Wednesday, January 24, 2018

Infant Incubators - An Amusement Park NICU

"Step right up..for one thin nickel see pint sized preemies in their incubators"
Vulnerable patients seeking care and hucksters with remuneration on their minds are collisions of opposites. Contemporary hospitals have been corporatized and proud professionals have been turned into mere employees along for the ride. Balance sheets and office sitting bean counters rule the roost.

Health care  finance took an unusual course around the turn of the 20th  century.  Dr. Martin Courey, a pioneering OB physician  who was equal part showman had a brainstorm. "Incubator Baby Exhibits" were initiated at Coney Island Amusement Park adjacent to a roller coaster. This venture was so successful that it spread to many expositions including Luna Park here in Pittsburgh.

Dr. Courey was as adept at showmanship as he was in his medical endeavors. He dressed the premature infants in oversize gowns to emphasize their miniature size and preferred nurses with the stature of a football linebacker to minimize the size appearance of the babies. A hybrid physician and carnival showman.

The amusement park exhibit resembled a typical hospital ward with nurses providing care 24/7 behind a glassed partition. After paying their 5 cent admission (inflation later increased the price of admission to a dime) the public could position themselves so that the distance between them and the babies was the length that the wrist is distal to the elbow.

 At the time of the exhibits the babies were referred to as premature which had a different meaning than preterm. Medical literature of the day described the infants as "weaklings" and viewed them as lacking energy or vitality. There was much debate about the etiology being hereditary vs. immature development.

Most babies of this era were born at home and cared for by the mother. It was common practice to keep babies warm by placing them in a laundry basket warmed by hot bottles. The invention of the incubator involved a transition of care from the mother to an institutional setting. Low birth rate babies were soon transferred to the amusement park incubators for care. HIPPA regulations were many moons away in a distant future.

The amusement park shows were really a celebration of technology and the promises of hope for premature babies. Some things never change and today the publics' expectation of medical technology is stoked by images of robotic surgeries and laser beam miracles. You pay your money and take your chances.

Thursday, January 18, 2018

Are Patient Lifting Devices Inhumane?

Cecil, a 26 year old quadriplegic reclines in bed waiting for a pair of nurses to transfer him to his waiting mobility device, an electric wheelchair. Standard operating procedure calls for the nurses to wrestle him to a sitting position with his legs dangling over the bedside.  The nurses then assume a position on either side of Cecil with their muscled arms hooked under his armpits.  A  Cape Canaveral countdown commences and at the conclusion we have a lift off as the stalwart  nurses heft Cecil's limp body into the wheel chair. A solid plop down completes the mission. The source of that ominous cracking noise is a toss up - a nurses back or shoulder joint popped.

The sensitive nurses recognize Cecil's vulnerable state of affairs and take measures to minimize the progression from helplessness to hopelessness by understating the difficulty of the manual transfer. No complaining or grunting and groaning by the nurses when the critical lift is at the peak of their muscular endurance. Pseudo smiles mask the aching backs and burning biceps. Cecil replies with a heartfelt "thank-you," as the nurses ignore their wounded backs and secure him to his electric chariot of a wheel chair.

When hospital administrators could reward nurses with service pins and non-monetary tokens there was little concern about nurse's damaged intervertebral discs or wrenched shoulders sustained while lifting patients. Angels in white were there to serve without concerns for remuneration.

Change was about to come when nurses had financial benefits like workman's  compensation and paid sick leave. Nurse's manual efforts to overcome gravity for their patients suddenly became an expensive commodity and red ink on hospital balance sheets demanded immediate action.

Hospitals began to institute a no lift policy and resorted to devices like the Hoyer mechanical lift for patient transfers. This handy dandy device had a hydraulic pump much like a car jack to lift patients. Straps or a sling were applied under the patients arm and legs and the operator initiated the lift by pumping a lever which resulted in having the patient suspended in mid air.

Cecil and most all patients that were accustomed to human lifts hated these mechanical monsters and pronounced them "inhumane." The herkey - jerkey movement of the Hoyer was offensive to some patients, but there was more to their aversions. Cecil related that here was nothing to hang on to and the feeling of being suspended in mid air was frightening.

I tried to understand Cecil's objection and related the lift experience to my climbing adventures as a foolish youngster. Climbing open structures like fire towers was indeed much more terrifying than scaling a solid rock face. Having a fixed object in front of you  as a reference took some of the fear out of the elevation. It's the  reason that mountain climbers don't necessarily make good workers on cell phone towers. The tactile presence of the nurse lifters added a measure of security to the precarious gravity defying adventure.

Old time nurses like me were falsely advised we were capable of lifting just about any patient if  "proper body mechanics"  were used.  Keep your back straight and let your legs do the work was the mantra. Science does not support this whacky notion. The spinal vertebrae can take only a limited amount of stress and damage to their fibrous structure is cumulative. Nurses have one of the highest occurrences of musculoskeletal injuries of any occupation.

The only inhumane aspect of lifting is  the high injury rate of manual lifters.

Saturday, January 13, 2018

A Scrub Nurse's Prayer

May your Mayo Stand rise up to meet you.
May the Bovie smoke always be at your back.
May the overheads shine glare free upon your sterile field,
and until the skin margins meet again,
may God load your needle drivers with 3-0 silk.

Wednesday, January 10, 2018

New Year - New You Thanks to Tapeworms

A penny in the fuse box solution for weight loss. Maybe I can launch a new career in retirement as a tape worm sanitizer by training the little critters to jump into a bottle of Phisohex.

Thursday, January 4, 2018

Trauma Blankets - A Macabre Masquerade

Let's face it trauma can be a visually offensive mess.  Before the age of enlightenment with paramedics and trauma centers, seriously injured patients were initially seen and promptly covered up in a trauma blanket by none other than ambulance attendants. The out of sight, out of mind  philosophy at it's finest. Trauma blankets were designed to camouflage the blood and gore making the victim appear aesthetically  pleasing to horrified onlookers  while essentially overlooking  the underlying trauma.

Bleeding? Get that trauma blanket STAT

  Ambulances were just converted station wagons like  Chevy Brookwoods or the Dodge Dart (below) and were maintained and operated  by funeral homes. Attendants were frequently apprentice undertakers and perhaps the skillset of closing body bags helped with trauma blanket application. Ambulance medical supplies were limited to a poorly designed stretcher with tiny wheels that fluttered back and forth like a butterfly's wings when in motion and of course the trauma blanket. Just the sound of those stretcher wheels clicking and clacking as they moved was enough to trigger nightmares and then a glance at a blood soaked trauma blanket was the coup de grace for a peaceful night's sleep.

Trauma blankets were heavy woolen affairs that could absorb their own weight (which was substantial) of just about any liquid or semi-liquid goo like sanguineous  substance. A chartreusy/maroon  color could obscure practically any blood  no matter the volume lost. Attendants made sure the victim was lying on the trauma blanket to mitigate the mess from pooling blood and rapped them up mummy style for the mad dash to the nearest hospital with that big V-8 roaring and drum brakes a smoking. The air  siren sounded like one of those air raid shelter blasts from old WW2 movies.

Removing trauma blankets upon arrival in the ER was like opening a Pandora's Box. Ambulance attendant transfers were done quickly with little finesse and no report from attendants who vamoosed as quickly as they arrived. Upon opening a blood soaked trauma blanket we found glass shards and a severed rear view mirror on the patient's chest. Alas..this must have been a motor vehicle mishap.

Ambulance attendants never heard of trauma shears so the bloody victim often had clothing that had clotted in place. A sort of crude hemostasis mechanism for the not so enlightened. Starting an IV on someone with blood stained extremities is a challenge and darn near impossible with the hypovolemic state induced by traumatic exsanguation.  Trauma blankets were probably one of the most useless, insensitive, and dimwitted items used in yesteryear's hospitals. They certainly creeped me out.

Before people regaled themselves with the flicker of glowing screens, events occurring in the immediate environment garnered diversion.  There was an oversize metal bath basin in the ER and a staff nurse noticed me inspecting the container with a quizzical expression. "That's for treating the trauma blankets. It's worth the show, so hang around after the next trauma," she said with a smarty pants look on her face.

Old time hospitals never discard anything; it's clean and reuse, trauma blankets were no exception. The blood assimilative nature of trauma blankets was reversed by placing it in the oversize bath basin and dousing it with a couple of liters of hydrogen peroxide. The explosive bubbling of the peroxide as it did it's work rivaled a Mt. Vesuvius eruption with the red foam serving as a stand in for volcanic lava. An impressive sight indeed.

History always repeats itself and trauma blankets have strong connective tissue to modern hospitals with their fancy atrium like  lobbies decorated with lush mini-forests of tropical plants. Those gaudy chandeliers  and fancy hardwood moldings add to the ambience. Patients who cannot pay for their treatment are not welcome here. These contemporary trauma blankets hide the uncontrolled diabetic or end stage pulmonary patients that lack resources for care and are forced to fend for themselves. The end result of untreated chronic illness is not pretty, but there is no blood on the ornate hospital's balance sheet.

Monday, January 1, 2018

Aortic Tears on New Years Day According to Dr. Slambow

New Years crashes sometimes resulted in torn aortas. Dr. Slambow
explains and acts out the mechanism.

When one year dissolves into the next, I often lapse into some serious retrospection of New Year's Days  past.  It's not the big time lifesaving trauma  surgeries  (I hate that all too common lifesaving balderdash. It's like a literate canker sore that shows up conjoined to it's favorite twin, trauma surgery.)  No, it's not those bigtime dramatic measures. It's the feckless and stupid little frivolities that come to mind like the way ratcheted instruments so neatly clicked in your hand or the way overhead lights glimmered and danced off a freshly prepped surgical site or being called in to work with my all time favorite surgeon, Dr. Slambow. I really miss him.

I've never been one to celebrate on New Year's Eve. Maybe it has to do with the fact that every one of these occasions resulted in a trauma call  when I was on duty.  I remember a variety of injuries; beer bottle broken over victims head and then stabbed with the left over glass shards, a young man that sustained a 12 gauge shotgun blast to his butt (not a good way to lose 20 pounds,) and of course the usual automobile wrecks on Lake Shore Drive with the victim sustaining an aortic tear that usually resulted in the poor souls  rapid demise.

One long night scrubbed with Dr. Slambow, I began asking questions as they popped into my young foolish, but curious brain, "Why do automobile mishaps cause torn aortas?" Dr. Slambow's eyes lit up like a New Year's Eve fire cracker and I knew I was in for a rare treat- the good doctor was going to act out his answerer. I could not wait.

He asked for a bloody 4X4 to use as a prop and as soon as I tossed down a needle holder that had been in play and fished around for the requested blood soaked  sponge it was show time. Just  as I expected, the rolled up sponge was going to play the part of the aorta and Dr. Slambow's partially closed fist was going to be a stand in for the chest cavity. This was going to be as good as his lecture on Sengstagen/Blakemore tubes when he inflated a used surgical glove (size 8)  that was partially filled with blood until the thumb portion of the glove exploded creating a colorful scene. The mess he created rivaled that of the grandma wrecked on  the Harley case we had last month. What a mess.

Dr. Slambow explained in his deliberate, eloquent tones that the great vessels in the chest were not tethered to anything and could rock back and forth in the mediastinum like a pendulum. He almost teeter- tottered of his booster stand as he rocked back and forth. Coleen, the circulating nurse was standing nearby to catch him in the event of a backward fall. OR nurses are taught to always anticipate the surgeon's action and we knew Dr. Slambow and his antics  all too well.

The good Dr. made a partially closed fist and suspended the twisted sponge between his index finger and thumb so that it resembled the tubular aorta hanging freely within the confines of his partially opened fist model of the chest. His next move was to make a punching motion with his fist just inches from my masked proboscis and suddenly arresting it's movement just before impact with one of the overhead lights. "There you have the mechanism of a torn aorta-the movement of the patients chest is suddenly stopped by impacting the steering column, but the heart is still moving forward a 65 MPH. The shear force tears the aorta."

Thanks for enlightening us Dr. Slambow, maybe next time you could explain why ostomy patients have so much trouble with excess gas. On second thought-never mind.