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.