Thursday, November 29, 2018

Retention Sutrures

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

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

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

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

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

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

Thursday, November 22, 2018

Giving Thanks

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

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

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

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

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


Sunday, November 11, 2018

When The KARDEX Was King of Communication

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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