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.