Merry Christmas

Merry Christmas to all. I can identify with that Christmas tree shown above because although I'm worn out and a bit scraggly, I'm still vertical. I spent a good number of holidays working in the hospital and like my colleagues above always found something to be joyful about even in the most dire of circumstances. There is always a silver lining, especially at Christmas.

Before my brain freeze set in, I came up with this a few years back. My readership was no where near what it is now, so if you need a chuckle, here's the link:    https://oldfoolrn.blogspot.com/search?q=twas+the+night

Nursing Diploma Schools Were Providers With a Price

Diploma schools provided "free" textbooks

It was the crack of dawn on the very first day of a new class and we were seated at our hard wooden chair/desk hybrids. Those  old hardwood seating devices had a writing surface that resembled a bent canoe paddle that followed a serpentine course until it was right in front of you. This clever design averted a hasty exit because you had to swing out laterally before standing up. Scanty student seats like this were scorned by those unfortunate enough to be left-handed as there was no upper extremity support while writing.

Miss Bruiser, my favorite instructor was doing her gestapo waltz around the classroom depositing a brand new text book smack dab in the middle of the business end of the canoe paddle desk. We all knew what was coming next and dutifully treated our new books as if they were a hot branding iron. Like all "gifts" from the school, books came with a harsh admonishment. Everything from uniforms to housing had a price and I'm not referring to dollar signs.

"Before you students put your grubby little lunch hooks on these brand new textbooks, I have a little paper for you to read and sign," Miss Bruiser bellowed as she dolded out the pungent scented mimeographed documents. We were conditioned just like Pavlov's dogs to the scent of mimeograph ink. That unique smell spelled trouble in the form of a test, written admonishment, or stern warning from a rigid authoritarian instructor or senior nurse.

Here is what the nursing school party line was on handling our sacred nursing textbooks. Hold the book  with it's back resting on the surface of your desk; let the front cover down, then the other, holding the leaves in one hand while you open a few leaves at the back, then a few at the front, and so on, alternately opening back and front, gently pressing open the sections until you reach the center of the book. Do this several times for the best result. Open the volume violently or carelessly in any one place and you will break the back and cause a start in the leaves. Never, ever force the back of a book.

I let loose with a muted chuckle before endorsing the mimeographed missive and paid a heavy price; I had to "volunteer" as a patient while the sophomores practiced their phlebotomy skills on my prominent veins.

Giving Thanks

I need to scribble  something  here to obliterate that image of a transorbital intubation in the previous post.  Jeez...that image gives me the willys. What was I thinking?  It's no wonder I got blacklisted by a couple of referral sites for being too grotesque. Blame it on poor judgment instilled by far too many years in the trenches. What comes to me, I suppose, not every time, but often enough, are the inelegant vignettes of trauma that have pitched a tent in my hippocampus.

So it's time to move on.  I'm wishing a festive Thanksgiving to all those who peruse my foolishness. I'm humbled by your readership and it simply  amazes me that someone is always viewing my foolishness-especially those who visit the middle of the night when all should be sound asleep.

I have so much to be thankful for, especially the patients I cared for in days gone past. They did more for me than I did for them. One thought that never escaped me was the notion that all those nasty ailments lurking out there in the world are equal opportunity afflictors. Anyone could be stricken down any time. It's really just a matter of chance accompanied by good fortune that I was fortunate to remain healthy and  vertical for so long.

Glioblastomas are out there in the world  and occur at the rate of about 4 per 100,000 people. I owe so much to those patients that suffered and ultimately succumbed to this terrible neoplasm. It could have just as likely been me with the glioma, but someone else took  all that pain and suffering to spare me of this terrible fate. I owe them a deep debt because it could have me.  I don't know how many times I uttered a silent thank you to these patients and tried to do something special for them. I am eternally grateful to these patients who took the hit for me.

This gratitude fills me with a sense of helpful sharing and a strong disdain for the greed and financial preoccupation of healthcare today. Oops... don't get me started on that one! The respect and peace that nursing has filled my soul with cannot be  derailed by dollar signs. It's what's left in your heart when the day is done that really matter, not your bank account.

Anyhow, for some genuine foolishness here is a link to a post I wrote some time ago https://oldfoolrn.blogspot.com/2015/11/how-do-you-cook-thanksgiving-turkey-in.html

Happy Thanksgiving! I treasure your loyal readership. It  means more to me  than you know!

Transorbital Intubation - An Artful Airway

Just when I thought the days of art in medicine were extinct,  the above image made it's appearance in my email courtesy of a long time reader. This  patient had extensive facial surgery for an invasive tumor and her maxilla and eye were sacrificed in the process. In a subsequent procedure, the creative anesthetist used this artsy approach in securing her airway. Instead of passing the endotracheal tube pharynx-larynx-trachea, the path was eye socket - pharynx, (or what's left of it) - trachea. Very clever, but how in blue blazes can the pilot balloon be visualized when it's deep inside the patient's face. Art in surgery always has a down side

Whippersnapperns live in a data driven, evidence based world of healthcare, but I know of  a different world where art played a dominant role  like the transorbital airway gambit shown above. Medical arts buildings dotted the landscape and old school surgeons pulled the art card to explain complications or pathology beyond their understanding. I do think the "medical arts" terminology when applied to physician offices  was so much less pretentious than the "institute" label trending today.

Unlike the group practices of today, most vintage surgeons were solo practitioners operating with minimal oversight. These surgeons of bygone years shared something in common with Picasso and Monet, they worked alone and relied on their ingenuity as much as scientific principle. "Based on empirical reasoning, I'm going to take out this lymph node over here and maybe the one over there too," was a typical intraoperative response.

Artful surgery could carry a heavy price for the patient. Someone cobbled together a procedure to "cure" Parkinson's Disease that involved harvesting cells from the difficult to access adrenal glands and injecting  them intracranially in hopes they would generate some much needed dopamine. The aggressive surgery resulted in lots of complications with poor long term results. Artful, but dangerous and usually ineffective.

A more benign example of surgical artistry involved the use of surgical instruments. Orthopedic surgeons found a novel use for Satinsky vascular clamps in that they were perfect for nabbing errant bone chips. I've written about the creative use for grooved directors in a previous post. They make great tongue depressors, templates for duct filets, guiding suture, and as mini retractors. Artistry in surgery always has an unsavory component and burying the sharp prongs of a towel clip in an unsuspecting abdomen to test the level of spinal anesthesia always shivered my timbers.

Unfortunately, patient's bodies make for a poor canvas and scalpel wielding surgical artists often come up with an unintended surprise on their hands. I wonder how that patient above felt about breathing through her eye socket. Breathing is a whole lot different than seeing.

Fine Dining Hospital Nursing School Style

Oh..The tales that were told during mandatory dinner hour.

Vintage  hospital diploma schools were hybrid affairs: one part workhouse, one part charm school, and one part plantation. The charm school component made attendance mandatory  for the evening meal in the hospital cafeteria if you happened to be fortunate enough to work  on a clinical unit during the 3-11:30 shift. Sharing a meal together was probably  thought to have a positive  social impact on  hospital confined and culturally deprived nursing students

The nursing school had commandeered a long table in the very back of the chow hall. A sense of decorum was added to the ho hum environment by the use of genuine china dinner plates emblazoned with "IMMC School of Nursing  Dedicated to the Service of Mankind."  Another unique touch was the  disbursement of several bottles of Red Hot Sauce prominently displayed as a centerpiece.

Nursing students were undernourished in social experiences and overfed on shame and degradation  dished out by mean old coots masquerading as instructors. The fine china and special sauce adornment was a lame attempt to mitigate the harsh realities of life as a nursing student and spice things up a bit.

Working with the most challenging patients was difficult enough, but our tough minded, anal retentive instructors demanded strict self-regulation of our behavior. There was no crying, complaining, or lamentations of any sort permitted. We always answered to our hard core instructors in plantation speak, "Yes'um, No madame, and Right away," were stock replies.

So when we all sat down together for dinner, it felt as though a weight had been lifted off our shoulders. Typical dinner table conversation revolved around difficult nursing procedures and technical tips for their  successful completion. Occasionally the various foodstuffs were used as props. I will never forget the time my friend, Janess, demonstrated her prowess at removing fecal impactions by using a stale donut leftover from breakfast and an overcooked chunk of bratwurst. The key was to bury your finger well into the brat and the flex the distal phalanx into a hook like device before pulling it  through the donut.

Being the sole male at the dinner table had it's awkward moments when I was called to mediate arguments about boyfriends or menstrual cycles. Although I may have been a disinterested party my knowledge base was not up to snuff and led to lots of round about jibber jabber.

Our final dinner together as student nurses was held outside the hospital at a really nice nearby restaurant, The Ivanhoe, which was just down the street between Clark and Halsted.  The senior dinner held right before we were crowned GNs was memorable because or instructors were finally nice to us because we survived and were on our way to becoming peers. I made up my mind then and there that I was never going to treat anyone as we were treated as students.

Old School Automobile Lap Belts Engndered Bucket Handles and Fruit Loops

Cars from the 1960s were rolling deathtraps. Two  tone paint jobs, wide whitewall tires, and chrome bumpers looked snazzy, but in a motor vehicle accident (incident or crash in today's lingo) the passengers were propelled into rigid spear like steering columns or protruding cowl like hoods over the speedometer which, to say the least, were evisceration proficient. Any poor soul lucky enough to escape compression injury via steering column impalement or gutting by the speedometer was hurled head first through the windshield and wound up with spidery split open lacerations on their forehead and all too often, hopeless neurotrauma.

Initial efforts to restrain vehicle occupants and  transfer some of the destructive forces to crumpling sheet metal consisted of lap belts.  Curiously, lap belts were always referred to as "safety belts," instead of the current seat belt terminology. These girth gripping girdles prevented some of the unfixable neuro trauma at the expense of the abdominal organs which ,at least, were potentially fixable with timely surgical intervention. Typical abdominal trauma from car wrecks  involved banged up and bleeding hollow viscus organs, blood oozing spleens, and contused and bruised livers. Retro peritoneal renal injuries were less common. Maybe all that fat surrounding the kidneys protected them from some of  the trauma.

Typical stigmata of lap belt trauma consisted of a 2 inch wide ecchymotic banding across the lower breadbasket. This ominous finding almost always meant internal injuries and called for the immediate diagnostic peritoneal lavage. After cannulating the peritoneal cavity about half a liter of normal saline was infused. After  about 10 minutes the saline was allowed to drain back out by gravity. Any blood in the drainage meant a quick trip to the anxiously awaiting personnel in the OR.

Innovative lap belts caused a surge in a new kind of deceleration injury, bowel/mesenteric separations which were a good trade off for the neurotrauma sustained from crashing head first through the windshield. Most abdominal trauma was fixable if caught in time, while neuro trauma usually meant a grim prognosis.

The bowel is fixed at the flexures,the ligament of Treitz, and last but certainly not least, the rectum.  With the colon and small bowel moving forward at 60mph ( or whatever speed) the sudden traumatic stop of an accident pulls like a John Deere tractor on the intestine adjacent to these tack down areas dividng bowel from it's lifeline, the messentery. Without mesenteric connection, the section of isolated  bowel withers up and dies like a man in the desert without water.

Mesentery supplies vascular, nervous, and lymphatic connections to the bowel. It also holds our  intestines up out of our pelvis where there are enough problematic structures without dropping another player into the mix. Mesentery is one of the most underrated abdominal players.

Suspense reigned as the surgeon cautiously entered a traumatized abdomen and when the problem was finally delineated and deemed curable, a feeling of jubilation and relief was experienced by the team. Hearing Dr. Slambow, my general surgeon hero, deliver his diagnosis was always a musical treat. As the Airshields ventilator chugged out bass beats in the background there was proprietorial pride in his harmonius voice as he practically sung out "bucket handle," four notes, key of "C," ascending. The hootenanny proceeded as the intestinal resections marched along with needle drivers clicking away like castanets and heavy instruments adding dissonance clunking away in the lap tray on the back table. The finale was always the best part as we stepped down form the podium with a meticulously patched up patient that was sure to recover.

 How did this injury acquire it's strange moniker? The section of large bowel stripped from mesentery did indeed look like the handle of  a bucket so the name fit. Small bowel separations were more subtle and were named after the little cloth hanging loops on the back of men's shirts of the day. Even though they did not resemble the popular breakfast cereal, everyone knew what an intestinal fruit loop injury looked like.

A bucket handle injury of the transverse colon and 3 fruit loops down below 

where small bowel parted ways with mesentery. That lower separation
is beginning to show the effects of devascularization.

(Photo courtesy Dr. Michael McGonigal)

When the call room phone incessantly rang  at 2AM and the harried voice on the other end intoned "Motor vehicle accident ETA 10 minutes," my feeling was similar to one of those daredevils going over Niagara Falls in a barrel. Lots of mental anguish leading up to the case because the final landing outcome  was unknown. Bucket handles and fruit loops usually led to a successful plunge over the falls.

The Surgical Abdomen

While fresh, young  surgeons pour over detailed cross-sectional CT scans or overpriced, extravagant ultrasounds, old surgeons relied on the wisdom gained from a physical exam and meticulous history taking to delineate abdominal pathology. "Hot Bellys," in the vernacular of the day could be a real hornets nest to deal appropriately with, and the wily veterans had there own brand of diagnostic techniques which were crude, but effective.

Decisive clinical diagnosis was elusive, but a strange hodge-podge of clinical maneuvers (if you could call them that) were enlightening to the battle tested old surgeon. Observations were also key element  of the work up.  A "sweated brow" or "a hypovigilant countenance" suggested a septic process. Jaundice suggested some sort of hepatic dysfunction and a strange blue periumbilicular coloration signaled an internal bleed.

The exam of the acute abdomen consisted of, euphemistically, what would be termed palpitation, percussion, and auscultation, but was really poking, pushing, lifting, listening, and twisting limbs around with gusto, much like a pretzel.

The psoas test was performed by forcefully flexing the thigh while rotating the foot outward. The test was contraindicated with concaminant orthopedic injuries. A positive response elicited a vociferous verbal response from the hapless victim  patient and suggested a lower abdominal process.

A shake test was of great value when the patient had difficulty identifying the area of maximal belly pain. While in a supine position the patient's hips were slightly elevated off the bed while a vigorous to and fro shake was delivered. Dr. Slambo, my favorite general surgeon, had an interesting method of augmenting the shake delivery that only applied to ambulatory patients weighing less than 75 kg.

With the physician and patient standing back to back with arms interlocked together at the elbows a gentle elevation is initiated by the good doctor leaning forward. The optimal height was with the patient's feet about 6 inches off the floor. The abdomen is bowed such that the viscera are near  the surface while a side to side shimmy/shake elucidates the problematic quadrant. The technical name of this procedure (according to Dr. Slambow)  was the elevated, gyrating, gambol gambit and it was far better than one of those new fangled CT scans when it came to elucidating the exact focus of abdominal distress..

Dr. Slambow also knew how to augment just about any type of palpation technique with a miraculous gooey, slippery substance known as ordinary Surgilube. He began with a full tube, superior to the umbilical concavity and began squeezing until there was a generous pool of  goop.  He then began exploring the aching quadrant with his hand gliding across the abdomen like a shoe that stepped on a banana peal. The quantity of Surgilube used during the procedure also provided valuable insights when planning the surgical intervention. More than 1/2 a tube of the gelatinous goo signaled problematic obesity that called  for extra long instruments and a platform for Dr. Slambow to stand on while he looked down into the wound.

Fist percussion commonly known as a blow to the upper bread basket was performed along the anterior thoracic wall by placing one hand on the skin and beating it with a fist. Exquisite pain evidenced by vociferous howls indicated cholecystitis or hepatic issues.

Murphy's inspiratory sign can be demonstrated in acute cholecystitis  by asking the patient to take a deep breath while pressure is judiciously applied below the right rib cage. As the liver descends, the inflamed gall bladder is brought into contact with the abdominal wall causing immediate cessation of the inspiration.

I really liked scrubbing on acute abdomens because the offending problem was identifiable and fixable. There was no better feeling than seeing a seriously ill person stroll out of the hospital with a new appreciation of life. Viewing that so vulnerable  prepped abdomen supine on the table awaiting the surgeon's ministrations always put me in a contemplative mood with the realization that despite all our political and religious differences  we are all just meatsacks enjoying an undeserved period of wellness so no matter what or who, With this thought lurking in the back of my foolish mind, I tried to be nice to everyone and treat patients as though they were my mother, father, or child.

Hospital Signage

Yesterday's sign was a model of stark simplicity

Today a ridiculous hodge podge of word jugglery. What a mess!

Cyclopropane Anesthesia - A Blast From the Past

Inhalation anesthesia was dominated by ether until cyclopropane made it's debut in the late 1930s. This new agent was potent and did not induce the unpleasant nausea and vomiting associated with ether. Those operating room scenes from Ben Casey or Dr. Kildare where the patient is asked to count to 10 after the anesthesia mask hit their face were classic cyclopropane inductions. Most were sound asleep by the count of 3. Cyclopropane was like magic pixie dust in an orange steel cylinder;  inhale it and almost instant anesthesia, back on room air, and presto... near immediate emergence. There was only one problem, cyclopropane was explosive and had the potential to turn just about any cysto room into a wiener roast.

Every old time operating room suite  had a cyclo room that was heavily modified to avert cyclopropane detonation. I always liked the way cyclo room sounded when pronounced, it had an eerie Alfred Hitchcock feel to it because it sound so much like "psycho room." Indeed these were different sort of rooms where strange rituals and  happenings prevailed.

Cyclo rooms persisted until the early 1970s. Any new OR suite constructed post 1970 lacked an explosion proof room. The first line of defense against exposions was the elimination of statuc electricity discharge by grounding everything to a terrazzo floor which was interlaced  with conductive copper dividers. A gleaming terrazzo floor lined with glowing copper dividers was a beautiful sight.

Everything in the room was supposed to be grounded to the conductive floor. Operating room personnel wore shoes that were modified by a metallic plug smack dab in the middle of the sole and shoe covers had a conductive strip running from toe to sole. First order of business upon entering a cyclo room was testing shoe conductivity by stepping on a small bathroom scale like device. A green signal meant all was well and it was OK to proceed. The shoe testing requirement also served to exclude rubbernecking snoopers and busy body administrators. Only the personnel that really needed to be there were present. An anesthetist, 2 nurses, and a surgeon with an assistant could handle just about anything that came along.

Equipment in the OR was grounded to the floor by tiny metal chains that jingled  when the furniture was moved about. Old operating rooms were always furnished, never equipped. The anesthesia cart which was always a repurposed Sears Craftsman rolling tool chest  had double chains. Why take chances?

The other approach to explosion proofing the room was a bomb squad containment mentality. Potential sources of explosion were shrouded in a heavy steel housing. Operay overhead surgical lights had a particularly robust containment chamber that I thought resembled Russia's Sputnik satellite. I'm not so sure I would like to be laying on the table with that ominous black orb hovering  overhead. It looked spooky to me.

The electrical switch for the Operay was covered in a heavy leather boot that looked like the covering on a Mack truck gearshift. Every time I turned the overheads on, I imagined the carefree life of an open road trucker as opposed to facing up to the stressful work ahead. Oh well...at least I did not have to worry about unannounced visits from my favorite nemesis, Alice, the all knowing supervisor, always steered clear of the cyclo room.

Working in the cyclo room was always the best part of my day, and then later on, the best part of my night. On call, high risk emergency trauma surgery was the perfect venue for cyclopropane because it actually elevated blood pressure to improve perfusion. A good question was; If cyclopropane is so frequently selected for the high risk trauma patient, wouldn't it be good for the healthier patient? The limiting factor was the risk of catastrophic explosion.

I loved the peace and quiet in the cyclo room. There were no Bovies  buzzing or power tools whirring, just the quiet swish as the anesthetist went about  breathing for the patient. The brisk snip sound of straight Mayo scissors cutting ligature after ligature was almost hypnotic.  Occasionally while in the midst of a messy trauma surgery you could actually hear a vessel bleeding.

 Cyclo also had a very pleasant, gasoline like smell that always reminded me of one of my favorite high school courses, auto shop. No matter how carful the anesthetist was with holding the mask, a tiny bit of cyclo always seemed to pervade the room.

Attending anesthetists often told the residents that cyclo was to be   handled with the finesse of a violinist, not with the banging of a kettle drum. Anesthetists were also advised to keep in physical contact with the patient at all times to keep the electrical potential balanced.

Whenever I see a modern operating room furnished with enough electronics to land a 747 in a whiteout and multiple OR personnel milling about it shivers my timbers to the core. To heck about worrying about the finesse of a violinist, these rooms are the equivalent of a symphony orchestra complete with a grand piano. Cyclopropane R.I.P.

Bed Scale Blues

It's easier to push a stalled '57 Chevy than a bed scale!

I made the mistake of reading some of my old posts and some of them resemble a distant ping from a satellite knocked out of orbit. Tales from a far away planet where bedside care was the only currency that mattered and what little money there was flowed away from nurse's pockets. It sounds paradoxical, but the more interface I have with "modern" healthcare, the more I miss the old days.

Oh well, Nero's circus must go on so here's my take on vintage behemoths that were part Hoyer lift, part ironing board, and finally part piano mover's dolly with enough free weights to open a gym. Bed scales were the hospital version of battleships, difficult to change direction when in motion, fraught with danger and best left alone.

The illustration above shows an intrepid  young nurse in transit for her mission; to weigh a bedridden patient. The ironing board part of the scale is hinged so it's vertical when in storage or moving  struggling down the hall. It's visible on the right side of the scale just inside the counterweights. After an arduous journey to the bedside, the ironing board like platform was tilted to a horizontal position. The patient is pulled, pushed, or glided onto the awaiting platform. You know, that old count to three and grunt routine.

The platform is elevated like a not so magic carpet by way of a hydraulic Hoyer lift like pump. Now for the fun part -  where the rubber meets the road. The patient is suspended inches above the bed while the nurse turns her attention to balancing the counterweights. A potential  hazard included becoming distracted by the precarious position of the patient and dropping a 20# weight on your foot. Clinic nursing  shoes did not have a safety toe so that's really going to leave a dandy bruise, if you are lucky. The not so fortunate will see the ortho clinic with compound fractures of the metatarsal bones.

One of the great nursing debates involved the question of including peripherals (How about that? I managed to hijack a term from the computer industry.) like Foley bags or surgical drains in the bedside  weight. The free spirit nurse simply tossed the Foley bag or drain apparatus into the mix and included it in the final weight. Dangling Foleys and drains were always at risk for unintended extrication during the transfer or elevation process so I usually left them be and subtracted a pound for the tare at the conclusion of the procedure.

One of my most colorful nursing instructors, Miss Bruiser had a favorite saying, "Work smarter; not harder." Every nurse hated bed scales with a passion and looked for a smarter procedure when it came to patient's weights. In nursing research there are methods for assuring interrater reliability so that results are consistent. Nurses weighing bedridden patients took a lesson from carnival weight guessing hucksters and followed suit. Before the bed scale weight was determined, the nurse took a guess at the patient's weight. When her guestimate came within 5 lbs. or so she became a certified patient weight confabulator. Leave that massive bedside scale in the clean utility room and bring in the certified nurse weigh approximator. These nurse's were also trained experts at clairvoyant counting patient's  respirations.

What happened to Mop Swinging Nurses?

"That spot you missed will cost you 10 demerits"

Nurses from my generation knew their way around a janitor's closet as well as whippersnapperns know how to monkey with a Pixis. Mopping floors was an integral part of any diploma school nursing education curriculum. Just when you thought nothing could top scrubbing mucous/emesis stalactites from bed frames, mopping madness was introduced.

The swabbing the deck curriculum began with an orientation to perhaps the most important and critical cog in the hospital hygiene world which was the lowly slop sink. These marvels of plumbing technology consisted of a square, slightly elevated receptacle just inches off the floor. They were marble back in the day, but toward the end of my nursing days they were (gasp) fiberglass which definitely  lacked presence and looked cheap. Slop sinks close to the floor were a real boon to a nurse's back because the massive 30 liter buckets could be filled and emptied with minimal lifting. Filling buckets was lots more fun than emptying the bacterial/blood/stew medley that frequently accumulated after a mopping session.

Home base for the RN mop crew was a trolley consisting  of two 30 liter buckets on a mobile platform.  Bucket # 1 was filled with 19 liters of hot water and a foul smelling witches brew of ammonia compounds and an overpowering  detergent that really meant business. The ratio of solution was 10:1 and this factoid was always a question on just about any test. Bucket #2 was equipped with a wringer and Miss Bruiser, my favorite instructor, claimed that aggressive mop wringing was good for the bust line. I don't know about that, but my signature move was twirling the high modulous cotton/rayon mop head as it settled into the wringer which really got the juices flowing (the mop's, not mine) when the wringer mechanism was actuated.

Alice, my favorite operating room supervisor was equally  adept at mop swinging as sponge stick loading. My mopping abilities were honed to perfection by lessons from Alice. She  said to always pull the mop toward you while moving backwards. I modified her technique to a sideways  stance after backing into a kick basin and nearly breaking my neck in a free fall to the floor. After that episode I often referred to them a trip basins.

I actually enjoyed mopping operating room floors. The rhythmic swinging of the mop had a meditative component to it and I loved seeing the immediate results of my labors. After dealing with verbally assaultive surgeons and aching fingers from loading needle drivers, mopping was  a refreshing oasis complete with the soothing sloshing of water. A gift.

In the sunset years of my work in the OR, young nurses were surprised at my love of mopping and suggested there might be a better use for my skills. I was far too compliant to question mopping duties and too foolish  to refuse, after all, I was doing it for the patients. Old nurses would do just about anything for their patients.

Today on my frequent visits to hospitals as a patient, it's as though I'm entering the Twilight Zone. I don't know which is worse, carpeted floors or the total absence of moppers of any permutation. Modern hospital have descended to a hellscape of ubiquitous beeping and bleeping electronic doo-dads with nurses caring for computers on wheels. I would much rather be wheeling around something of substance like a fully loaded mop trolley.

Clandestine Patient Restraint Techniques

Nurses providing ambulation assistance 

for an afternoon nap.

Restraining patients is probably one of the most unsavory elements of nursing practice and old school practitioners were masters of obfuscation when it came to forcible restriction of movement. Even office sitting nurses of the academic/administrative complex eschewed patient restraints. Everyone did their very best to find ways around outright restraint of those under their care.

Memos from on high regarding patient restraints were filled with officialese and gobbledygook in an attempt to camouflage what was really  going on. I found a VA restraint and seclusion Professional Services  Memorandum that illustrates this point: VA Form 10-2683, Report of restraint and seclusion.  "The doctor's orders (SF508) will be initialed by the GS9-11 ward nurse. The nurse will copy the prescription (form 10-2913) on the nursing notes (SF510) indicating the type of restraint and 24 hour report of patient's condition (VA form 2915). The nurse in charge of the ward during each tour of duty will maintain a record of each application of restraint on VA form 10-2683. After the last day of the month, the nurse will sign this form and forward it to the Registrar Division - 114A."  Some head nurses referred to the monthly reports as the "Funny Papers" because restraints were not always used according to Hoyle with the frequency of use almost always understated.

Downey VA Hospital, the long term psychiatric hospital I worked at in the early 1970s made extensive use of full restraints that consisted of heavy leather cuffs secured by robust belts. My ways of caring for these patients were unique and foolish, but averted some  of the unpleasantness associated with 4 point restraints. I began a patient enlightenment program that involved patients recognizing when they were beginning to escalate and request restraints before anyone was injured. A veteran of the Viet Nam war summed things up quite  nicely, "Restraints are just like an Asian civil war-much easier to get in than get out." I couldn't have said it better myself.

This illustration clearly shows the time tested maneuver aptly called "let me hold your hand...DOWN. Whether inserting nasogastric tubes or assisting with  excruciating procedures like the removal of Jackson-Pratt surgical drains, every old nurse had experience with this one. Initially, good intentions entailed holding the patient's hand for support, but soon evolved  into a vice grip not unlike the panic induced squeeze on the overhead bar of the Ravenswood EL train as it rounded an acute bend. Hold that patient's hand like a trapeze  artist grips the bar while the good doctor gives that J-P drain one final yank.




Distraction is another useful tool in the nurse's position inhibition  armamentarium   (please note, I did not use that dreaded "R" word.) This trick procedure does not work well with painful ministrations about the head and neck, but is very effective for procedures below waist  level like bedside urethral dilitations or removal of orthopedic external fixation devices. The nurse elevates the bed so that the patients eyes are close to the height of the nurse's ocular orbs. The patient's  head is immobilized between the hands as the nurse locks eyes with the hapless patient. Extreme eye contact seems to slow things down  and put a damper on some of the unpleasantness.

Children are especially vulnerable and the isolated snippets  in my mind of pediatric restraint have long sense departed. Whew! Am I ever happy for that. There is a harrowing  pediatric restraint device known as the  Pigg-O-Stat. Google it if you dare. This thing looks like a blender with the lid off and the youngster is dropped into it for X-ray procedures. It's no wonder so many people have claustrophobia later in life. They were probably popped into a Pigg-O-stat as a mere youngster.

 One of the more humane child restraint devices is a take-off on the old Trojan Horse idea. The restraint device is a toy rocking horse that lures it's young patients by whimsical looks, not brute force. While the child plays horsey, an X-ray plate is slid into position and the exposure made before anyone is the wiser. An elegant restraint solution! I wish they all could be so easy.

Quora

I've been having a difficult time organizing my thoughts for a post and my right hand has been acting up so that's limited my blogging activities. Lots of really nice people peruse my foolishness even when I fail to post so that's dampened my motivation.

I find myself doing better answering or making up answers to questions is easier than blogging so my latest addiction has been to the Quora web site. I was answering questions as Oldfoolrn, but received an email admonishment from the administrator (probably one of those despicable office sitters) that real names must be used, so I call myself Bob Balfour.  Bob seems like a friendly enough name and some how Balfour surgical retractors are engraved somewhere in the hindquarters of what's left of my nervous system so that's my pseudonym. Just visit the site and type Bob Balfour in the search box to view my lame answers.

I've had a couple of ideas for a post but can't make a selection. Here is what's been percolating somewhere in my mind; Zomax-A pain reliever that became a pain, Patient restraints-how to restrain without restraining, and finally, belly buttons, the black hole of the human body. Any advice about which topic I should explore would be appreciated.

Head Nurse, Crazy Annie, Implements the Finder's Rule

Long time bedside nurses are just plain different, a breed of their own forged in a cauldron of unspeakable pain, suffering and just plain old garden variety misery. A mystical force motivates these caregivers to give all of themselves in the care of others. Mention self care to one of these hard core nurses and you are apt to get a snoot full of Camel cigarette smoke propelled by the robust laughter. If you were taking care of yourself, you were neglecting patients.

Crazy Annie was one of the most memorable old  nurses I had the experience to work with. Her facial expression reminded me of the Whistler's Mother painting; an aloof stare just waiting for an opportunity to unleash a verbal bomb.  She was a big lady with the arms of a power lifter from transferring patients. One of her innate beliefs was the notion that Hoyer lifts were impersonal and dehumanize the patient. I suggested that back breaking lifts were inhumane for nurses and received  an ear beating that I remember  all too well. Annie did not tolerate fools.

With retirement looming Annie became  even more vociferous with her various edicts about patient care. She believed that nurses should be on their feet the entire shift. "You can't take care of a patient if you are warming a chair," was her admonishment to anyone sitting around the nurse's station. She hollered at me for "holding up the building" when I was so exhausted that I was leaning against the wall in the dirty utility room after an especially grueling session with a balky hopper.

An assistant director of nursing outfitted in her finest attire made the mistake of rounding on Crazy Annie's floor. She was an unwelcome outlier to Annie. Bedside nurses were a tight knit group where people were unimpressed by degrees or rank, but how dedicated they were to caring for the sick. Annie  had a not so latent dislike for nursing administrators and derisively referred to them as "office sitters." I think that's where I picked up the use of the pejorative reference to those nurses who choose to avoid patient care. It might be insubordinate to think so negatively  about those in charge, but it would not be a mistake.

I hope the nurse administrator had room for gloves in her Vuitton Purse.

A fancy dressed, nurse busy body, from administration came strutting up to Crazy Annie with an urgent message. "The patient in room 606 bed 2  is covered in feces."  I smelled trouble in the air as Annie's eyebrows began their little dance as her mind percolated. Annie then started tapping her toe and had that look about her that always made me nervous. She squared herself to the offending nurse office sitter and sternly announced, "I'm instituting the finder's rule on this unit. Whoever finds the mess cleans the mess. Now get to it."

The Gucci nurse was paralyzed as Annie volunteered me as a helper by exclaiming, "Nurse Fool will help you turn the patient to make it easier for you. You look like the type that wears gloves for the unsavory tasks. The Central Supply Cart is in the clean utility room."

I hustled on down to room 606 with the Gucci nurse in tow. Upon arrival, the unsavory nature of the scene began to unfold. It was one of those my cup runeth over type of code brown's to use the whippersnappern  vernacular. A gurgling, gooey, smelly  mess of the highest order. The befuddled office sitter pressed her hands to her cheeks in deep thought. Just as I thought she was about to pitch in and help, she backpedaled like a circus unicyclist into the nearby stairwell.

As I went about the task of making the patient clean and comfortable, I could hear Crazy Annie proudly proclaiming, "I bet we don't see hide nor hair of her for a good long time!" A temporary victory in the land where all wellness is fleeting and office sitters have the final word.

A Shout Out To My Russian Readers

I've been delighted by a sudden increase in pageviews from readers in Russia. It boggles what's left of my foolish mind to realize that I can reach folks so far away from the basement of my humble little hovel. Maybe it's therapeutic to put my reclusiveness on the back burner and extend my foolishness to others.

I had the wonderful experience of working with a Russian educated surgeon - one of the perks of working at a big city academic hospital. I admired how she used her newly acquired English language skills. None of that subject, verb, predicate rigamarole that was drilled into us during high school English class. Direct, no nonsense commands were the order of the day. One of my favorites was, "Fix him to the bed," which meant limit the patient's mobility with a restraining device. "Scissors," became "scissor" because there was only one scissors used at a time. Russian English really made sense and got the point across.

Dr. Ospov, had a couple of unique surgical customs. She loved using long handled needle drivers and forceps. Muscle memory is a powerful force and once acclimated to a long surgical instrument, it's tough to change. Long instruments always amplified any fine tremor present in my lunch hooks fingers so I regarded them with caution. If you want to see an angry surgeon, just try to slip a smaller length needle driver into the mix. Don't fool with muscle memory.

I'm not certain that its a wide spread custom in Russia to eschew prophylactic surgical drains, but Dr. Ospov hated them. Her tight closure of tissues eliminated dead space and  minimized the need for drains. She also liked to throw in a couple of half hitches at the end of suture lines to help maintain the integrity of the closure which seemed like a good idea to me.

I vividly recall one scene that illustrates her no nonsense, get it done approach. We were called to a ward because a patient toppled out of his wheelchair sustaining a nasty occipital skull laceration. When we arrived on the ward, the patient was sprawled out on the floor next to a festive looking Christmas tree. As I prepared to transfer the patient back to the ward for suturing, Dr. Ospov barked, "Grab me a suture set and get down here to help me." The patient was positioned on the floor with his Bye Bye decubiti pad comfortably under his wounded head. I knelt down next to the good doctor as she deftly threw a half dozen sutures in the wound. It was quite a scene with the red blood and green Christmas tree in the background. She really knew how to get things done without a fuss.

Show Me the Money and I Will Show You Why That CVP Line Stopped Transducing

It really grinds my gears when entrepreneurially minded nurses seek to monetize assorted tutorials for learning clinical skills. Theoretical nursing in an academic environment is ridiculously overpriced and I understand the plight of whippersnapperns facing exorbitant school loans, but bedside procedures should be passed along  with a sense of pride and  respect for the history of nursing. The sense of well being gained by seeing a young nurse confidently perform a procedure you showed her how to do is priceless. It's your extension in time and will bring a warm feeling to your foolish heart when you are old like me.

Image courtesy Maklay 62

Diploma schools were big on ceremony and pageantry with ascent through the nursing hierarchy. Youngsters today may have dollar signs in their eyes, but for us, the ultimate reward was that coveted pin. Dreams of walking down the aisle  with our Nightengale Lamps leading the way to receive our pins were what we thought of in troubled times. Thinking about money was distant in our minds and any mention of financial gain earned you a speedy exit from the program. It was just palin wrong headed thinking and an egregious example of putting your needs before others.

How do you unite nurses from different generations with different values? One  way was  passing on  clinical skills from experienced nurse to novice. The scrub nurse tricks of the trade that I learned from my nemesis, Alice, are precious beyond any means of monetary compensation. I didn't learn how to load a sponge stick one handed or count out ten 4X4s in a nanosecond by paying money to watch a video. No, she never smiled or encouraged me like the glad handing  nursing procedure hustlers selling their videos. Humiliation was a powerful motivator.

I shudder to think of the consequences incurred by  offering a Greatest Generation nurse money for procedure tutorials. They could survive on next to nothing because working as a nurse was a reward in of itself. Their  notion of self care was a 15 minute nap in the lounge after being called in for a middle of the night case and working 9 hours the next day. Life was meant to be difficult and nurse's were destined to a life of poverty. I admired them with unbounded abandon and was a mere sissy compared to their resolve. I wish a few of them were around to deal with today's nurse monetizers.

CVP lines were in their infancy when I was practicing and I made it my mission to learn all I could about central line procedures. Obtaining a central pressure involved a carpenter's level, a three way stop cock, and a manometer. Connecting them to a transducer opened up a Pandora's Box of problems and involved endless fiddling for a reading of dubious value. They were a real pain to deal with. I was thinking of producing a video explaining some of the pitfalls of CVP lines and possible solutions. Of course this is going to cost you, but, in all honesty, I would rather sell a kidney than profit from teaching the next generation of nurses. We are all in this together so let's pause and think about the needs  of novice  nurses before whoring out something sacred like the mastery of bedside procedures.

Overhead IV Racks Done in by IV Pumps and Controllers

An overhead IV rack in it's safest position-on the ground

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Imagine a device that would take advantage of unused vertical space above the patient's bedside and free up congested floor space. Sounds too good to be true?  Well, it was.  In the early 1970s a new fangled device came to our fancy new state of the art ICUs. Designed by architects with decades of office sitting experience, but loathed by nurses at the bedside, the wonderous new creation was overhead  suspended IV hangers.

The ceiling was equipped  with tracks that ran around the periphery of the bed in a semi-circle or as a single diagonal running from the foot to the head. A looped hook with ball bearing wheels roamed the confines of the track. The IV rack  had a pigtail like structure at it's upper most  point  that was carefully threaded through the hook and you were in the  business of IV bottles in the sky.

These clever contraptions utilized a release button that dropped the rack down to working level that just happened to be the height of the average bedside nurse. It was fun and games for all until  a spontaneous release that dropped the loaded rack in a nondeviating  path on the top of a vulnerable cranium below. Talk about Excedrin headache #47, that really smarts. I think overhead IV racks may have been the impetus for semi-private rooms. A nurse was concussed by an overhead IV rack and rather than open another hospital room, an additional bed was wheeled in for the traumatized practitioner.

Another problem with overhead racks was a phenomenon known as "uplifted bottle drift." My recollection of high school physics is a bit fuzzy, but one of the facts of inertia included the notion that once a body is set in motion, it stays in motion. A sudden lateral adjustment of the heavy glass bottles position in the ceiling track sometimes meant the contrivance flew past it's intended stopping point resulting in a most unpleasant crash/bang with light fixtures or anything else in it's path. Twin overhead racks over a single bed were an accident waiting to happen. If both loaded racks collided, a shattered glass shower was inevitable as the bottles self destructed. If you think cleaning up glass IV bottles from the floor is bad, you haven't seen anything, as an occupied bed full of injurious glass shards glass was far worse. A two for one deal of the supremely noxious variety as both nurse and patient were potential laceration victims.

Gravity was a dependable vector to deliver IV fluids, but there were lots of variables when the only controlling mechanism was a roller clamp. This necessitated endless fiddling and adjusting as vascular resistance varied or the fluid level in the bottle dropped. See-sawing IV drip rates were always explained by that ubiquitous "P" word. Positional covered lots of possibilities from the position of the IV catheter to the movement of an extremity.

A revolutionary development appeared in the mid 1970s. Fancy little IVAC machines with glowing electric eyes plastered to the drip chamber began appearing. This clever little apparatus accurately controlled pre-set drip rates. Older nurses thought they would never catch on due to their expense, but to me, they were magic in a box. IVACs and the even more sophisticated pumps that followed required an IV pole for support. IV poles meant the death of overhead IV racks. We did keep a couple of the flying IV racks on the unit because a few of the patients enjoyed posting family photos or inspirational slogans on the overhead racks. It was a genuine boon to patient morale to look up and see a reassuring image and some of the hazards of these racks was mitigated by the absence of heavy bottles.

If you are interested in acquiring an artefact of nursing/hospital history, there are loads of these fickle firmament flying fixtures for sale on EBAY. Just don't forget to duck!

Custom Made Signage by Nurses

 Hospitals are infested with signage developed by office sitting busy bodies promoting policy, giving direction, or threatening grave consequences for those with the nerve to be non-compliant with their all important edicts. Signs have authority and grab your attention. Who  in the world is going to fool with a red bag tagged with the warning: CHEMO THERAPEUTIC INFECTOUS WASTE? It's enough to scare the daylights out of a Pope.

Bedside nurses  put other's   needs before their own  because they are wired differently at the factory as compared to business minded hospital big shots. Information flows down from the top with a remarkable efficiency, but enlightenment gained in the trenches stays there. Hand made signs posted by harried nurses are an attempt  to break this communication barrier. It's difficult and dangerous to transition a one way street to bidirectional traffic, but that doesn't stop sign maker nurses from trying.

Nurses can be their own worst enemy. In nursing school we had a bulletin board for posting NLN test results that we called the wailing wall. Instructors were also known to publicly humiliate their students by posting signage advertising particularly egregious clinical  blunders. One memorable sign announced with great fanfare that "Gwen had attempted to irrigate her patient's Foley catheter with a TB syringe." That was cringe worthy because the syringe was too small by a factor of 100cc. or more.

Step down units are typically located adjacent to critical care units and the staff members get along about as well as cats and dogs. Step down nurses think ICU nurses are cowboy or girl know-it-alls with overblown egos and are eager to put these hot shots in their rightful place. I noticed a huge poster plastered on the ICU locker room door stating "THIS CAME OUT OF ICU." It was a double heparin locked IV catheter. An ICU nurse was probably doing a gazillion things at once and failed to notice the patients IV was capped with a heparin lock and hep locked the needle previously inserted. I figured out a scheme to convert the sign from an admonishment to amusement by inserting several more needles and hep locking  them in place so there was a series of hep locks about a foot long. A dose of good natured badinage helps improve relations among feuding groups of nurses.

UPMC, the health care behemoth here in Pittsburgh has power. When they acquired Montefiore Hospital which was built into a hillside ala Pennsylvania bank barn style they changed the names of the institution's floors. What nerve!  The hospital was entered from the summit of the hill on a floor called "Main." A, B, and C floors were underground and the floor above main was the first floor. UPMC renamed "C" level as the  first floor and the other units followed in numerical sequence. A series of lengthy, confounding memos and signage flowed from the corporate geniuses at UPMC explaining the new nomenclature. Leave it to a nurse to explain things in simple, straight forward language with her sign explaining, "MAIN HAS MOVED TO 4TH FLOOR AND FIRST FLOOR HAS MOVED TO THE 5TH FLOOR." It may have sounded whacky, but everyone knew what she meant.

Who made this sign? Not me!

Coffee is an essential on any nursing unit and anything impeding it's consumption must be dealt with. Our neuro ICU coffee pot shared electrical outlets with a vending machine and somehow the coffe maker was often unplugged. A nurse attached a sign to the electrical cord running from the coffee maker: "DO NOT UNPLUG-VITAL LIFE SUPPORT EQUIPMENT" Folks honored the official looking sign and we always had hot coffee.

Paul Obis RN - A Pioneering Nurse Influencer

Every young nurse graduates from training school with high minded dreams to heal the world, but after  a couple of years at the bedside the dream begins to fade as burnout sets in. No matter what you do to get around it, sooner or later, it's going to set in like the darkness of night.  An often times rigid and authoritarian hospital environment quashes outside the box thinking and  innovation. I was fortunate to attend school and work with a nurse that could see beyond the bedside and promote health and wellness on a more global scale. We were good friends even though our paths diverged as I stubbornly clung to bedside nursing and he moved on to a more grand vision.

Paul Obis entered nursing school a year after me. He was a slightly built young man with an engaging personality and shoulder length hair. The hair issue was a big deal in nursing school and addressed frequently at uniform inspections. Hair was thought to be a source of infection and everyone on the nursing staff had to keep their hair off the collar while working in the hospital. Paul opted out of the Brilliantine butch haircut for the  typical men in nursing coiffure and went with a pony tail to keep his locks off the collar. What worked for the girls worked for the guys.

Every student nurse has a shocking epiphany early on in nursing school, for me it was how much patients suffered. For Paul, it  was how terrible hospital food choices were for recovering  patients. In the early 1970s the ideal meal was a huge chunk of meat surrounded by something deep fried. The notion of "healthy food" was decades in the future. When someone heard that artificial ingredients and colors were a big component of their diet, the line of thinking was; those clever scientists are at it again. What will they think of next?

Nutition classes in the early 1970s nursing programs promoted notions that white bread was  just as nutritious as whole grain and the ideal protein source was a big chunk of animal flesh smothered in gravy. Paul was quick to note the malnourishment present in hospital patients as diets of the time did practically nothing to promote recovery. Vascular bypasses of one variety or another were the cutting edge procedures of the era. The sad part of this miraculous new surgery was the temporary nature of the complicated fix. Patients were returning to the hospital a few years down the road with their fancy grafts occluded by the very same atherosclerotic changes that afflicted their native anatomy.

The cholesterol theory relating saturated fats to vascular disease was in it's infancy, but this did not deter  Paul who began researching and promoting vegetarian diets as a boon to good health. Vegetarians were few and far between in the early 1970s and excluding meat from a diet was viewed in a freakish light. There was no internet or social media for folks to connect so Paul started writing a little 4 page newsletter with the proud title of Vegetarian Times.

Distribution was limited to the area around the immediate hospital on Chicago's North Side. By Vegetarian Times Issue No. 3 the newsletter circulated to areas that Paul could reach on his bright green  Schwinn Varsity bike. The VT footprint gradually grew to the point where I let Paul deliver them in my brand new Ford Pinto. Paul christened the little Runabout as  the Vegetarian Times Staff Car. A "LOVE ANIMALS -DON'T EAT THEM"  bumper sticker was proudly displayed which got me bemused looks in the Burger King parking lot. I was a blatant  carnivore and never really adopted the meatless life.

Vegetarian Times evolved into a full scale magazine and by 1990 Paul had a media blockbuster on his hands. He worked from an office in Oak Park with a staff of 25 producing the monthly magazine. When I saw the magazine for sale in the gift shop at the hospital where I worked in Pittsburgh, I came to realize the publication had journeyed full circle back to a hospital.

Yep, That's me endorsing VT. It's a good thing that

scrub nurse thing worked out. I was an awful model!

When we were young nurses it seemed as though time was giving us more and more. I now realize it can take everything away too. Sadly,  Paul died of Lewey Body dementia last June His memorial website of a life well lived is: http://paulobis.com/

A Vintage Operating Room Table

A classic Amsco O.R. Table. Turn one big wheel for elevation, the other for tilting

the head up or down. Grab the gear shift handles to activate breaks. Shift into first

gear and use the stirrups for gyne and urology procedures.

Old time operating rooms were furnished, not equipped like today's technological marvels. The focal point of just about any OR is the table because that's where the all the action happens. Vintage surgical platforms were crude, but effective pieces of furniture that could function without electricity. No complicated owner's manual  necessary. The adjustment wheels applied torque to gigantic screws that moved the table.

One of the design flaws was locating the position of the exposed screws with their inclined plane below the table.  Accessing the controls of a draped table required a trip down under for the circulating nurse. Circulating nurse was one of those new fangled terms and fools older than me called them "hustle nurses."  I was a frequent volunteer for this duty because I relished the serene environment  under a draped OR table while all that noise and fuss emanated from above.

During my under table sojourns it was all too easy to allow for some foolish daydreaming. Those big shining control wheels looked like they belonged on a yacht and sometimes I  imagined myself at the helm of a pleasure vessel on peaceful  Lake Michigan or driving a race car in the Indy 500.  A break from all the drama above always refreshed.

The exposed screws were also in a vulnerable spot when it came to collecting fluids from above. Blood would clot and dry on the surface of the adjustment screw so that subsequent rotations would produce a colorful rooster tail  of flying red flecks that reminded me of those spinning fireworks shooting sparks. The mini pieces of dried blood flying about would also refract the light from the big overheads creating a miniature light show that was a sight to behold

Surgeons had no direct control of patient positioning and were at the mercy of nursing and anesthesia to adjust the table. Positioning attempts were initiated immediately after the one...two...three... count  transferring the patient from a cart. Kindly surgeons like Dr. Slambow would always help lifting and transferring patients from the cart to table. Non verbal, cold as ice stares awaited less helpful surgeons who soon learned the up side of team work.

There were no specialty OR tables back in the days of one size fits all surgical platforms. Sand bags, rolled towels, airplane belt restraints padded with egg crate, and whatever else we could scrounge together made up our somewhat barbaric positioning armamentarium. (I just love that A...… word because it sounds like I might know what I'm talking about!) When we applied a restraint belt to a conscious patient the party line was always, "Since the table is so very narrow we use this for safety." There was no mention of the fact the belt helped keep them on the table if an abrupt anesthesia emergence occurred giving an alternative meaning to ambulatory surgery.

Looking Good - Feeling Bad

Back in the late 1960s  cures for serious illness were few and far between. Undaunted by bodies mutilated by serious illness, old school nurses were true artisans when it came to making sick, debilitated  patients look good. That old adage, You can't make a silk purse out of a sow's stomach, did not apply to these embellishment minded nurses. Cachexia never looked so gorgeous.

Every bedside nurse was a master when it came to the quick shave. A wash cloth heated in the blanket warmer served to mollify the most robust beard. A few deft strokes with a prep razor produced a dapper looking patient despite the paroxysms of sustained DTs of an alcoholic in the process of sobering up.

Shaving had one well known complication. Intubated patients always had  that pesky pilot balloon dangling in the razor's path and slicing into that tiny little bubble resulted in lots of excitement. A massive leak around the deflated cuff of the endotracheal  called for a STAT reintubation, but, at least, the patient looked nice if you could overlook the terrified expression elicited by a crash intubation..

Another trick in the looking good procedure manual was fooling  around with the lighting. Jaundiced patients always looked much worse under incandescent illumination, so open the drapes and turn off the overheads in the room. Avoiding yellow bedspreads helps too. Patients with an elevated bilirubin of 4 mg/dl  never looked so good.

Out of sight, out of mind was the philosophy of wound management and the bigger the surgery, the bigger the dressing. Abdominal surgeries incorporated another layer of obfuscation, the scultetus binder. A patient might feel as though their belly lost a battle with a chain saw, but hey, they can't see a thing until that dreaded dressing change.

The importance of accessory items such as eyeglasses and wrist watches in the looking good gambit  is illustrated by the sad tale of a 47 year old man suffering from terminal heart disease. Haskell Karp of Skokie Illinois was the first recipient of an artificial heart. Famed Texas heart surgeon, Dr. Denton Cooley made quick work of the situation and in a 47 minute surgery the artificial heart was in place. The device functioned for 3 days when a transplant became available, but death came 2 days later from operative complications.

It was especially important that a patient  fortunate to receive  doomed by the first totally mechanical heart to look attractive. This was international news and lots of folks were watching. Nurses went all out  to convert what was a terminal event to a flattering photo op. The illustration below shows Haskell fresh off the operating table awaiting the return of consciousness and the delivery of The New York Times. Reading glasses in position for a cursory perusal of the business section. Looking good!

Haskell Karp   Circa 1969

Nurses of The Greatest Generation

Miss Bruiser, a proud member of The Greatest Generation

My indoctrination , if you could call it that, to the world of nursing  came under the tutelage of a rough and tough assemblage of gallant geezers from the heart of The Greatest Generation. These nurses were forged in a cauldron of  devastating diseases, arrogant paternalistic physicians, and a life of abject poverty where it was a virtue to eschew any accumulation of material goods.

Battle scared nurses like these aroused paradoxical emotions among lowly student nurses. We held them up as the ultimate in role models, yet we wanted to be nothing like them in their surly approach to nursing care and life in general. Their level of dedication was without question, but their demeanor left much to be desired as they were a frightening assemblage of care givers.

These  nurses had sacrificed and paid the price on a daily basis. Trivial pastimes and activities for amusement were unheard of. Today's notion of self care for nurses would have ignited a hearty belly laugh from these nurses and a stern rebuke, "Spend more time with your patients and stop thinking about yourself. It's not about you!!" The notion that caring for others required caring for yourself was the ultimate in tomfoolery.

These nurses were masters at giving up personal comfort for what bordered on self  torture. Sacrificing ease for discomfort to benefit patients was second nature to this intense hard core group. Their footwear, Red Cross shoes, were metatarsal unfriendly to say the least. Remember that Pulitzer Prize photo of the nurse kissing the sailor at the conclusion of WWII?  Those were bunion busting Red Cross Shoes and a podiatrist's nightmare. Those heavy, white starched uniforms looked very official, but on those wards that were brick oven hot, cotton clothing acted like a sweatsuit. I don't know how they functioned with pools of sweat dripping from overheated extremities.

Vintage diploma nursing schools were ruled by a set of rigid authoritarian regulations. Marriage was prohibited any time during those tortuous 3 years and pregnancy meant an automatic expulsion. One of my fellow students had a fascinating tale about her mother's determination to graduate from nurse's training. Mary's Mom was a large-scale sized person so a few extra pounds on her was like an extra suitcase on a Boeing 747; not something noticeable. Near the end of the nursing program she became pregnant with Mary. She delivered the baby at nearby Ravenswood Hospital a couple of weeks prior to graduation and was present for the final awarding of her nursing pin with not a soul the wiser. Mary was in the graduation audience cradled in her grandmother's arms.

Nurses from this era had a sense of consecratedness to their profession where persistence was one of the primary themes. These folks had a never say die mindset and persistent nurses never quit when it gets rough, when they lose, or when it hurts. I've known older nurses to continue working despite disabling arthritis and physical disability that would hobble just about anyone else.

Older nurses were highly skeptical of anything new. I remember the outcry over the installation of  nurse call lights when wards were being divided to semi-private rooms. These nurses thought it was ridiculous for a patient to summon a nurse by pressing a button. The nurse should always be close to the bedside. Team nursing, disposable needles, anything made of plastic,  and  swadged, atraumatic sutures were other useless new fangled ideas. Why tinker with something that worked for decades.

It's a good thing that Press Ganey patient surveys were unheard of  in this era. Old nurses were in charge and always  knew what was best for their patients. Any health problem that could be construed as self-inflicted drew a particularly tough, unsympathetic rebuke. As a student caring for an alcoholic patient with draining wounds on his legs, I was enlightened by one of the older nurses, "That's all the filth and evil leaving his body," Rita knowingly advised. I was belittled when coming to the patient's defense. Clearly, these nurses were not ones to tolerate dissent.