Sunday, October 28, 2018

Le Mesurier's Hammock - An Early Scoliosis Treatment

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

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

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

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

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

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

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

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

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

Wednesday, October 10, 2018

Drinking Bile

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

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

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

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

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

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

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

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

Wednesday, October 3, 2018

High Tech Hemorrhoid Surgery Meets Old School Positioning Techiques

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

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

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

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

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