Sunday, June 16, 2019

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.

Friday, June 7, 2019

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.

Saturday, May 25, 2019

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.

Saturday, May 11, 2019

Overhead IV Racks Done in by IV Pumps and Controllers

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


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!





Thursday, May 2, 2019

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.

Sunday, April 21, 2019

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/

Saturday, April 6, 2019

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.

Thursday, March 28, 2019

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


Thursday, March 21, 2019

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.

Friday, March 15, 2019

Fun in The Sun at Diploma Nursing Schools

"After I sink this one, let's  visit the sun deck!"
Old time 3 year diploma nursing schools lacked the recreational amenities  of modern learning institutions, but they did provide some outlets for brow beaten,  harried students to unwind. The notion of fresh air and sunshine as a curative modality was a core value of the traditional Nightengale mindset; hospitals had solariums and almost every nursing school had a sundeck.

As sundecks were the common denominator at diploma nursing schools, most hospitals had at least one other diversional activity. Cook County School of Nursing had a magnificent indoor swimming pool. After a brief journey through dingy, rat infested catacombs an elegant facility complete with Romanesque columns emerged. The lavish pool was a  unique oasis oddly situated in the midst of a dingy, depressing, medically underserved environment of intractable social problems and abject poverty. A true diamond in the rough.

 Our hospital had a lowly pool table located adjacent to the sun deck entrance and students often picked up a cue and attacked the racked balls before sunning themselves. Nearby Ravenswood hospital had dual purpose sundeck that also served as a badminton court. Weiss Memorial Hospital had a combo shuffleboard court sundeck.

Most all sundecks in Chicago hospital nursing schools  were located on the roof of the nursing school as a concession to the cramped urban environment. The nurse's sundeck was on the roof and 4 stories off the ground at our beloved learning institution. (If you could even call it that.) The operating rooms on the seventh floor overlooked the nurse's residence sun deck and provided geezer surgeons an unobtrusive vector for ogling the scantily clad students. An amorous break from the rigors of the operating room was only three stories away and many took advantage of the opportunity.

A generous sized cedar wooden deck that occupied about a third of the roof top made up the formal deck. This structure was surrounded by a chain link fence that prominently commanded a sense of forbiddance. A few deck chairs and a large phony looking  plasticized   palm tree provided atmosphere. A tropical paradise amongst the Chicago concrete jungle seemed to be the idea.  Just toss a dime in the nearby beverage  vending machine for a can of Tab soda and stretch out on a beach chaise. Life was good.
Tropical Bliss Comes to a Chicago Nursing School
Sundeck activities, like everything else, were governed by the rules set forth in every student nurse's bible, the official student hand book. Here is what the powers at be had to say:
A sundeck is provided for the convenience and pleasure of the students. It is open from 8AM to sunset. School linens, pillows and blankets are not to be taken out on the sundeck. Radios are permitted on the sun porch if played softly. Suitable chairs, chaise lounges, and mats are provided and must be returned after each use. Some type of beach coat or covering must be worn to and from the sundeck.

Like Baptists, diploma nursing schools firmly believed in total immersion, not in water, but in the hospital milieu.  I think any oppressed minority cultivates  a latent rebellious streak and student nurses were no exception. The sundeck overlooked the faculty entrance to the hallowed halls of the lecture auditorium where bitter, hardened, old instructors put their students through their paces. After a severe ear beating on the clinical unit for a pillow oriented the wrong way  toward the door, one of the students, Rose, hatched a diabolical plot for revenge. An Asepto syringe and a bath basin created a sluice of water that cascaded over the sundeck just as the formidable Miss Bruiser made an appearance. She was an aficionado of flowing capes, but nevertheless received a generous soaking

Soon after Miss Bruiser's unfortunate encounter with the cascading fountain of water, a warning sign was posted; Any  student caught propelling any substance off the sun deck will be referred to the student disciplinary committee for possible expulsion. As young Rose loaded her Asepto for another aquatic volley she replied with a snicker, "They have to catch us first!"

Friday, March 8, 2019

Professional Courtesy - A Lost Custom




Forty years ago physicians would have never considered denuding fellow doctors and nurses of their limited financial resources to pay for health care. Any doctor would see any colleague without money changing hands. Physicians were apex predators in the hospital food chain and they always got what they wanted without question.

One of the ideas behind professional courtesy was to prevent doctors from treating their own family members. Physicians and surgeons tend to overthink and overdo things when caring for close relatives. Laproscopic minimally invasive surgery was in the distant future and overdoing procedures like radical mastectomies or laryngectomies was not a pretty picture. Professional courtesy spared fellow health workers from lots more than financial pain. It was a grand idea that was a tradition for many years.

I worked with the internationally known ENT surgeon, Maurice Cottle, who thought virtually anyone could benefit from a "Cottle Nose." The purported gas exchange improvement by breathing through remodeled nostrils was  claimed to improve everything from longevity to energy levels  Student nurses were among his favorite subjects  patients and many took him up for the free, albeit painful rhinoplasty which of course was done as a professional courtesy. I treasured my native proboscis and politely declined his frequent offers for cost free, fragile nasal bone crunching surgery. When scrubbed with him I made darn sure my mask was covering my nose completely so as to not give him any bright  ideas. There was something about hearing those loud snap, crackle, pop noises as he plied his trade on a wide awake, locally anesthetized patient that gave me goose bumps. This was not for me.

A triangular alliance of administrative busy bodies, health insurance companies, and governmental regulation put a halt to the long standing tradition of  professional courtesy. Physicians now had to kowtow to a host of  policy makers outside the medical world as managed care became the norm. Healthcare became technology proficient, but empathetically deficient. Balance sheets and quarterly reports were the metric that defined hospitals. Professional courtesy was gone for good as business minded bean counters controlled the medical landscape.

Some old time docs did not go quietly into the night when it came time to abandon professional courtesy. When an old school surgeon like Dr. Slambow received a medical bill for banding a series of uncomfortable internal hemorrhoids he went ballistic with the poor young lady from the billing office. I only heard one side of the memorable  phone conversation argument, but the snippets were permanently engraved in my long term memory including  phrases like: "I demand professional courtesy - I'll bend over and extricate that overpriced elastic ligature and  mail it back to you C.O.D.- if I ever see you on the OR table." I don't know if his medical bill was forgiven, but the hapless young lady from billing received an earful.

There have been many attempts to reform medical billing such as the ill fated Medicare DRG schedule where hospitals received fixed amounts for procedures. Maybe it's time to go one step further and take a lesson from attorneys with their contingency fees. Simply place all the funds paid to correct a health problem in a reserve fund. When a physician accomplishes the final cure, he gets the whole pot. This would incentivize finding a cure rather than finance a medical goose chase with pricey diagnostic studies that produced minimal result. Now that's something to think about.


Thursday, February 28, 2019

Student Nurses Misappropriate Birth Certificates to Imbibe

Vintage diploma nursing schools had rigid, authoritarian  rules for just about everything  that could be construed as fun. From restrictions on outside visitors, especially men, to strict study hours, all recreational outlets were meticulously managed with onerous regulation. The rules regarding alcoholic beverages were especially strict and came from the hallowed chambers of  The Hospital  Board of Trustees. This mysterious and often cited governing body was a force to be reckoned with because just one measly slip up of their regulations could get you expelled from the nursing program.

According to the esteemed board, alcohol was the ultimate in forbidden fruit, especially for stressed out and underaged nursing students. The notion that imbibing in the magical elixir of alcoholic drink was wrong, made it all the more appealing. Diploma nursing students were in the same boat as Eve in the Garden of Eden.

By the time nursing specialties: pediatrics, psych, and obstetrics, rolled around, nursing students were feeling the pressure of their chosen vocation. I was going to say chosen profession, but we were brain washed into submission and nobody really believed we were worthy of such a lofty title. I'm just a nurse was our mantra. Doctors were professional-nurses were not.

All nursing specialties were difficult and stressful. Cures for seriously ill children were few and far between. Leukemia of any variety was a death sentence. Our clinical psych experience was on the back ward of a state hospital and it was your lucky day if your patient wasn't homicidal. I don't know which was more trying on your soul,  psych or pediatrics. It was a toss-up.

Obstetrics was different, especially post partum where the exuberance of young mothers was uplifting. Our time in OB was rotated in monthly intervals through delivery room, nursery, and post partum. Everyone had their particular favorite, but delivery room duty was the highlight of just about any young student  nurse's  training. The miracle of birth was something that stayed with you and served as an antidote to all the pain and suffering in the rest of the hospital. Birth and death were the ultimate Yin/Yang experience.

The delivery room had another up side. Stashed right next to vials of silver nitrate which was used prophylactically in  babies' eyes to prevent blindness from contact with gonorrhea was a stack of blank birth certificates.

The unwritten rule was that each student nurse was entitled to one blank birth certificate at the conclusion of their delivery room rotation. Students treasured documents from their various specialty rotations and I still have a plundered birth certificate along with a sponge count record from the OR and a restraint and seclusion record from psych.

I first learned what could be done with a blank birth certificate from one of my fellow students who had been released from Cook County School of Nursing as being unsuited for the practice of nursing. That "unsuited" business was a catch all phrase that covered a multitude of sins and was a step up from academic failure because some of these students were able to transfer to another diploma nursing program after "maturing." Transfer students were a valuable resource when it came to surviving nursing school because they knew many of subtle ins and outs of getting through the madness of three years of torture.

Light fingered nursing students knew exactly what to do with a poached birth certificate. "All you have to do is fill in your own name with a birthdate of more than 21 years ago and the document becomes your ticket to freedom from the evil clutches of the sanctimonious "dry" hospital environs," explained one of these wise transfer students. Time to unleash the libations.

Barkeepers found the neighborhoods surrounding hospitals as fertile ground for their trade. There was no shortage of stressed out workers that had pay checks to support their bar tabs. These taverns often had clever names like "Recovery Room" or "Barborygmi." The bar of choice near our hospital was "Ratzos" and the barkeep would just wink and pour when presented with a birth certificate with freshly inked infant footprints. This little charade had been going on for a very long time and was one of the dirty little secrets of old school diploma schools. Cheers! as Sue  would say.

Thursday, February 14, 2019

How Hospitals Transitioned From Chairity Care to A Corporate Cash In Culture

The land of the free and the home of the brave is home to some  the most expensive health care in the known universe. What the heck happened? The last I remember,  the  rate for nursing, room, and dietary in a big inner city hospital was 68 bucks per day. The charge was known as the hospital NRD fee and it covered just about everything except for OR fees and pharmaceuticals which were dirt cheap.  A visit to the ER was 28 bucks if you had it and no patient was ever out of network or even asked about insurance.

 Hospital superintendents were paid slightly more than nurses and there were no big bonuses for anyone. We were all in the same boat and everyone knew and respected frugality. This is my anecdotal account of what happened during the transition to the current cash-in culture of today's healthcare. One caveat, these notions have been filtered through what's left of an ancient nervous system that remembers old school nurses who never expected to own much of anything and lots of MDs were content with an apartment.

It's easy to rattle of a list of culprits in the stratospheric rise of healthcare cost. Entrepreneurially motivated physicians and nurses wth the notion that I worked hard and deserve bountiful financial compensation for my work is a part of the story. Patient care in of itself was the old school compensation and material deprivation produced a sense of solidarity among nurses with everyone looking out for one another.

Old nurses like myself really had it easy compared to the all for one, and one for all whippersnapperns of today when it comes to salary. Our basic needs were met without worry and there were no school loans or financial demands. If we needed medical care any MD would gladly see us as a professional courtesy and if a hospitalization was required, our diploma school had a private "alumni room" for our exclusive use. It was the only room in the hospital with genuine Karastan carpeting. Nurses lived the good life without money changing hands. It's no wonder we affectionately referred to our hospital as "Mother."

Explosive growth of technology and electronic record keeping consumes lots of dollars. So do mindless Press Gainey surveys. Old school physicians would argue until they were blue in the face that patients are not qualified to make judgments about the quality of their care. I can see their point. Some of the very best surgeons I worked with were not very touchy-feely, and that's putting it nicely. Dr. Slambow would visit post-op patients with part of his breakfast and/or lunch spilled on his tie and shirt. I can see why folks would question the credibility of a surgeon wearing his breakfast and lunch, but he was one of the best when it came to minimizing post-op complications.

In the late 1970s my humble school of nursing was closed down for good after being in existence for almost 100 years. The building functioned as an oncology clinic for a couple of years and was then razed for the construction of a multi-level, monstrous parking garage. Fancy hospital parking facilities are given short shrift when considering how corporate interests made health care such an expensive commodity. This is where the rubber meets the road (or parking garage) in my woe filled tale. Parking garages are at the root of the problem.
Parking garages became the welcoming mat for hoards of greedy go-getters

Very few nurses owned cars when I was toiling at the bedside. We made do with the CTA, bicycles or good old fashioned shoe leather, those Clinic shoes were made for walking, It's interesting to note that our nursing school was way ahead of the curve when it came to alternative transportation. The first object to greet someone approaching the school was a massive bike rack, usually at least half full. There were no worries about locking your bike. Who would even think of stealing a nurse's bike?

Physicians and the fortunate few that owned autos found ample space on the street or small unregulated surface lots. Patients arrived at the hospital by taxi, bus, or walk-ins. There was no EMS, and trauma patients frequently arrived in the back of police cars or paddy wagons. Chicago police operated unique,  three wheeler Harley-Davidson motorcycles  which could be ridden just about anywhere. I vividly recall a drowning victim from Montrose Beach being hauled up to the ER secured to the back of a police officer's tricycle motorcycle. The officer even went so far as to suggest the road bumps jostled the water out of the victims airway. The patient survived with quite a story to tell. Maybe the cop had a point.

Hospital parking garages dramatically demonstrate the ridiculous profusion of administrative busy bodies, clerical, and unnecessary hucksters attempting to sell everything from pharmaceuticals to medical equipment. Visit just about any hospital parking facility on a Sunday morning to observe first hand how few workers are  really necessary to take care of patients and it's not because administrative big shots and pharmaceutical representatives are attending church. The Sunday morning deserted parking garage syndrome is even more acute at government agencies such as VA Hospitals.

Hospital parking garages are like a beacon to pharmaceutical hucksters. In the old days drug reps were a non-entity. No one needed to sell penicillin because it really did kill strep and everyone knew it. Much of drug pricing today is done with blatant extortion. A marketer of Zyprexa might claim that his drug will negate the necessity of long term hospitalization saving untold tens of thousands of dollars, hence,  his product is worth a ridiculous charge.

Epinephrine was dirt cheap. Everyone  knows what Mylan's Heather Bresch did with exorbitant charges for that "lifesaving" drug. I betcha if drug reps had to ride a bicycle to hospitals they would be few and far between.

Parking garages and the influx of money seeking hucksters changed how doctors and nurses thought about their patients. Money changing hands at every corner of the hospital amidst a bean counter culture changed who people were. Mega bucks doled out in bonuses to administrative big shots who never helped anyone except for themselves became the rule. It was so  much better when all I had was a Raleigh Super Course bike to ride to work and to heck with all those monstrous parking garages.


Sunday, February 10, 2019

What Blood Loss??

 What blood loss? That's all irrigation in the suction bottle. At least 2 liters.

A good scrub nurse always agrees with the surgeon even if the patient lost a unit or more  of blood. I felt just like Nancy when concurring with a surgeon understating the blood loss. I always felt there were 3 categories of blood loss estimates: ABL, anesthesia estimated blood loss -  EBL, estimated blood loss by the surgeon  and NBL negotiated blood loss after the surgeon vs. anesthetist argument concluded. Actual blood loss was one of the great mysteries.

I promise this is the last of my political foolishness. Blame it on my brain freeze.

Thursday, February 7, 2019

Euphmistically Speaking

I overheard a group of whippersnapperns discussing the advantages of rewording the term "terminal wean" to "compassionate extubation" when discontinuing mechanical ventilation and  allowing nature to take it's course in a critical care unit.  Over the years lots of terms were changed: Directoress of Nursing is now Chief Nursing Officer, Hospital Superintendent is now CEO, Janitors are Environmental Engineers, and Personnel became Human Resources.

All this got me to thinking, which is always a dangerous proposition. I'm  in the midst of a midwinter brain freeze when my thoughts are too incoherent for a typical post. Anyhow, here are some terms that could be reworded to be more politically correct or incorrect, depending on your perspective.

Suicide to euthanasia from unbearable emotional pain.

Bathroom privileges to free range bathrooming?  That sounds dumb, but anything is better than B.R.P.

Doctor's orders to physician's proposals.

Physical restraints to boundary maintenance aids.

Near miss to near hit

Drug addict is a label loaded with lots of pejorative connotations. I've never really had to deal with this issue because old school discharge criteria mandated that a patient be relatively pain free upon discharge. There were very few legal narcotics outside the controlled environment of the hospital. So..lets start referring to those poor souls addicted to drugs pharmaceutical aficionados

I'm saving the best for last. An oldie but a goddie; Emesis to feedback. The simplest ones are always best.


Monday, January 28, 2019

The Smoking Finger

No, I don't have one of those fancy new fangled phones
that take photos, so I put what's left of my index finger in the scanner.
Surgeons and nurses toiling in an operating room become habituated to a very controlled environment where everything from lighting to air quality is subject to rigid regimentation. Unpredictable events throw a monkey wrench in the midst of this enforced order, often times, leading to a cascade of adverse events  which can result in personal  injury to staff.

Voice modulation morphs into a surgeons unduly harsh verbal  admonishment of the offending party. Harried nurses, desperate for a resolution to the problem throw caution to the wind and find themselves in a precarious situation while attempting to solve the problem. Desperation seldom leads to reasoned thinking. The ensuing pandemonium is enough to flummox a pope.

Operating rooms can be dangerous places. Surgeons waiting for someone to fall asleep before cutting them might, at face value, seem unsavory, but the notion of live by the sword; die by the sword holds true in the OR.  Those sharpened chunks of stainless steel do not discriminate when inflicting their trauma and Bovies don't care what  tissue they roast.

 As a circulating nurse I was known for constructing elaborate platforms for height challenged scrub nurses. My colleague, Janess, loved my elevation tactics and was so enamored with one of my creations she failed to notice an unusually low hanging overhead light. As she emergently  ascended my stairway to operating room heaven for an urgent trauma case,  the crown of her head struck the low hanging illuminary with a sickening THUD..CRASH. After finishing the case, a close inspection of her cranial vertex revealed a hematoma the size of the distal end of a Babcock. After a quick neuro check and 15 minutes with an ice pack she was back on duty. I've witnessed several intraoperative injuries to staff and not a single nurse or surgeon broke scrub, no matter the extent of the injury.

Karma can be a cruel mistress and I soon received my payback for contributing to Janess's unfortunate mishap. I was finishing up a case with Dr. Oddo that entailed resecting a menengioma. These tumors are outside the brain and with removal have an excellent prognosis. I was in a great mood thinking about how we were actually being  of some service to the poor soul suffering from this nasty,  neoplastic malady. One thing I've learned over the years is to be wary of those euphoric Kumbaya moments when everything seems to fall in place because a true shitstorm is often in the works.

Dr. Oddo had been using a foot pedal actuated Mallis bipolar cautery during the case. This nifty little device looks like a pair of tweezers with an electric cord attached to a high voltage generator. When Dr. Oddo tramped on his foot pedal electricity flowed between the tips of the tweezer like device cauterizing anything in between. It was a great little gadget for controlling bleeding in small vessels.

Dr. Oddo loved to instruct the anesthetist to lighten the anesthesia near the end of a case. One  of his favorite phrases in the post-op report was, "The patient was able to transfer from the OR table to the awaiting carriage independently." This sometimes made for exciting moments near the end of surgeries when the patient took ambulatory surgery to a new level and decided to bail out before the final skin sutures were in place.

Sure enough, just as Dr. Oddo started closing the skin flap the patient began to emerge from general anesthesia. As he came to, his right leg spasmed into a mighty lateral kicking motion impacting Dr. Oddo's leg poised with his foot just above the Bovie actuating pedal. I was tidying up by clearing off the operative field and was preparing to wipe down the distal, business end of the Bovie forceps. The patients kick to the good doctor's leg turned the Bovie forceps ON and as the juice flowed a sickening burnt flesh/charred rubber glove malodorous scent filled the air.

The Bovie had cooked my right index finger on the distal phalange. As the smoke cleared I requested a new glove and plunged  what was left of  my smoking finger into a fresh sterile barrier. There must be some truth to the notion the body releases pain killers when traumatized because initially I was pain free. Upon finishing the case and pealing off the second glove the extent of the injury became apparent. The end of my finger had extensive "remodeling" with the distal aspect about 1/3 AWOL.

Dr. Oddo helped me remove the melted latex glove from the wound and suggested wrapping the finger with iodoform gauze. Dr. Slambow was consulted and said "welcome to the club" while showing off a massive scar on his right palm. After about 4 weeks, it was time for the unveiling. Dr. Oddo involved himself in a spirited debate with Dr. Slambow questioning whether  the nasty blackish tissue around the wound was eschar or scar tissue.

After the unveiling and the scar/eschar mess was pealed off I had a functional but rather disfigured index finger with a square tip and missing 1/2 the nail. I never missed a day of work and today I regard what's left of the end of that finger as a badge of honor. It's better than thinking of it as a living monument to my foolishness.

Sunday, January 13, 2019

What if Pathologists Performed Surgery?

A pathologist's Mayo Stand.  " Pass me the hack saw, nurse."

Delay of game is not limited to football. Action in the operating room can be subject to breaks in the action too. Waiting for a frozen section report to come back from the pathologist  or a time out while the circulating nurse scrambled to flash sterilize an esoteric instrument that the surgeon just had to have were common interrupters of what had been feverish goal oriented action in the tiled temple.

I liked to busy myself with buffing surgical instruments until they shined in the overheads or wrestling with wiry twisted chromic suture in a vain attempt to get the kinks out during these postponements. Dr. Slambow did not like my heightened activity during these surgical layovers. One of his life lessons was to take a break whenever you have the opportunity, and as an oldster, I've put that lesson into practice way too many times.

As the intense intraoperative activity ground to a halt, he dropped his usually tense voice  an octave or two as  he admonished, " Take a break Fool, and rest those oversize lunch hooks of yours, I've got a little joke for you; In a perfect world the English would be police officers. The Germans would be engineers, and the French would be the cooks. In a more ghastly universe things would be different. The English would be cooks. The Germans would be law officers and the French would be engineers." Ha..Tee..Hee.

Every scrub nurse knows the obligation to laugh at the surgeon's jokes and make a comment about his clever wittiness, but my mind sometimes wandered and thought about what would happen if physicians other than surgeons performed surgery, just as the characters in his joke switched roles. Standing at my Mayo stand in a post joke moment, I came up with an off the wall  idea that made the notion of German police officers sound like a good thing.

What if pathologists performed surgery? The instruments they would bring to the table are enough to shiver just about anyone's timbers. I had never heard of a #60 knife blade because it's exclusive to the morgue. This monster blade made a meat cleaver seem like small potatoes. It's the only scalpel blade I'm aware of that has an edge sharpened along it's entire length. This blade eschews attachment to an ordinary scalpel handle and prefers mating with an autopsy handle that resembles the throttle of a Harley Davidson Electra Glide. This sabre like snickersnee  reduced cutting to it's most barbaric level. In surgery millimeters mattered. A pathologist's  mindset was calibrated in meters. Monster incisions were OK in the morgue, but wouldn't make for a happy ending in the OR.

A pathologist is experienced with slicing through chilled skin that doesn't bleed. I wonder how the novel experience of dealing with those little bright red bursts erupting from the yellow subcutaneous fat would be dealt with. I wonder if a foul smelling liquid like formalin would cauterize a bleeder. There certainly is an abundance of that nasty stuff in a morgue, but surgery is no time for foolhardy experiments. I suspect they would have to learn how to use a Bovie like everyone else.

That's just about enough of my foolish ramblings. I don't want to even think about those giant hedge pruner implements found in a morgue would be used for. Pathologists are conditioned to simply cut structures  out of the way to expose anatomy. Could they adapt to using retractors for accessing organs?

I pondered that last notion while sipping bean soup for my midday sustenance. Glancing down at my fasciculating fingers and realizing I forgot to take my Sinemet, the thought suddenly occurred to me. Dr. Slambow was right, I do have oversize lunch hooks for hands.

Thursday, January 3, 2019

When the Human Body Works Like a 3D Printer


Here is a case of human reproduction that does not involve a gamete, egg, or mitosis. I would have mentioned "ploidy" too, but I'll be darned if I can remember what that involves. A 35 y/o man who was critically ill had a vigorous  coughing fit which was so  productive that he hacked up this blood clot which formed in his right main stem bronchus; a near perfect anatomic reproduction of the airway cast in blood.

Hemoptysis in the extreme, which formed a perfect casting demonstrating 5 branches of the bronchial tree. The clotting cascade was a real challenge to memorize and about the only thing I can remember  is the cross linking of fibrin forming the framework for the clot. It certainly out performed it's intended purpose in this case.

 The right main stem bronchus is like a grease trap in a fast food restaurant because almost anything that goes down the trachea winds up here. It's the first bronchial segment to branch off and has a larger lumen than the left main stem bronchus. It's also more perpendicular making it the perfect exit ramp for just about anything coming down the trachea. Anesthetists always checked for bilateral breath sounds because it was so easy to selectively intubate the right main stem bronchus. An absence of left sided breath sounds?  Time to pull the endotrach tube out a bit to clear the right bronchus.

It's difficult for me to understand how a clot of this size could form because the most likely scenario would be a clot occluding the upper segment and blocking the filling of  the middle and lower branches.  This perfect cast of the bronchus jolted my memory and brought to mind another memorable anatomic replica produced by the human body.

Fecal impactions were a miserable experience for all parties involved and were common in old school hospitals as a side effect of prolonged bed rest combined with opiate analgesia. With the passage of time, pressure from the upstream accumulation of stool in the sigmoid colon  numbed the nerve endings of the internal sphincter. The end result was a massive hardened bowel movement firmly lodged in the sigmoid colon.

Removing these forbidding fecal accumulations was no easy task because the stool hardened to a consistency of Sakrete concrete. The first step in the unpleasant (to say the least) removal process was the rectal installation of warm mineral oil  in an often times futile attempt to soften the painful putrid plug. The final step was similar to a Roto Rooter operation whereby the mass was manually extracted.

One of my colleagues, Ann, was especially proficient at removing fecal impactions. Her fingers were lithe and she had the unique ability to curl the distal metacarpal at a right angle to the rest of her finger resulting in a hook. Her fecal impaction removal technique involved twisting her index finger much like a boring brace to gain entrance to  the tenacious turd. Having bored inside the monstrous mass much like an African dung beetle  she hooked her finger and gently increased traction until the massive mess slid out.

After the patient's  screams of agony subsided, the oows and ahhs began as attending staff members marveled at a perfect sculpture in brownish stool  of the sigmoid colon. The distal part of the colon is lined with haustral markings which delineate colonic saculation.  As the stool hardened a perfect colonic cast was formed.

Most nurses chipped away at fecal impactions which resulted in a hodge podge collection of fecal shreds. Ann's technique of rmoval in toto resulted in an anatomic model not  unlike the cast of the bronchus. Simply amazing!