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. 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.

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.

Tuesday, April 10, 2018

Blood Bag Blues

It's been a very long day. The somber cacophony of suctions sucking, Bovies burning, Airshields ventilators chugging , instruments clanging, and surgeons bellowing has decrescendoed to a strange and rare moment of blissful silence. Those weary legs wobble like Jello as they acclimate to an absence of weight bearing stress. The impending fatigue unleashes a contemplative frame of mind so different from the acute attentiveness  required of a scrub nurse busily loading needle holders and delivering the exact required instrument at the exact right time. My mind sometimes fixated on the remaining flotsam and jetsam scattered about the tiled temple as I planned my clean up activities.

Drained of their miraculous magenta contents, empty blood bags are neatly stacked sit on the anesthetist's  gas machine awaiting their round trip journey back to the hospital blood bank. The few remaining droplets of blood form an intricate spider web design visible through the transparent container that always reminded me of stained glass. The drained bags are now a component of the detritus remaining as an artefact of the previous surgical adventure with their own tale to tell.

Artefacts and relics mean different things to different people when their intended function has ended. I thought many times how strange it sounded to keep blood in a  "bank," but then I began to figure it out. Some of my very best insights occur when fatigued and sleep deprived as that caffeinated jolt works it's magic.

Blood bank CEOs and commercial bankers have much in common. Blood banks rely on the innate goodness of volunteer donors  whose reward might be a glass of orange juice and a stale cookie. Bankers of money pay paltry sums of interest to the hapless savers and charge exorbitant fees to credit card users. Blood bank CEOs and bankers reap their massive  salaries and stock options on the backs of little people just trying to do the right thing. In nursing it always felt as if large sums of money flowed  right around me much the same as the  blood in a suction tubing. Nursing and donating blood is a waste of time if you are doing it for the money. It may sound strange, but I always felt a sense of pity for the greed consumed CEOs lounging in their administrative playgrounds. They probably never had the warm feeling that comes upon you when really helping someone at a critical time in their life.

Blood had almost magical qualities when transfusions went well and the source of blood loss could be corrected. Used blood bags always had redundancy in miniscule sticky labels with an identification number. There were always plenty of these little stickers left over even when all the documentation was complete. I tried to keep the good juju times a rolling with these little stickers by sticking them on the back of my name badge or wrapped around the earpiece of my trusty stethoscope. I don't really know if they helped, but when times were tough, I could cheer my spirits with a quick glance at the back of my name badge.

Sunday, April 1, 2018

A Remembrance of Nursing Pins Past

The land of the free and the home of the brave was once home to 4,000 diploma schools of nursing  each with their own unique nursing pin. These pins were typically designed by committee and the final version was often a hodge-podge collection of sometimes divergent elements. It was tough for a committee to come up with a consensus for a coherent design.  At my alma matter the pins were the responsibility of the Admissions and Promotions committee and it required weeks of heated discussion to decide if one letter on the pin should be changed to reflect the conversion of our hospital to a "medical center." After much heated debate it was decided to change the "H" which was for hospital to "MC." Nursing pins were sacred symbols and change did not come easily.

Implant something in an adolescent brain while it's developing and it sticks forever. We were brainwashed  conditioned  into believing our pin was the ultimate reward for 3 years of soul crushing labor while  subjected to near constant badgering and belittling by down right mean instructors like Miss Bruiser. That beloved pin had a transcendant element to it that required a compulsory level of reverence. It was the alpha and omega to any 3 year diploma student. The  radiant pin glowing against a pure white background was the first thing your eye settled on when a nurse appeared on the scene and it told the story of a nurse's experience. If only nursing pins could talk.

I spent many hours staring at the cover of RN magazine when their annual nursing pin edition was published. A cover adorned with 30+ pins in glowing color was a feast for any diploma grad's  eye. The most common pin design was a Maltese cross with the schools initials plastered one on top of another over the center. I just loved pins with a singular sculpted design like the  Ravenswood Hospital School of Nursing in Chicago. The pin featured a beautiful version of the Good Samaritan that seemingly glowed in the dark. Wow.. that was one heck of a pin.

Speaking of good samaritanns this unusual pin featuring a beaver really got my attention. Simple, straightforward design at it's best. Beaver's are like nurses; hard working and they have the ability to modify their environment for unexpected needs. Beavers are also continually growing just like me after too much hospital cafeteria food. I really cherish this pin and think it has much better aesthetics than mine which resembles a policeman's badge. While working in psych, I found that it was prudent to remove my pin lest I be confused with an undercover cop.

Another animal themed nursing pin with a serene looking moose in the foreground framed by the hospital's name. I wonder why the moose is gazing in the opposite direction from the beaver. I think it looks better from a nurse's view looking down to have the animal facing the nurse.   The cross in the background forms a lovely backdrop. It takes a moose 3 years to attain adulthood and 3 years for a diploma nurse to graduate; an interesting fact that ties it all together. A moose also has muscular shoulders and nurses acquire the same qualities  after a stint on the orthopedic ward. I admire these two pins because they are straightforward and very pleasing to the eye.

So many pins contain multiple symbolic features that are difficult to decipher. I was admiring the floral design on a friend's pin and was quickly informed they were no ordinary flowers. "That's the Papaverum somniferum plant that is the source for opium," I was told. Her pin was symbolic of the nurse's duty to relieve pain.

It really bothers me when I hear that present day nurses must pay money for their nursing pins. A nursing pin was no ordinary commodity that could be purchased with money. Blood, sweat and tears were how we paid for our pins. The symbolic meaning of a diploma nurse's pin stays with a person forever. I sneak little glances at my pin all the time just to remind myself of who I was am.

Sunday, March 25, 2018

Blowing Smoke to "Settle Your Nerves"

For some proven measures to ameliorate shaking hands and promote smoke free steady nerves please peruse my long forgotten post;  "A Fool's Foils for Fasciculating Fingers. Please pardon  my lame attempt at alliteration-sometimes my foolishness overwhelms me.

Sunday, March 18, 2018

Successful Swallowing Secrets

It's one of those rare occasions when it's time to sequester my foolishness to the back burner as I offer some time worn proven measures to help patients experiencing difficulty swallowing.  Long term endotracheal intubation,  TPN,   and neuro problems all invite dysphagia.

Position the patient upright and check for a gag reflex or at least some indication of an intact airway protective response. The famous ramrodding a patients posterior pharynx with a tongue depressor is not what I had in mind. The gagging and retching elicited by this cruel trick does not necessarily indicate a protective response against aspiration. A kinder, gentler  method of assessment involves asking the patient to say "Ahhh"  and observing if the uvula and posterior pharynx retract. I have also been told that an intact blink reflex indicates an intact gag reflex because the same nerves are involved. Cross over of neural impulses makes me hesitant to trust eye blinks as an indicator of airway protection.

Caution is the key so don't even think about injecting fluids into a patient's mouth with an Asepto or using drinking straws. The suction applied to a straw to permit atmospheric pressure to propel the liquid into the mouth can compromise airway protective reflexes. The act of applying suction can impede the transition to an airway protecting response.

Drinking from a glass replicates a familiar experience for the patient, but hyperextending the neck by tilting the head back to drink opens up the airway. The epiglottis is repositioned from closing the trachea-something to be avoided at all cost.

The secret to keeping the epiglottis positioned over the trachea when swallowing from a glass is to keep the chin level or even slightly tucked down. How do you raise the glass to drink without tilting your head back? All it takes is a few snips of your trusty bandage scissors to create an aspiration resistant drinking device.

Cut a nose clearance notch in the side of a paper cup and you can drink without tilting your head back maintaining the airway. Just drink from the side opposite the open notch and as the cup is tilted up to take a sip the opening accommodates the protuberating nose. The mandible remains level and the epiglottis remains intact covering the trachea.
Smaller notch for more petite noses. This 
aspiration resistant cup works perfectly for 
Oldfoolrn's like me.

Tuesday, March 13, 2018

Fevers - Antiquated Defervescent Interventions

Venerable, old nurses were taught that fevers were a destructive response that required immediate intervention to bring the body temperature back to that magic number of 98.6F or 37C. Since there were few real cures for much of anything back in the good old days, rigid authoritarian protocols, whether they worked or not, were established to control the chaotic world of febrile hospitalized patients.

Temperatures of all patients on the ward were routinely checked first thing in the morning with glass mercury  thermometers. We had one complete class session on the proper way of shaking thermometers down.  It's all in the wrist snap.  Fevers did not follow a rigid time  schedule and could spike rapidly just about any time of the day or night. It was easy to miss fevers with routine schedules because they could rise and fall with reckless abandon within a very brief time frame.

Protocol called for cultures for temperatures over 101F even if the cause was suspected to be neurologic and their was no sign of sepsis. Fevers climbing to that dreaded 102F threshold triggered a series of unpleasant and down right miserable interventions for suffering patients. Denial exists on both sides of the bedside rail and lots of compassionate nurses reported thermometer readings of 101.8 to put a halt or delay to some of the more miserable interventions to drop temperatures. Hyporeportinosis in it's finest glory.

This illustration shows the fight fire with fire fever treatment. That's a teapot propped up on the stand at the foot of the bed. The steam cools as it infiltrates the tented sheets and the nurse is applying ice packs to the patient's head. The thinking (if you could even call it that) behind the steam bath was that it opened pores and promoted a profuse diaphoretic response. From the patient's perspective, I suspect it felt like receiving a hot foot while having your head stuffed in a freezer. Miss Bruiser, my favorite nursing instructor had many tales about patients in steam baths; none of them pleasant. I don't think she ever had a temperature reported as 101.8.

Alcohol sponge baths were another weapon in the armamentarium to battle fevers. Equal parts of water and 70% isopropyl alcohol were combined in a bath basin. After placing axillary and groin icepacks the nurse swabbed the patient's entire body with the alcohol laced cooling solution. The shivering induced by the strategically place ice packs  was bad enough, but the fumes from the evaporative  cooling action of isopropyl alcohol was even worse. I'm certain the shivering and hacking cough produced enough muscular activity to counteract any of the cooling attempts. Some old nurses replicated the experience of greenhouse workers by borrowing misting bottles from housekeeping and spritzing the febrile patient with a toxic mist of alcohol and water.

Introducing ice water into just about any available orifice was another hoary nursing intervention favored by those practitioners with a masochistic vein. Nasogastric tubes were swiftly passed and flooded with boluses of ice water. Miss Bruiser would rest her oversized meat hook of a hand on the patient's epigastrum as the frigid water infused and arrogantly nod her head, "Ahh..he feels cooler already." It was always a mystery to me how she could feel past the barrier of the stomach wall, abdominal muscles, fat, and skin, but it was never prudent to question Miss Bruiser or her whacky methods.

Just about any ailment had a specific enema treatment and fevers were no exception. Febrile patients were subjected to backside buffoonery that entailed ice water enematizations. This approach from the rear did seem to reduce fevers, but I always suspected it was limited to the localized cooling of sphincter muscles when temperatures were measured with rectal temperatures. I always had the notion if Miss Bruiser could catch a glimpse of the patient's misery filled facial response to this frigid intrusion that she would temper or soften her approach to patients. Fat chance of this occurring, Miss Bruiser's field of view was limited to the icy enema tip and it's intended target.

Asking questions of old time nurses about the science behind their crude interventions could land an innocent student in a heap of trouble. Fever interventions were largely based on empirical notions and asking to see supporting data was seen as an indirect way of telling the person they really did not know what they were doing. Both parties full well knew there was no science to support their dubious activities and asking for the data when there was obviously none, was seen as rubbing salt in the wound.

Monday, March 5, 2018

Finger Cots - Minimum Coverage Saves Vintge Hospitals from Bankruptcy

"Here is your daily allotment of gloves. Use them judiciously and I better not here about one shift hogging them - remember they have to last 24 hours."
Finger cots substitute for gloves in budget minded hospitals

This was the warning issued by one of those stern nursing supervisors as she reluctantly surrendered a box of one size fits all gloves. A box of 24 latex (nobody was allergic to this substance in the good old days) gloves was supposed to suffice for three busy wards inhabited to the gills with patients vomiting, excreting, and  oozing every bodily fluid known to mankind. At least these fluids were organic, the Cidex based cleaning solutions we used on hospital equipment would make unprotected skin boil and bubble up like a dousing with boiling water. We always tried to handle cleaning solution soaked rags with forceps, but sometimes the volatile fumes were enough to accelerate skin lesions. Nasty stuff indeed and don't dare get caught wearing a precious glove on an ordinary cleaning mission.

Old school nurses eschewed gloves for reasons other than the negative impact such extravagant expenditures had on hospital budgets. Nursing was a hands on affair and this meant bare hands  with skin to skin contact. Gloves imposed an unnatural barrier and were viewed as an offense to the patient.

I was conditioned like Pavlov's dogs when I had gloves on. This was just not right and my shoulders hunched over with a strong sense of self consciousness. Even when using gloves appropriately, I was anticipating that cranky old nursing supervisor in the background  hollering and belittling me.

Finger cots came from the supplier in boxes and were clean (hopefully) but unsterile. Sterile finger cots like Montgomery straps and scultetus binders were produced in house by cantankerous, past their prime nurses who toiled diligently in central supply. Three finger cots were oriented in the same direction and placed in a glassine finished envelope which was then autoclaved. A piece of autoclave tape sealed the envelope and verified sterility by proudly displaying diagonal black stripes.

You could do lots of fun tasks with sterile finger cots such as dressing changes or Foley catheter insertions without bankrupting the hospital on  exorbitant expenditures like sterile gloves. Donning sterile finger cots took lots  more practice than  sterile gloving. After carefully opening the sterile packaged fingercots with your ever present bandage  scissors, place them business end down on a bedside stand. Judiciously apply a very small dab of tincture of benzoin to the tips of your thumb, index, and second finger with an applicator  and blow dry with a couple of puffs. Smokers (which compromised 95% of all nurses) with their comprised tidal volume might need three puffs.  Press your thumb into the very center of the rolled finger cot and let the tincture of benzoin work it's adhesive magic. With the finger cot firmly stuck to your thumb slowly and carefully unroll it with your free hand while touching only the inside surface of the finger cot. Rinse and repeat for your index and second finger.

Now that you're all  gloved cotted up it's time to rock 'n roll. To maintain sterility it is essential that you curl up your bare naked  third and fourth fingers. For the time being just pretend they don't exist (I used to make believe  they were burned off in a Bovie mishap.) You do not want them flopping about contaminating the sterile field or the catheter.  You can now use your finger cot festooned fingers to make like a forceps and guide that Foley home to pay dirt. When you're in (urine) haha, its time to peal off those finger cots and hook up the drainage bag.

Finger cots have limited surface area compared to gloves and can be predisposed to slipping off your digit at inopportune times.  The no finger cot left behind doctrine incorporates several measures to prevent in vivo loss of cot custody. The tincture of benzoin trick helps ameliorate wandering finger cot issues when sterile technique is used. For the more common everyday uses of finger cots  the keyword is restraint. Discretion is definitely the better part of valor when exploring any internal orifice with a finger cot. Never ever inset the finger cot into anything past it's cuff. If you poke that finger cot in deeper past the cuff all it takes is a sphincter contraction to strip it off faster than  a chimp can peal a banana.  It's a real challenge to gain purchase on a retained finger cot and the best course of action is probably benign neglect while hoping that it works itself out.
A tenaculum  grasping cervix and a cot on
the index finger. Note the 3 exposed fingers
providing traction on the tenaculum. Gloves optional.