awaiting stomach.  "The patient will have to swallow eventually, just like the fish have to bite."  Meanwhile the patient was coughing and spraying the forced water right back in the direction of Miss Bruiser's face. Karma in action.

After the position of the NG tube was verified by auscultation; I always wrote that exact line in my nurse's notes because Miss Bruiser gave brownie points to students that used esoteric medical terminology.  Most of my fellow students simply noted that the position of the tube was checked. Next on the agenda for this procedure was an uncomfortable painful injection of histamine that burned like a blow torch and resulted in a sore arm for at least 5 days.  This stimulated acid production in the stomach just as pouring gasoline on a fire exacerbates the blaze. Headache, dizziness, flushed face, and profuse sweating were frequent side effects of the injection.

The last component of the test is where the rubber meets the road. At 30 minute intervals X3  a gigantic piston syringe is coupled to the NG tube and as much gastric acid as the law allows is sucked  aspirated and placed in a carefully marked specimen cup. Patients often complained that it felt their stomach was being pulled out through their nose. My stomach used to churn and ache just witnessing such an ordeal and it was a cause  for rejoicing when those slippery specimen cups were on their way to the lab for analysis..

When learning about the cause of peptic ulcers the "ulcer personality" was stressed and was described as a person experiencing resentment, anxiety, and anger. I never believed these traits were the cause of ulcers. I always suspected the ineffective medical interventions of the day and the sheer misery quotient of the diagnostic testing caused much of the ill will and bad feelings on behalf of the patients. It's amazing how long  such an inappropriate treatment can remain in place and become accepted practice. Of course such foolishness would never happen in the healthcare environment of today!

Saturday, May 12, 2018

Skin to Skin Post Mortem Care

Skin to skin contact meant something entirely different to me than the currently popular post partum mother / infant tactile bonding technique. When I first heard the term, I asked myself  How in the world did someone discover one of my personal secrets?  I  felt compelled to lift the patient from the death bed or OR table with my bare arms contacting their skin. It was part of my way of saying goodbye.  There was a trick to this that involved spreading the morgue shroud open on a nearby Gurney with the distance dependent on the patient's weight. A 50 kg. patient could have the waiting litter across the room while a 100 kg "heavy hitter"  better be close to the bed. I tunneled my right arm under the patient's shoulders for a mid axillary target and my left arm went under the knees. A helper carefully supported the head while I carried the patient to the cart. There was something special about being there in actual contact with the patient skin to skin as they say. I always said a silent prayer for a peaceful journey to a peaceful place as I gently lowered them to the awaiting shroud.

Every old nurse had something unique and special to impart during post mortem care. Jane who was a dental hygienist before becoming a nurse always offered meticulous mouth care to the departed patient. When she was done the waste container was always filled with lemon glycerine swabs and an empty peroxide bottle. Bonnie hated to leave any tell tale sign of invasive medical procedures. The first thing she went for from the supply closet was adhesive tape remover and cartons of 4X4s. Every little bit of residual adhesive tape was lovingly removed. We did not have those fancy task specific devices to stabilize endotracheal tubes and all that tape about the lips and around the neck made an unsightly mess that Bonnie always made disappear. Lois hated those flimsy shoelace-like ankle and wrist ties and always substituted soft strips of wide Kerlix. After her gentle ties were in place she often kissed the patients hand. I hope I have a nurse like Lois when it's time for me to enter that shroud. I'm certain the journey to the other side will be pleasant with a send off like that.

Thursday, May 3, 2018

Glass IV Bottles - Breaking Bad

Breaking a  glass IV bottle was the stuff nightmares were made of. There were three elements to
consider with shattering  old time glass IV bottles. The glass bottle, a liter of fluid (D5W took the prize for making the biggest mess due to it's inherent stickiness,) and an air gap. The air in the bottle served to amplify the crash of the glass breaking so as to sound almost like a rifle shot. Hearing that booming "CRACK" followed by a piercing scream alerted the entire floor of the mishap and summoned a legion of gawkers for the messy clean up. It was an unwritten rule that the clean up was the sole responsibility of the unfortunate breaker of the bottle - don't even thing about calling for a janitor, oops, I mean housekeeping person. An empty Cardboard IV case was placed on the floor close to the broken glass which was gingerly pushed  into the enclosure with a portion of the box top. The procedure always reminded me of catching a piranha  with your bare hands, a slippery mess with a laceration or bite close at hand.

Glass IV bottles were at risk for breakage because their girth made them difficult to grasp. When CDs were designed one of the goals to make them easy to handle. Designers of glass IV bottles were not concerned with ergonomics and the diameter of the glass  container expanded to fit the volume of the fluid. Thank heaven there were no 2 liter  IV bottles.

Another common mechanism of bottle breaking was undershooting the hanging notch on the IV pole. That thin wire hanger was difficult to see especially under bad lighting conditions and many an old nurse thought the bottle was about to nest safely on the pole only to have it come crashing down. A good luck/bad luck conundrum occurred when the rapidly descending bottle came crashing down on the nurse's foot. The bottle, cushioned by the nurse's toes remained intact but hobbled the hapless nurse. Maybe nurses should have worn steel toe shoes like heavy construction workers.

Miss Bruiser, my all time favorite nursing instructor had a favorite tactic for dealing with bottle breaking students. After haranguing and berating the student during the clean up she insisted the clumsy student carry a glass IV bottle with them for 24 hours. A unique combination of public humiliation and learning how to perform daily activities with an ever present glass IV bottle was an excellent deterrent.

Finally the rolly polly crash and break was another way to reduce the glass bottles to glistening shards.  Everyone was acutely aware that there was only one safe position for a glass IV bottle and that was vertical. Inadvertently setting a glass bottle on it's side resulted in it rolling away and crashing at some distance from the nurse. Nurses frequently turned the bottle to this vulnerable position to apply a timing strip or write a note on the bottle label. This unfortunate event almost always occurred at times of great stress when there was an unforeseen complication or unexpected event. An acute hypoglycemic crisis required an immediate IV and if that gigantic ampule of D50 rolled and shattered it was like having a bull in an IHOP restaurant with all those syrup bottles; sticky, gooey syrupy stuff everywhere.

Despite the potential for breaking, nurses hated to see those glass IV bottles morph into those silly looking flexible plastic bags. If the complaints and derisive comments about heavy duty enema cans being replaced by flimsy bags was bad, the ill will directed toward IV bags was even worse. Veteran nurses used to joke  ( I hope it was in jest)  about using those newfangled flexible plastic IV bags for enemas because that was about all they were suited for.

Thursday, April 26, 2018

The New Nurse - circa 1965


Many thanks to Sue from Australia for discovering this vintage classic  of yesteryear's nursing practices.  The signing of papers before entering diploma school really brought back memories. We had to agree to several articles before entering school: Learn 4 pages of medical terminology before the first day of class, follow all rules in the student handbook, and be available to work any shift.

Those open casement windows reminded me of hospital renovations in the  1970s at our beloved institution of training. Old wooden double hung windows were replaced with inward tilting aluminum  casements and older nurses had a fit. It was a dirty little secret that nurses emptied urinals and even Gomco suction bottles out those spacious old windows. The inward tilt of the casements made the act of hurling excrements over board much more difficult.  I wrote a post about this disgusting practice and was careful to give open windows a wide berth when walking outside.
https://oldfoolrn.blogspot.com/2016/04/look-out-below.html

Thanks again Sue, for this incredible time capsule of old school nursing.



Thursday, April 19, 2018

When and Why Glass IV Bottles Disappeared

Glass IV bottles were all fun and games until you dropped one.
Up until the early 1970s you could receive your IV dispensed from any container as long as it was a gleaming glass bottle. These time tested and trusted  vessels had been the workhorse of infusion therapy for decades and possessed a sense of inertia that suggested  they would be around almost forever.

Having been raised  with glass IV bottles, older  nurses had a special reverence  for them. It was easy to view the level of remaining fluid and  glass was inert to allay any worries of interactions with the fluid contents. A strip of ordinary adhesive  tape could be easily applied to the side of the bottle with the time marked for the fluid levels. Pumps and controllers were nonexistent so we counted gtts/minute (gtts is a Latin abreviation for "gutta" meaning drops.) It  always amused me how health care folks  used  Latin to obfuscate the issue, but alas, that's a post  for another day.

KCl  and B&C vitamin supplements could be added to bottles without even using a needle, just plug that naked syringe into the air vent and inject away. I used to relish the visual treat of the deep yellow vitamin solution as it merged and mixed with the clear IV fluid in the bottle. Inject the colorful solution rapidly and a model of a spinning water spout could be replicated. I've heard the term "lightening in a bottle," but a miniature water spout was even more impressive.

 Nurses mixed all  IV fluids  on the patient care  floors, no need to involve the pharmacy with all those superfluous phone calls or redundant paper work. The air vent had another feature nurse's came to know and love. As the air bubble gurgled it's way through the fluid in the resonant glass botle to equalize  pressure, the soothing noise  was an auditory cue that all was right with the infusion. Infiltrated IV sites never produced the  gurgle. Glass IV bottles had a special place in every nurse's heart. We never gave a thought to their disappearance. What could possibly replace such a dependable and familiar piece of equipment?

The beginning of the end for glass IV bottles occurred in July of 1970. Outbreaks of hospital acquired sepsis by the bacteria  Entrobacter cloacae  were linked to Abbott Labs newly designed glass IV bottles with screw caps. The decades old bottle cap was pealed off to open the bottle similar to a pop tab on a can. Occasionally the metal would peal off unevenly resulting in a problem opening the bottle. A new screw on cap was designed to eliminate the opening problems. There were also problems with spiking the old design caps. Sometimes a tiny portion of the black stopper would break free and float freely in the IV solution. We were always told not to worry about it, but foreign bodies like little black flecks of stopper made every nurse nervous. Who in the world would want something like that coursing through their veins?

The newly designed threaded cap was easy to use and the problematic  black stopper was retired. We all liked the new design, but problems were waiting in the wings that would spell the end for glass bottles.

Viable bacteria gained access to the IV fluid while it cooled following the autoclave procedure which created a vacuum drawing bacteria in through the threaded interstices of the newly designed  screw- on cap. The end result was 412 known infections among hospitalized patients and 50 deaths. All of Abbott Lab's intravenous solutions in glass bottles  were withdrawn from the market in March, 1971.

On May 29, 1973 a Federal grand jury indicted 5 corporate officers from Abbott Laboratories. Investigation revealed the Abbott IV plant in Rocky Mount, N.C. was contaminated with a variety of pathogenic bacteria. The proliferation of bacteria was exacerbated by glass bottles of D5W falling from the assembly line and breaking ( a problem nurses knew all too well)  which provided the bacteria with an ample supply of growth media. This was one of the initial cases of health care officials facing criminal charges.

Hospitals were desperate for a supply of IV fluids and Baxter Labs had just introduced a novel product - IV fluids in a flexible rectangular configuration featuring a plastic container that collapsed as fluids infused. The flexible IV bags were tagged with the clever  name "Viaflex" and the revolution had begun. These bags could be stored in any position and touted a completely closed system-the bags collapsed as the fluid exited. No venting required. With the old bottle system it was risky to piggyback antibiotics into a primary line because drugs like Keflin came in 2 gm. bottles requiring a vent and connecting a vented secondary bottle to a vented primary line could allow for air embolism. Small plastic bags of piggyback medication eliminated the air embolism risk. Baxter acquired a pharmaceutical company and began selling premixed drugs in small 100cc plastic bags. The IV piggy back was off to a running start with the closed system mini-bags.  Soon many drugs administered by IM injection were being given IV and fancy new fangled notions of determining peak and trough levels of drugs evolved.

For a brief time period (1976-1980) Viaflex bags and glass IV bottles assumed  a tenuous coexistence. Vented IV sets were bicultural so to speak and could be used with either Viaflex IV bags or glass bottles. Using  nonvented  Viaflex IV tubing set up on a glass bottle was strictly taboo. Hapless practitioners that pulled this stunt found that without a means to relieve intrabottle pressure the drip chamber collapsed like a lung in a punctured pleural cavity. If the problem was not promptly corrected the negative pressure could begin to draw venous blood through the angiocath producing a tell tale red streak of blood in the IV tubing. Spooky indeed and guaranteed the nurse a prominent position on the wall of shame and vulnerable to endless gossip..."You would not believe what Suzy did with her IV last night...yada..yada," nurses only made this mistake once.

By 1980 the intravenous therapy world was ruled by Vialflex like flexible bags and glass bottles were gone for good. Abbott even began producing their own IV bag that had an unusual feature that nurses disliked. The port for adding medications was a blue bull's eye  target about 3 inches up from the bottom of the bag. When adding drugs to an IV, nurses were used to holding the port in one hand to steady it while injecting with the other hand. There was nothing to grasp on that blue bull's eye and nurses in a hurry were known to poke a hole through the opposite wall of the bag resulting in much cursing and  general unpleasantness.

This transition from glass to plastic  was difficult for seasoned old nurses who by  nature of their basic constitution were resistant to change. Glass bottles had prominent labels and were easy to identify; bags were produced with an over wrap that obscured the label. Drip chambers on glass bottles hung perfectly vertical; on bags the drip chamber was often hanging at an angle. Patient transfers with a bottle always required the careful use of a pole to maintain the positioning of the bottle. Nurses were appalled at the occasional  practice of tossing the IV bag on the patient's lap or chest during brief transfers.  Bottles would roll off and break if this crude trick was attempted. It was easier to thread a solid object like a bottle through an opening for an arm when changing patient gowns. Those IV bags were like getting a grip on a handful of Jello.  Finally, hanging those flimsy bags could be difficult. It was necessary to free up the folded vinyl hanger and thread the small opening over the hook on an IV pole.

I am truly impressed by the variety of realistic sounds produced by electronic devices like that camera shutter clicking noise on cell phones or that  "whoosh" noise when sending an email. The Oldfoolrn  medical equipment design institute has come up with another innovation. How about an electronic IV pump or controller that emits a skeumorphic noise replicating that gurgling noise as a bubble coursing through a vented  glass IV bottle. Lots of old nurses would  truly love hearing  that reassuring noise again.