Thursday, December 31, 2020

What Was the Most Viewed Post of 2020?

This has been a really strange year, just when I thought that I'd seen just about every thing, the Corona Virus pops up and attacks some of the most vulnerable members of our population. Dr. Slambow, my surgeon hero of yesteryear, always said it was the things you cannot see that should cause you the most worry. I suspect he was talking about lesions hiding out somewhere in the small bowel, weird anatomical variations, latent coagulopathies  or breaks in sterile technique. Viruses were not on the radar back then, but I thought of Dr. S. many times while the COVID19 mortality and morbidity numbers were flashed across my computer screen. He was right about hidden danger being the ultimate source of worry.

There has been a flight of ideas coursing  through the remnants of my nervous system about subjects to post;  the long tenure of ether screens (anything that lasts for over a century grabs my attention), questionable adjuncts to ventilator therapy (proning, the latest and greatest of these interventions prompted this idea), the demise of doctor's dining rooms, the disappearance of ortho beds with traction frames and a personal tale of TPN addiction.

It's sometimes a long road from an idea to typing up a new post. Declining eyesight and gnarly fingers from IP joint arthritic changes have put the brakes on my once upon a time nimble fingers. My latest status post encephalomyelitis MRI showed a loss of brain volume, so I best get cracking before my vintage memories evaporate in that looming cognitive abyss. Oh well there is always next year and I will strive to post more than once a month which was my 2020 goal.

The most viewed post of 2020 by a swarming plethora of views  was...drum roll please:oldfoolrn: March 2020. I was really taken off guard by the popularity of a post about such an unsavory topic. I think there is a post languishing in my unpublished drafts about every old nurse's favorite colonic, the 1...2...3... enema. Maybe some day I'll hold my nose and publish it, although I was never one for over rated enemas and their associated backside buffonery.

 My personal favorite was about the crude, but effective Wagensteen suction oldfoolrn: Wagensteen Suction - Elegantly Simple Without Electricity In this electonically complex world filled with flat screen monitors and assorted doodads, it's a delight to see a simple mechanical device do it's work. Just because we were ludites doesn't mean we were stupid or lacked creativity.

Happy New year and I appreciate your loyal readership of my never ending  foolishness. You give an old man a sense of deep rooted purpose.

Tuesday, December 15, 2020

Christmas Arrives at Downey VA Hospital With a Gift for Warren



Warren was a big, tall man with a complexion that reminded me of custard pudding, forty-one years old, with half a lifetime spent on the back wards of Downey VA Hospital, a warehouse for the mentally ill. Like most all the patients here he was branded with the diagnosis of schizophrenia, chronic, undifferentiated. By the 1970s psychiatrists had given up on the idea of delineating the various subtypes of the illness; catatonic, hebrephrenic, paranoid, or schizoaffective,  all permutations were treated the same at Downey. Determining the underpinnings and concocting efficacious treatments for complex mental disorders like schizophrenia made nuclear physics look like a game show.The brain was a complex organ with very complex disorders.

Warren's most visible problem was that he was literally lost in space and required constant contact with a wall to do just about anything that required movement. Staff members regarded this as a behavioral manifestation of his psychosis and dealt with it  accordingly by initiating harsh measures like restrictions on privileges such as smoking and moving his bed to a dark, grim, windowless  area for special observation with threats of physical restraint if he persisted in his wall rubbing routine.

Watching Warren navigate the subterranean world of Downey's interconnected tunnel system was like following a bumper car at the state fair. He repeatedly bumped or bounced his right shoulder off the rough red brick walls leaving a trail of textile shards in his wake, similar to the sparks trailed by the bumper car contact wire on the electrified ceiling. His posture resembled the letter "J" upside down with the end of the letter in constant contact with the wall as he gallivanted along his way.

Just about any staff  reprimand, which was nearly constant,  to cease this shirt/coat shredding behavior was meant with a look from Warren that could smelt lead. Out of pure frustration, Warren developed a unique skill that involved tapping on the few panes of glass windows that had not replaced by plexiglass, skillfully he increased the force of the impact until the glass shattered, leaving his hand virtually without injury.

I talked to Warren about his need for wall rubbing and came away with an assessment much different from my esteemed colleagues. I thought the  incessant wall rubbing was not a direct manifestation of his psychosis or voluntary acting out. Warren had a proprioceptive disorder where he really could not tell the position of his body in space. He felt that without contact with the walls while moving he  would follow a circuitous path and never arrive at his destination or fall injuring himself.

That evening while pouring medications my eye was drawn to the heavy plasticized bottle the pharmacy provided for a solution we mixed with Thorazine concentrate liquid to make it palatable. The side and bottom portion of the bottle had a contour that was a near perfect match to Warren's right shoulder where it interfaced with the brick walls.

I took an empty bottle home that evening and went to work on a garment that could slide along those rough Downey walls and remain intact. Warren loved football, having played receiver  in high school, but while his team mates soared to the stars with their lives. he burned up as he plunged back through the atmosphere like the space shuttle Columbia.

After fashioning an appropriate skid plate from the pharmacy bottle, I drilled a series of tiny holes around the periphery of the plastic armor  and carefully sutured sewed the protective armor to the right sleeve of a Chicago Bears jacket  ala a craniotomy bone flap. A test drag across the outside wall of my apartment building proved successful. Warren was an avid Bears fan and I had a feeling he would really enjoy the jacket, especially if he could rub the brick walls without worry.

I carefully wrapped Warren's special Christmas gift complete with the  abrasion tested shoulder armor in a box that was emblazoned with the corporate jingle, "Tarreyton  100's for smokers who would rather fight than switch." He eagerly unwrapped the present half expecting a mother lode of cigarettes, but as he eyed the special jacket, his eyes gleamed. The look was priceless. He quickly donned the jacket with a renewed sense of purpose. When he spotted the shoulder guard, he couldn't wait to try it out with a quick mosey down along the hall walls. It doesn't take much to make some folks happy - one of the special rewards of working at a place like Downey VA Hospital.

Sunday, November 29, 2020

Egyptian Fun in The Nursing Dorm

 Hospital diploma nursing schools mandated that all students reside in the dorm which was conveniently located within the hospital complex. Individuality was nipped in the bud with all student nurses sharing the misery while at the same time maintaining a pseudo happy face. A monastic-like existence was thought to enhance the nursing educational training experience. Older nurses viewed nursing as a cult and eschewed an outside life for the good of nursing.

These dorms were not fun places and novice nurses slept, woke, ate, slaved for 8 hours on the wards, ate again and studied under the watchful eyes of house mothers before sleeping again. As the bewitching hour of 9 PM rolled around it was time for some fun. House mothers, affectionately known as house hags, completed their last rounds before mandatory lights out at 10PM. The end result was one hour of time for which there was no accounting. Between 9 and 10PM was the bewitching hour.

Student nurses had to make their own fun in this  stark environment that was devoid of  televisions or any form of recreation that cost real money. Of course the sewing room was open, but who felt like mending aprons or fussing with uniforms after working or studying all day. Novice nurses were pretty much left to their own devices when it came to recreational pursuits.

Water fights were popular diversions with an enema can rigged above transoms to dump a deluge on anyone answering a knock on the door. The downside to water sports was the clean up and the screaming frequently attracted uninvited attention from nosy house mothers.

Water fights were fun, but messy

Human pyramid building was the activity of choice in many diploma nursing school dorms. The base of the structure was formed by 4 girls kneeling on the hall floor and gradually built up until the tiniest girl was perched at the apex. Pyramids were fun because there was an immediate sense of accomplishment. This was something novice student nurses could do on their own without being harangued by overbearing instructors or busy body housemothers.

Pyramid diagrams were often used in nursing school to explain the nursing hierarchy or illustrate the priority of patient needs. There was an inherent sense of satisfaction in having fun with something that was not fun.  Human pyramids in the hall were good, clean fun.

 I looked forward to our pre-clinical cafeteria breakfast at 6:30 AM where the first topic  of discussion was frequently the last night's  pyramid building adventures. Early one morning there was an unusual buzz in the air and the discussion was preceded by a "you are not going to believe this disclaimer." The girls had constructed an inverse human pyramid with the most petite girls at the base and "Big Betty" who tipped the scales at about 100kgs as the top. I wondered why so many of the more diminutive students were hobbling about!

Tuesday, November 3, 2020

Nursing Was a Great Sanctuary from the Forlorn Politics of the 1960's

Chicago Police vs. Demonstrators 1968

 On this election day, my thoughts turn to the days of old school political tomfoolery. Some things never change. The day to day political process in Chicago during the late 1960's was a mine field of toxic emotional response fueled by the unending Viet Nam War. There was the police riot just outside the doors of the Democratic National  Convention in 1968, followed by the mayhem  so freely sewed by Jerry Rubin's YIPPIES.

Richard Nixon's  election and subsequent inability to bring the war in Viet Nam to a conclusion, incited a renewed rift of student demonstrations. SDS or Students for a Democratic Society was the mover and shaker on college campuses and had divided over the issue of violence as a means to end the war.

In the fall of 1969, the Weathermen contingent of the SDS staged the Chicago Days of Rage. Stores were ransacked and police cars overturned. Lengths of chain, slinging case hardened padlocks were one of the weapons of choice. The police countered with batons and tear gas, bringing many of their more seriously injured customers to the ER. Some of the victims arrived at the ER strapped to the back of Harley-Davidson Servicars which were unique 3 wheeled motorcycles. A rough ride on the back of one of these contraptions was one of the social engineering experiments by law enforcement. A ride on these bucking broncos was enough to deter further bad behavior.

I was a 19 year old student nurse at the time and often came in contact with some of the hapless student demonstrators as they were triaged. These well intentioned youngsters sometimes asked me if I was going to attend the next demonstration on Halsted Street in the morning. "No, I have clinical all day on 3B tomorrow. There is no time for any of that if you are a student nurse."

Nursing was a wonderful shield from the political tumult of the day. Being present to my patients in their time of need felt so good compared to the emotional cauldron stewing within the tear gassed and beaten demonstrators. Diploma nursing schools, with instructors like Miss Bruiser on your back all the time, could be trying, but  the monastic life did have it's peaceful moments-some of which I would like to call to mind on this strained election day.

Saturday, October 3, 2020

All Nighters in The O.R. Were Real Stinkers


Bovie smoke carried olfactory nightmares into every 
nook and cranny

As lengthy night time trauma surgeries came to a close, nurses were often presented with a cafeteria-like  assortment  of wounds to dress. The deep stab wound on the medial thigh called out for iodoform packing which had a nice, sweet, iodine like scent. After the thigh wound was ram rodded  packed to the hilt with ribbons of iodoform, it was time to dress that monstrous midline abdominal wound. Tincture of benzoin would be applied to secure Montgomery strips in anticipation of frequent dressing changes. Montgomery strips spared the patient the pain of abrupt removal of adhesive tape; just loosen the ties to swap out ABDs.

This juxtapositioning of one scent (iodoform) on top of another (tincture of benzoin) often led to the creation of a completely new and frequently unsavory smell that I thought of as the third effect. Under this principle, when two smells are brought together, their individual effects are irreparably  altered  and potentiated into a novel, foul, lingering witch's brew completely  unlike that of the initial contributors. I think the technical name of this newly created stink fest was compound smells.

 The addition of residual  Bovie  smoke made  the foul smell penetrate every nook and cranny of  just about any object or person in it's path. Just as a syringe and needle transported medication to a site, the Bovie smoke delivered the stink as reliably as a  mailman.

Underlying scrub attire reeked of the compound smell when our impermeable surgical gowns were removed. I always thought of this as the diaper principle, because as long as the gown was intact the smell was relatively contained. Removing the diaper...OOPS...I meant surgical gown was another story as the foul odor homed in on awaiting olfactory senses like a cobra strike.

The best part of a  long night  in the O.R. was the beautiful sunrise over Lake Michigan as this usually signaled an end to the mayhem and the arrival of reinforcements in the form of day shift nurses. Fresh, kindly arriving nurses always stopped to help the  worn out, bone tired trauma victims and I'm referring to personnel-not patients.

One July morning, my friend Janess, bounced into the room as a case came to a conclusion to act as cheerleader and help us off with our gowns. I noticed her eyes and jaw roll as her eyebrows popped toward the top of her head as she assisted. She looked distressed - to say the least.

 The next day I thanked her for the moral support adding, "We must have looked pretty bad, Dr. Salmbow and I felt like we had been beaten to a pulp after that doozy of a case."  I'll never forget her immediate response, "It wasn't how you looked. It was how you both smelled."

Wednesday, September 9, 2020

Lights Out in The O.R.


Late night trauma surgeries were performed in  a parallel universe diametrically opposed to run of the mill, day-to-day, elective surgery. In place of the measured orderliness, gowned and gloved players were often blinkered by an all consuming bone tired, sense of fatigue that descended on the room like a choking mist. The emergent condition of the patient spurred a driving sense of expedience among the weary staff. Fatigue and the hurry-up nature of trauma surgery can have bad consequences no matter how well intentioned the staff, a lesson I was about to learn the hard way.

Delusional thinking, fueled by the infinite wisdom of youth, falsely told me that fatigue was a nonissue.  I sometimes played make believe, telling myself  that fatigue actually made me perform better by focusing on the things that really mattered.  I often felt like the grand wizard from the land of OZ. Hidden behind the curtain of mask and gown, I was just pulling on the strings and manipulating the levers to quickly load needle drivers and collect bloody sponge sticks.

My delusion of being fatigue proof was about to be shattered when the phone in the call room awakened me with an 0200 hour  emergency one early Sunday morning. The trauma gods always got restless on Saturday nights in Chicago. It was a harried nurse from the ER advising me that a hot trauma was being loaded unto the elevator for a nonstop flight to the 7th floor OR. A teen aged stabbing victim with volume depleting abdominal bleeding was our patient and the ER nurses had applied a scultetus abdominal binder in hopes of slowing things down. Not an encouraging prognostic sign.

The Lakeview  neighborhood was home to the Aristoctats, a youth gang that often meted out punishment with the blade of a knife. Firearms were thought to be unmacho and eschewed with youthful vigor. Not a bad concept in my book, as knife  wounds were more amenable to surgical repair. 

Although these kids looked menacing on the street, on the OR table they looked like the vulnerable little children they were. Their vicious behavior was often mixed with the typical adolescent sense of humor and more than one of them smiled as they related, "It's not how deep you stab your knife, it's how you wiggle it around."

I had just finished setting up my back table as the bleeding youngster crashed through the doors accompanied by the usual cast of lifesavers, pushing the gurney like it was a guided missile. Dr. Slambow had gowned and gloved himself while I quickly tossed  together a basic laparotomy setup. I was loaded for bear, complete with a boatload of Satinsky vascular clamps. My heart always did those little flip flops when an attending surgeon volunteered to gown and glove independently without the help of a nurse. Something unsettling was usually close at hand.

Dr. Slambow urgently announced that this was going to be a "Whoop-dee-doo" case. (His unique vernacular for an O.R. free-for-all.)  He  was going to start cutting  immediately without the anesthetist present. The patient was unconscious with a secured airway, but cases like this always hit me with  a feeling of raw, primal panic. Obeisance to sterile technique was tossed to that void behind the vacant ether screen and  questions like, ""What if he wakes up while we're inside his belly?; Can we stop the bleeding in time?;  Do I have all the instruments and supplies?;  What happens if that fenestrated sheet that I hastily tossed over the patient for a crude drape falls off?" I don't think there is anything more pathetic  when a drape falls to the floor exposing an unfortunate  little kid with a big hole chopped down the middle of his puny, little bread basket. Truly the stuff of nightmares, at least for me.

Things went better than expected. After Dr. Slambow carved a midline incision and  sucked out the blood things began to slow down. The inferior vena cave was intact along  with all of the other major vessels. The bleeding was brisk but confined to lots of superficial venous circuits and the spleen. After a quick splenectomy, the bleeding was pretty much under control. Dr. Slambow would clamp off a group of bleeders together and give the command to "meatball it" so the resident would tie the mess off in the shape of a little sphere. After making a few meatballs we were done cooking and the patient was doing well.

The O.R. room for trauma  was one of the oldest on the floor, selected because of its proximity to the elevator and nearby autoclave which although vintage, worked great for flashing a last minute instrument or preparing Thanksgiving dinner. We even nicknamed the old autoclave Mr. Yell N' Cuss because that's what we did when the door was unbolted and we got hit with a burst of steam due to a constipated venting mechanism.

During  the emergency trauma  surgery  I noticed, Clarence, our diligent housekeeper, peering through the porthole-like window in the door. I thought  that he was admiring our lifesaving surgery, but when the case was over, Clarence wheeled his mop bucket in with a perplexed  expression. "You folks 'spear- menting again?" he asked. "What do you mean by that Clarence?" I asked.  "You done that whole operation without the great big overhead lights tuned on!" Oh my gosh, I could not believe what we had done. I ran to the surgeon's locker room and updated Dr. Slambow on our oversight. In a tired voice he wearily explained, "Well the ambient lighting was pretty darn good and we weren't deep within a body cavity. Sometimes things work out in spite of our screw-ups."

Friday, August 21, 2020

Zomax Was an Anguished Analgesic

 "Now I know how Zomax works. My stomach aches so bad 
I don't even notice my fractured femur!" (GI  distress was a 
common side effect of Zomax.)

Pharmaceutical representatives also known as drug salesmen had free run of the hospital in the early 1980s and offered endless supplies of assorted trinkets and free lunches to all who would listen to their huckstering. A revolution in pain relief by an innovative new analgesic supposedly as strong as a narcotic, but non-addicting , Zomax, manufactured by McNeil labs was the hot new product in 1980 and the sales folks were chomping on the bit. Alas, a non addicting drug as strong as morphine was too good to be true.

Zomax  marketing was unique in that ordinary nurses were targeted by the vulture like drug salesmen. I suspect McNeil was emboldened by their success in marketing the anesthetic, Sublimaze, to nurse anesthetists. The American Association of Nurse Anesthetists even increased their case load requirement for anesthesia  students using Sublimaze after McNeil greased the skids for their product. 

Like Pavlov's dogs, every nurse was conditioned to always have a pen, scissors, and a watch. There was even an organization to recruit unsuspecting, innocent youngsters to the brutal field of  nursing known as Penwaciez which was named for the 3 things a nurse must always have in her possession: a watch, pen, and scissors.

 McNeil had this holy nursing equipment  triumvirate covered with a cheap Chinese made nurse's watch with a huge Zomax insignia on the dial. It did work well until the non-replaceable batteries bought the farm and  even had a nice white band. Most nurses were easily suckered into the corporate marketing gamesmanship because it was rare for anyone to give nurses  much of anything. Physicians were the traditional recipients of pharmaceutical company swag. Fancy golf club cover ups and writing instruments were popular. 

Zomax pens were  soon ubiquitous at every nurses station and were really nice upgrade  from the  cheap Bic stick pens we were raised on. Zomax emblazoned scissors were functional and were one of the first bandage scissors with blue plastic covered handles. We liked them a lot even though "Zomax" was emblazoned on any place available..

With nurses being the boots on the ground for Zomax marketing, McNeil came up with a battleground themed sales campaign code  named "Operation 111." The  notation represented the 111 million dollars the pharmaceutical company planned to gain in sales when the drug was introduced. A salesman summed the scheme nicely, "We're calling it operation 111. Now if that sounds like a war, well in our world of sales that's what it is." Sales memos were complete with a crossed rifle insignia as well as tanks and fighter planes. Fighting and battle themed analogies are all to common in health care, but the human body was never meant to be a battleground.

Nurses were bombarded with the mantra that 100mg. of Zomax was the analgesic equal to 10mg of morphine and there was no risk of addiction or tolerance. The centerpiece of a sales meeting with medical folks frequently featured  a small ornate punch bowl filled with single Zomax pills wrapped in colorful foil which glowed incandescent in the room light as a beacon in the fight (oops another war analogy) against the formidable foe of pain. We were invited to help ourselves to experience this breakthrough analgesic. I took one for low back pain and my stomach felt like a threshing machine left out in the pasture way too long. One dose was more than enough for me and I had a tough time figuring out which was worse my stomach distress or my back ache. 

Zomax pills were manufactured in the shape of a cute little house or cottage. The soothing green tint and image of a happy pain free home, sweet home were definitely alluring. As the big name pharmaceutical  houses began to loose patents to generic manufacturers  on their lucrative name brand  drugs the age of distinctive pill making was hatched. The most unusual of the bunch was a molded hollow scripted Valium pill. Roche had really out done itself with this design. The hollow fancy scripted "V" appeared to float in the center of the pill.

Despite the fact that most nurses were unimpressed with Zomax's efficacy, it did produce 15 million prescriptions in the first 2 years on the market. Trouble was on the horizon. In March 1983, McNeil announced the drug was being pulled from the market as a result of 5 deaths following Zomax ingestion.

It was discovered that one of the metabolites of Zomax caused an anaphylactic reaction in a small subset of users. Over time, especially with intermittent use, antibodies  accumulated  and caused the adverse reaction. For the time being the dream of a non-addicting analgesic was dead.

Sunday, July 26, 2020

Alice Was the Grand Poobah of the Operating Room

God bless dear old Alice until she eats you alive
I've posted many times about my all time favorite OR supervisor, Alice.  During these sometimes discordant  COVID times I miss her strong willed imposition of order and discipline. Alice was like a gas heeding the laws of physics.  She could fill the entire room with her  presence  by virtually wearing authority the way a meticulously attired nurse wore her blindingly white uniform. At the ripe old age of fifty something, command was hers because it was earned by spending decades in the boiling cauldrons of  operating rooms and their combative surgeons. She had dodged more flying instruments and administered more scores of painful knuckle bashings with a sponge stick than I care to remember.

Her repertoire of corrective interventions consisted of humiliation, infliction of pain and  shows of physical strength (Alice had the upper body strength of a linebacker on steroids.) Pain was usually delivered by a snapping blow to the wrist and/or fingers by the business end of a long sponge stick. The length of this instrument could deliver a blow of variable power based on where the fingers grabbed it to form a fulcrum. I usually sustained  the full meal deal for my transgressions with Alice grasping the instrument at the hinge and really winding up. Passing an instrument to a resident before serving an attending or counting sponges too fast or slow were typical transgression. Any break in aseptic technique was also harshly corrected.

While scrubbed on a long, grueling oncology case I began subconsciously doing hamstring stretches at my Mayo stand and lo and behold Alice strolled in. I knew I was in for one of Alice's lectures about how scrub nurses were supposed  to be uncomfortable and any unnecessary movement was a vector for the spread of that dreaded entity known as perineal fallout. Personal comfort and well being of her charges was as much  a priority to Alice as mindfulness was to Moe Howard of The Three Stooges. Luckily, Dr. Slambow saved my hide. As he was meticulously fileting a duct he said, "Alice can't you leave him alone. I can't do this without him." It really paid off making
your services indispensable to surgeons. I always thought of it as the best job security move a scrub nurse could make.

Alice's show of physical strength was also quite impressive. I've seen her single handedly transfer patients of her weight with the ease of an Olympic weigh lifter. She claimed that manually cranked beds were one of the best forms of upper body exercise and who would argue that point with a hulking Alice?

Alice made it a special point to mentor medical students in her own unique fashion. I knew what was coming next when one especially whiney student complained she could not see the operative field. Alice stealthily approached the novice from behind and ram rodded her lunch hook-like hands under the miscreant's arm pits and lifted her a couple of feet off the floor. She always followed maneuvers like this with a suggestion to utilize platforms instead of bitterly complaining.

Old nurses like Alice lived for nursing which was the alpha and omega to their life. Her idea of self care was a quick break for a Coke and a smoke. I never questioned Alice's dedication to her patients because it was her whole life.

Tuesday, June 30, 2020

The Emerson 3PV Ventilator (Circa 1964)

Gather round the ol' manually cranked  hospital critical care bed all ye Whippersnapperns and take a quick little quiz on the history of air becoming breath. What do you get when you combine a Westinghouse hot plate, an ordinary natural gas meter, a couple of AC delco automotive switches, a trombone slide, copper mesh and a V belt from a 1960 Chevrolet Brookwood? House them all together with an air pump in a Maytag washing machine cabinet and you have a pioneering ventilator known as the Emerson 3PV.
The control panel of the Emerson 3PV ventilator shows it's
Maytag roots. Does that black knob control the rinse cycle or tidal volume?
Although a high school dropout, Jack Emerson was an innovative young man. His 2 brothers were physicians and Jack being an inquisitive young man, asked them what they needed in their medical practice. At age 22, Jack bought a rudimentary machine shop at an estate sale and began manufacturing medical equipment. His first device was an automatic agitator for laboratory use.

The idea for a cost effective ventilator came to light when he heard one of the leading trauma experts of the day, R. Adams Cowley, complaining about the high cost and availability of Engstrom ventilators which were the standard of the day. Dr. Cowley received  a $100,000 dollar grant to research shock following trauma and had to spend most of it on expensive Engstrom ventilators. A cost effective ventilator would free up grant money for other vital research.

After some tinkering in his Cambridge, Massachusetts machine shop, the ever enterprising Emerson cobbled together a ventilator created from a hodge podge of ordinary and readily available household and automotive parts. His unique creation was the first ventilator marketed with a humidifier thanks to the hot plate and a water vessel.

 Modern ventilators have filters to prevent contamination, but Emerson's 3PV went a step further. He incorporated copper mesh in the return tubing. Copper has antimicrobial properties and actually kills bacteria and viruses by degrading the cell membrane or protein coat of the virus.

One thing missing from Emerson's pioneering ventilator was an electronic monitoring screen made by extracting toxic elements from the earth via a process that is probably slowly killing us. Old school practitioners were satisfied with watching the rise and fall of the chest and auscultating breath sounds to verify ventilatory function.

Simple devices like Emerson ventilators have an inherent beauty. One way or another we could all wind up flat on our backs with a ventilator chugging away in the background. While we are thinking, "Is this all there is?" an image of the ventilator blowing air into our wounded meatsacks appears in our peripheral vision. I know my emotional bandwidth will feel like it's been hit by a grenade if I see a computerized microprocessor controlled gizmo keeping me alive. Find one of those old Emerson's in the basement somewhere and I'll be smiling even with that endotracheal tube jammed down my old, foolish craw.

Thursday, June 4, 2020

Don't Crash That Gurney

It's all fun and games when pushing an old Gurney in a straight line.
Objects moving through space at high speed with a sense of urgency are prone to mishaps. No, I'm not talking about the space shuttle Challenger. I'm thinking of  old school hospital Gurneys which were also known as prams, trolleys, or carts. These unwieldy conveyances had tiny wheels which were really more like casters. Each wheel had an independent locking mechanism that was activated by stomping on a tiny lever.

Adding the weight of a patient to the cart  resulted in a very high center of gravity that conferred an inherent lack of stability. Vintage Gurneys had no counterweights in their base like the meticulously engineered transport devices present in today's hospital. Tiny wheels, poor brakes and a high center of gravity were the recipe for disaster.

Pushing an old fashioned Gurney in a straight line at low speed was a walk in the park. Speed, uneven terrain, sharp corners or heavy loads were complicating issues and relevant factors in Gurney crashes

Crack ups while rounding corners with a loaded hospital trolley had some of the same elements as motorcycle wrecks. I've had personal experience with both types of mishaps. High side motorcycle and Gurney crashes are among the most catastrophic because the patient I mean, rider is thrown off the vehicle ahead of the line of travel of the vehicle and risks not only the fall but the cart or bike then plowing into him. The cause of these crashes is suddenly regaining traction after sliding or skidding around a corner. In the hospital any type of liquid spilled on heavily waxed terrazzo floors is the most common hazard responsible for high side Gurney mishaps.

More benign crashes are of the low side variety where the bike or   Gurney simply skids around a corner and the conveyance  slides sideways gently spilling the patient. Thankfully, this is probably the most common type of Gurney crash and results in minimal injury because the driver is often able to contain the patient before he impacts the floor. Collateral damage from broken glass IV bottles is a common complication of low side wrecks. The Gurney driver is usually in an emotional hyper response  state with marked frontal lobe detachment  after one of these mishaps and hastily picking up glass shards can result in colorful displays. Please, don't ask me how I know about this one but the scars on my fingers are probably a dead give away.

Another factor in gurney wrecks is overloading or raising the center of gravity by personnel standing on the cart for procedures like joint reductions.  This graphic illustration of an intrepid emergency medicine physician is a good example of a high flying reduction. Hopefully the good doctor  returned safely to terra firma when the procedure was completed.

CPR perfomed on a rapidly moving Gurney always reminded me of a rodeo where a sudden fall is awaiting  the rider.  The nurse performing compressions (somehow it was always a nurse in the saddle) straddled the patient while maintaining the exquisite balance of a Brahama  bull rider as the Gurney surged forward toward more definitive care. Once again the center of mass is raised and the urgency of the situation always manages to exacerbate the propensity for a mishap. The nurse furiously doing chest compressions above the patient was the canary in the coal mine since she was likely to take a tumble before the patient fell. Caution usually prevailed when the Gurney driver sensed the CPR provider was about to take a tumble and slowed everything down befor a crash ensued.

Just like Gundam mech robots patrolling an infinite universe,Gurneys were just about everywhere in the hospital orbit. Gurneys always held a warm spot in my heart because I saw them as a symbol of unification and, oh boy,  we could sure  use some of that in these difficult times.. We are all going to take that last Gurney ride someday no matter what event terminates our earthly existence. Pay close attention to the next soul you see on a Gurney because they can show us all how to take that final ride with a dignified sense of peace. All bets are off if an OFRN like me crashes the cart.

Saturday, May 30, 2020

Is Nicotine an Effective Prophylaxis for COVID19 ?

If one cigarette chases away that pesky Corona virus will a dozen smokes 
improve your odds?  Further study needed.

Sunday, May 10, 2020

Writng on Bed Sheets

Spotless white sheets were perfect for bedside note taking

I'm a diehard aficionado of the esoteric little nuances present in hospital culture. Before  I begin writing (if you could call it that,) a Google search is usually in order. If the topic I had in mind fails to show, I have a winner. I googled nurses writing on sheets and up popped, report sheets, hand off sheets, ICU cheat sheets, and brain sheets. Ahh...perfect, nothing what so ever about nurses and doctors physically writing on hospital linen. 

Seasoned, well past their prime doctors and nurses scribbled on hospital sheets all the time in vintage hospitals. The usual weapon of choice was a ball point pen, but a fine tipped felt marker would do in a pinch. Pencils simply did not cut it for sheet writing and were usually in short supply. Some physicians are inventive and I have witnessed sheet scribbling done with a broken applicator soaked with  Zepharin  solution which added an artsy fartsy touch to their scribbling  due to it's bright reddish/pink color.

Anesthetists in the OR loved to keep track of things like units  of blood or dosages by scribbling hatch marks on the sheet near the patient's head. Procedures calling for an intraoperative position change would frequently throw a monkey wrench into linen record keeping systems. The vital hatch marks could all to easily relocate to an inaccessible position. Another SNAFU was keeping simultaneous tallies such as one for units of blood and the other for ventilator settings and then confusing one recording for the other. This could lead to strained conversations such as, "Those markings are for the units of packed cells and this one over here is for tidal volume...or is it the other way around??"

Orthopedic surgeons were frequent sheet scribblers and left notes for the proper positioning of traction equipment. Before Campbell's Operative Orthopaedics became the dominant textbook, closed reductions with traction ruled the roost. All those weights, slings, and pulleys just called out for sheet side illustration.

Pioneering total hip replacements were affectionately referred to as low friction arthroplasties and required complex post-op nursing care. Hemovac drains required constant attention to maintain patency and Pehr splints to prevent abduction generated lots of twiddling. Putting an octopus to bed would have been small potatoes compared to caring for total hips.

Arthroplasty patients were to stay flat on their backs for 7 days and could not be turned side to side to make a typical occupied bed. The arduous procedure entailed suspending the hapless patient over the bed while making the bed from top to bottom. Many students sought to avoid the linen change ordeal by carefully maintaining the condition of the bottom sheet. Miss Bruiser, my favorite instructor, was always one step ahead of her intrepid students. She would make a tiny mark on the sheet in an unobtrusive spot and then check back to see if the sheet was changed by observing for the absence of her mark. If the mark was observed after the student finished morning  care a tongue lashing and demerits were liberally issued.

An  unusual sheet writing adventure occurred in the OR just prior to an induction. One of the staples stocked in our break room was canned sardines which were opened by inserting a special key into a slot and unrolling the top of the tin. The discussion among the surgical residents was how to open a can of sardines without the key. A diagram of a sardine can was scribbled on the top sheet covering the patient and the explanation ensued. "The first step is to center a knife over the crease (in the can) and make a fist around the knife. Next strike the top of your fist until it pops open." The patient thought the good doctors were discussing operative technique and let out a shriek of horror. It took several minutes of explanation to restore order and calm the patient. You can never be too careful when patients are awake in the OR!

Thursday, April 30, 2020

Corona Pandemic Hits the Nursing Culture Reset Button

A few days ago, I passed by a nearly empty hospital parking lot. The  ER entrance was backed up into the street with all sorts of emergency vehicles  so there was  no shortage of patients. Sirens screamed in the background and the place was hopping.

 The lonely vehicles present in the parking  lot were of the Ford Focus or Toyota Corolla permutation. It wasn't too hard to deduce where the BMWs and Infinitis  with  their nursing themed vanity license plates had gone. The self proclaimed  elite members of the nursing academic/administrative office sitter complex were holed up in their fancy abodes while a dedicated contingent of bedside nurses were slogging it out  in a challenging environment with a crude hodge-podge assemblage of personal protective equipment.

The righteousness of the busy body administrators at the top of the nursing administration pyramid looks especially iffy when lowly bedside nurses lack even the most basic equipment for safe patient care. Bedside nursing is a tough, often thankless undertaking and a lack of support from above for necessary equipment exacerbates the misery. Bedside nurses have a long history of facing insurmountable difficulties. Florence Nightengale lasted only 3 years at the bedside.

In years past, charity hospitals with no concern for personal financial gain were the  institutions that sanctioned and preserved nursing culture.  No patient was ever asked for an insurance card or copay. Everyone was welcome and eligible for care rendered out of kindness without a preoccupation with remuneration or the bottom line on a spread sheet. There was a strong feeling that we were all in it together for a greater good.

Money is the sand in the gearbox of healthcare today and the end result is a public health meltdown. Reimbursement for heroic, expensive  procedures without improvement in  patient outcomes grease the skids in hospitals of today. This one for all and all for one approach does not meet the needs of a population that  is threatened by a pandemic.

It's no wonder countries with readily available healthcare not dependent on an individual's wealth or yoked to employment  are doing so much better. You cannot buy your way out of a pandemic with profit centered care. In the land of the free and the home of the brave we do have the very best healthcare money can buy and it's proving to be lacking. Folks here are lucky if they can even get tested for corona virus.

Nursing is about to change and nobody is sure of the "how," but people in crisis help each other. Caring  for those near us begins widening the care net for others. Maybe the nurse office sitters will emerge from behind their computers and help others because it's the right thing to do. Experienced nurse "rockstars" will rejoin the band and help young nurses at the bedside instead of soaking   funds from a vulnerable group of nurslings for overpriced video courses. Nursing is not about being an Instagram influencer or money changing hands. It's about helping others without concern for self.

Just maybe the pandemic will  transform nurse entrepreneurialism  with it's  inner impulses geared for money grubbing and influencer prestige to more charitable  values delineating our nursing lives - duty and responsibility to our patients. Preoccupation with over indulgent, extravagant, nurse "self care" be damned. We were meant to suffer along with our patients. Oh..and  don't let me forget, sometimes at the hands of our patients.

Thursday, April 16, 2020

Smokeeters Cleared the Air at Downey VA Hospital

That coffin sized brown box hugging the ceiling of a Downey VA Hospital dayroom was one of the most indispensable elements of the therapeutic milleu; a Smokeeter. This machine droned on with an intestinal rumble as it digested hazy nicotine laden air and expelled a mountain fresh breeze from the opposing end. In with the bad-out with the good.

Downey VA Hospital dayrooms had a dismal aspect about them with bars on the windows and the walls reflecting a gloomy potatoe-y  noncolor with brown gravy like nicotine stains in just about every nook and cranny. Worst of all was the unbearable effluvium of cigarette smoke combined with the scent of men densely packed into a confined area. A palette rinse and sinus lavage was mandatory at the conclusion of a shift. The place just plain stunk.

 The lighting cast a yellowish pall over the entire unsavory mess reminding me of a Foley bag long overdue to be emptied. Smokeeters were an acknowledgement of the foul conditions and an inadequate intervention to remedy the situation, a microcosm of the mental health treatment system.

Serious mental illness does strange things to folks. Emotional channels become intricately wound together so they coagulate and strangle each other. Recreational chemicals like nicotine, alcohol, and caffeine are some how involved in the masking of the pain induced by nervous dysfunction. One of the mantras often heard on the ward was, "nicotine cuts thorazine." Patients truly believed in the therapeutic effects of smoking and would go to great lengths to ingest as much nicotine as possible.

Smokeeters worked by electrostatic precipitation and the nicotine that adhered to the electrodes in the device required daily flushing. In an addition to an electrical connection, Smokeeters required plumbing to provide a water supply for routine cleaning. This maintenance operation called for twisting open the supply valve and making sure the drainage line to a utility sink in the laundry room was patent for the final journey to the sanitary sewer system.. A kink in the drain resulted a most unpleasant blowback of the toxic brackish nicotine concentrated effluent.

Curiously, there was always a contingent of anxious, over eager patients volunteering to flush the Smokeeter. I soon discovered their strange motivation one evening  while making ward rounds. I was perplexed to see a patient whose entire upper torso was contorted into the depths of the utility sink where the foul liquid from the Smokeeter drained.

As I eased his head from the sink a syrupy brown exudate covered his lips. He had been guzzling  the foul drainage from the Smokeeter.  "What in the world are you doing?" I asked. With an ear to ear grin framed in the brown nicotine laden sludge he replied, "I'm drinking nectar from the nicotine gods courtesy of the Smokeeter.Try a swig-it's like smoking a whole carton of cigarettes in one drag. WOW..what a rush." I declined and made certain the laundry room was secure prior to flushing the Smokeeter.

Wednesday, April 8, 2020

Downey VA Hospital Presents the Communication Book

It's been quite some time since I've written anything about the long ago shuttered psychiatric facility known as Downey VA Hospital. I worked there 1974-76 and recently discovered an interesting old tome in my basement junk pile extensive nursing archives.

Every ward at Downey VA Hospital  maintained a communication book which consisted of random comments by just about anyone involved in direct patient care. Relevant notes of significant findings during multidisciplinary ward rounds were among the more important recordings. The book was also supposed to contain notes of meetings with nurse officesitters and assorted busybodies, but any staff member with an ounce of sense steered clear of these crazy conclaves as a matter of survival. There is very little in the way of notes about meetings.   When one volume was filled it was tossed in the trash and a new one started. It just so happened that I rescued one of these delightful digests  from the dumpster and will share a few choice entries with my loyal readers. The entries provide a brief snippet into the life on a Downey ward. Patient names are all pseudonyms.

Insulin shock therapy was one of the more barbaric treatments administered to inpatients at Downey VA. The patient was given a significant dose of regular insulin and allowed to descend into shock The following note by a resident offers a valuable tip to ward nurses.
.All ward nurses should carry a round or two of Lifsavers brand candy with them in the event they have a patient that is slow to respond from insulin shock therapy. Each piece of candy raises the blood sugar approximately 10mg/%.

Mason, Wm -  admitted to drinking a pint of vodka under the water tower. Return to locked ward.

Ayers, Bob - No longer feels homicidal. Was under the influence of drugs and alcohol when he attempted to assault a psychologist with a dagger. Intelligent with insight into problems.

Farna, Kyle - Attempted to break into father and step-mother's home while on pass. Family does not want him back.

Grounds crew workers are busy spreading used grease and oil from the motor pool over the barrier wall around the building in an attempt to deter elopements. If you see a patient covered in grease you know what he's been up to.

Night shift- Please see  that patients remove pajamas before dressing in the AM

The roofers were a bit overzealous with spreading hot tar above the "C" ward dayroom. A small amount leaked down and burned the head of  Ronald Alt. Patient sent to Bldg. 133 for medical evaluation.

Jack Ray caught guzzling from a bottle of William's 'Lectric Shave. speech slurred with unsteady gait.

Cockroaches the size of a small Shih Tzu are taking over the  "A" ward dorm. Please be more careful about screening patients for foodstuffs before retiring to bed. Several partially consumed HO HOs were found under Harry Vonsickel's bed.

Ressary, Jorveit- Eating from garbage cans again and Linda is missing a box of paper clips. Abdominal flat plate X-ray requested.

Note from a nurse detailed from the medical building to cover a last minute call out on night shift: Unsafe to be in attendance in this building at any time!

Glen Rimes bit Thomas Reynolds on the calf without provocation. Since this is his second serious bite will refer to dental service for full mouth extraction.

Carlton Searing needs an ENT consult. He has been impacting his ear canals with Thorazine 200mg. tablets in a futile attempt to "stop the voices."

There is more, but I suspect you have read enough. I hope this has been a brief distraction from the Corona virus horrors. This pandemic sure has me concerned for all the whippersnapperns out there in harms way. I think of you often and hope that you are staying safe.

Wednesday, April 1, 2020

April Fools

"Yikes..that's going to be a challenging intubation. Get her to a trauma bay!"
A pseudo zombie got a jump start on April fools day tomfoolery when she presented to a level one trauma center in Michigan. Professional dancer Jai Fears was in the process of having gruesome make- up applied for a grisly photo shoot and was overcome by an acute panic attack

Maybe the artisan who applied the cosmetics did such a good job that it scared the daylights out of  Jai or perhaps it was an allergic reaction. Over use of make-up is never a good idea.  At any rate, the autonomic storm it prompted was enough to send her to nearby Beaumont Hospital.

As she hit the entry doors to the ER the ever vigilant staff expedited her transfer to a nearby trauma bay. While rituals of ACLS alogorithims danced through their heads a cursory assessment left them flummoxed. Quickly pressing 2 fingers behind the mandible showed a nice regular pulse and an auscultation of her chest revealed the lovely muted swoosh of active gas exchange without rhonchi or rales.

As the apparent acuity of the victim rapidly vamoosed, the trauma team's unconsciously formed tableau dissipated  faster than a snowball on the 4th of July. The hollering that ensued from the trauma bay was not the typical shout out for life saving measures. A shriek more akin to that of an elderly matron who had just been scammed out of her monthly Social Security check reverberated about the trauma room. "My God," hollered the duped trauma surgeon. "It's all just make up."

In a public relations gambit the hospital released the following statement: The emergency room is not a place for fun and games. They see many patients with severe medical issues where lives are at stake. doctors and nurses need to be able to focus on those patients with true emergencies.

In a strange torque of therapeutics, I wonder if the young patient was cured of her panic attack by transferring her feelings to the trauma team.

Wednesday, March 18, 2020

Getting to the Bottom of the Tidal Wave Enema Story

The trinity of nursing care for big invasive abdominal surgeries included scultetus binders, Montgomery straps, and last, but certainly not least, tidal wave enemas. I briefly mentioned tidal wave enemas in a previous post and I received an email asking about the unsavory details of this backward procedure. I just love esoteric, little known nursing procedures and  nothing came up when I googled tidal wave colonics. So, an idea for this  post about this bowel ballooning buffoonery was born

Before the late 1960s enema administration apparatus consisted of a 2 liter metal can with a tapered spout at the bottom that mated with a 2-3 foot length of opaque rubber tubing. This tubing was connected to a nozzle that ranged  in size from a small straight length to a longer tapered instrument that resembled a bandicoot's snout. Small straight nozzles were useful in uncomplicated cases, but it was tough to beat a large tapered nozzle when retention problems caused unpleasant blow backs. Once a tapered nozzle was snugly ensconced within the leaky aperture, it tended to stay there, putting the brakes on the flustering back blow.

"The only tidal wave I wanna see better be in the ocean."
Rank had privilege in hospital  nursing and full fledged RNs had the benefit of an IV pole to suspend an enema can above their anxious patient awaiting the hydraulic highjinks. Student nurses were mandated to hand hold the enema can at the prescribed height; no easy feat with a fully loaded 2 liter can. That loaded can got heavy rather quickly unless you had the arm strength of Miss Bruiser, my favorite instructor.

 Enemas could be embarrassing for both patients and student nurses alike with Miss Bruiser's running commentary about our lack of arm strength. One of her favorite lines as we struggled with the heavy enema can was, "Is the responsibility of nursing care WEIGHING HEAVILY UPON YOU?" Of course it was and in more than one way.

The  transition to disposable enema sets with crystal clear tubing  illustrated  an interesting phenomenon. While struggling to hold the clear enema  bag airborne, an observant nurse noted the oscillation of the infused solution rising up and down with the patient's respirations. As the enema was nearing completion, expansion of the chest pressurized the colon causing the fluid level in the tubing to rise. Exhalation resulted in a marked descent of the fluid level.

Hand held enema bags and the graphic illustration of the  to and fro flow of the solution provided one of those rather profound "EUREKA" moments in nursing history. The tidal wave enema was born. Nurses soon discovered that any enema could be super charged, so to speak, by aggressively raising and lowering the enema bag while the solution was flowing in. Suddenly raising the enema bag to it's maximum height from a level which was sometimes below the patient produced dramatic results. Patients often complained bitterly of cramping during the peak of the tidal wave, but the end results were often impressive in restoring normal bowel function.

Peristalsis, the progressive wave like movement of the bowel was frequently brought to a halt by old school open abdominal surgeries. When the surgeon noted an absence of bowel sounds during the post -op period, action was required. An order for TWE was written. A plain old TWE order was for the run of the mill tap water enema. A TWE order  with wavy lines scribbled alongside was a directive to bring on the big guns of the tidal wave flush.

The proof was in the pudding with tidal wave enemas which worked wonders in restoring normal peristalsis. They really did the trick.

Sunday, March 1, 2020

Wagensteen Suction - Elegantly Simple Without Electricity

Wangensteen suction in action during the 1930s. The water level in the top bottle
drains by gravity into the lower bottle to the left generating negative pressure. 
A glass drinking straw inserted to the top of the top bottle conducts suction to the patient.

Whippersnapperns  don't give a second thought to the equipment  needed  to suction a patient. Intermittent Gomco, straight tracheal suction, or low pressure Wangensteen, just plug that suction  regulator into the handy dandy wall socket and go to town. Like everything else in today's high technology world, handy dandy wall suction is a convoluted, complex system masquerading as something  simple. Hospital  centralized suctions are anything but simple. Bright  young whippersnappern are  tapping into an over-engineered, overpriced  pipeline connected to hidden pumps, vacuum reservoirs, traps, filters, regulators, sensors, and alarms. I shudder to think of the resources required to maintain this complex hodge-podge of exorbitant  components.

There is an easier way to maintain GI  suction on  a post - op patient suffering from a paralytic ileus. I'm not talking about those plug in "portable" machines that weigh 1/2 as much as your patient. There are few pieces of medical equipment that generate a more annoying buzz saw  noise than portable suction machines. A bone saw in action might sound worse, but at least the patient does not hear it.

Electrified  suction machines in action remind  me of the time a yellow jacket flew inside my full coverage motorcycle helmet while cruising on Lake shore Drive. You can't turn off a buzzing suction machine when suction is necessary and you can't remove  a helmet in heavy traffic. Meanwhile that persistent  buzzing is driving  you  nuts.

In old diploma nursing schools, instructors like Miss Bruiser, my all time favorite, frequently said that we should learn how to do something "just in case."  Students were required to "learn" how to smoke cigarettes so we could better relate to psych patients. Other various hacks were part of the "just in case" curriculum like using sterile finger cots to perform procedures in the event we ran out of gloves.

We were also taught how to construct a do-it-yourself Wagensteen suction using 3 large glass bottles, rubber tubing and a glass drinking straw "just in case" of a power failure. Old hospitals had no backup power supplies.  The  principle underlying manual Wangensteen suction was Boyle's gas law which stated there was an inverse relationship between pressure and volume. As the water flowed out of the glass bottle on top, a negative pressure was created by the increase in size of the void within the bottle. A glass drinking straw inserted through a hole in the stopper served to harvest the vacuum created by the falling water

The clothesline pulley on top of 
the stand facilitated bottle exchange
There were a couple of ways to suspend one large glass water filled  bottle above another. The easiest way was to hang it  with a canvas sling suspended on the rail for the bedside curtain, but this required lifting the bottle on the floor when it had filled upon completion of a cycle. A big glass bottle filled with water requires the arm strength of Magilla Gorilla to heft back into position.

 A more elegant system involved a pole outfitted  with an ordinary clothesline pulley which according to my notes could be obtained at any hardware store. A length of rope about 7 feet long was attached to each bottle and threaded through the clothesline pulley  assembled at the top of the pole.When the bottles needed exchanged after draining, a nurse could swap their position  with a  not so gentle tug on the connecting rope. As the bottles made their up and down journey continuous suction was maintained as water continually drained from top to bottom. Dr. Owen Wangensteen, the inventor would have been most proud.

There is something to be said for simple devices cobbled together with a nurse's two hands. Wangensteen suction was a breakthrough discovery in the 1930s that reduced operative mortality from 44% to less than 20%. Owen Wagensteen should have received the Nobel Prize for medicine in 1931, but they gave it to someone who discovered an esoteric enzyme. Simple, silent devices like this suction engender those immersive, visceral feelings old nurses experienced from directly helping someone feel better even if the nurse  was too busy yanking on the clothesline to take a break for a Coke and a smoke.

Friday, February 21, 2020

The Disappearance of Needle Stylets

A thing of beauty is a joy forever. A stylet at home in the bevel of a needle

New fangled disposable injection needles with their cheap looking plastic syringes were just beginning to show up on wards at the beginning of my nursing journey. I just love that "journey" vernacular so common in today's healthcare lingo. See, I can talk just like a whippersnappern if I try really hard.  Anyhow, old school nurses had lots of laments about disposable equipment of any permutation because it  went against the grain. We were taught to reuse just about everything. Throwing away Monoject disposable syringes was bad, but the elimination of stylets was even worse.

Reusable injection needles always had a stylet running the length of the needle bore that terminated at the beveled business end of the needle. Whippersnapperns might start out their day by logging on to a computer, but their predecessors started out by sharpening injection needles. The stylet was a vital component to reusable needle maintenance and sharpening. Ramrodding a stylet through the needle served to clean the bore of any residual debris. When sharpening was completed the stylet served to clear the needle bore of any residual micro shards from the grinding process.

Stylets also served as a template to maintain the appropriate angle of the needle bevel during the sharpening operation. Minimalist minded nurses could sharpen a dulled needle on an ever present match book striker. Needle sharpening was one of those rare instances when a nurse was off her feet and the matchbook was a cue for a quick smoke. Smoking and sharpening needles went together like peanut butter and jelly. Mechanical devices for needle sharpening were most commonly hand cranked gizmos where the bevel of the needle was rocked back and forth by a cam while pressed against a rotating wheel all the while an indwelling stylet maintained the bevel angle.
Every nurse's station needs a needle sharpener

Biopsy needles with their very shallow bevel always have a stylet as a stiffening mechanism and as a control over the cored tissue sample. When sampling liver tissue from an obese patient the stylet is left fully engaged during it's journey ( I go again with that "J" word) through the subcutaneous tissue. When the final liver destination is reached the stylus is withdrawn to snatch a core of tissue. Stylets are also needed to expel the cored tissue from the biopsy needle.

When performing spinal taps or removing fluid from a body cavity, the stylet is also necessary to control the flow of fluid. No stop cock can halt the flow of fluid through the lumen of a needle like a trusty stylet.

Inventive nurses discovered that stylets have  unintended uses that have loads of utility. When the hinge screw mysteriously disappeared  from my ever present eyeglasses a quick fix was needed. I discovered that a stylet from an 18 gauge needle was the perfect diameter to fit the void left by the missing screw. With the stylet in place, it was a simple matter to bend it in the shape of a horseshoe with a needle holder. A perfect fix. It was also common knowledge that a stylet was the perfect instrument to pierce ear lobes for those nurses that liked to decorate themselves with earrings.

It's nice to know that stylets have survived into the present age with spinal tap and biopsy needles, but once upon a time every needle worth it's jab had a stylet.

Wednesday, February 12, 2020

John R. Brinkley - A Pioneering Transplant Surgeon

Dr. Brinkley in action. Just say BAA
The recent outbreak of Corona virus piqued my interest in past outbreaks so I began reviewing the events underlying the great influenza outbreak of 1918-19 and lo and behold the strange career of Dr. John Brinkley came to light. This man was no ordinary surgeon, in fact his only medical credential was a $500 phony diploma he purchased from the Eclectic University of Kansas. His skills as a pitchman exceeded his surgical skills by huge margin.

Dr. Brinkley, a physician of questionable  competence, to say the least, began his career treating victims of the great influenza outbreak. On  a house call to a farmer named Stittsworth, he found the hapless patient  complaining of impotence, Brinkley had an epiphany that would make him a millionaire. Eyeing the proud testicles of a nearby penned up Toggenburg goat he remarked, "You wouldn't have any tumescence troubles down there with one of those goat glands in you."

The troubled farmer replied, "Well why don't you just put one of them goat balls in me?" To an eager surgeon, the external anatomic character of male genitalia is like dangling the keys to a Pontiac Trans Am before the eyes of a hot rodder. All that exposed  anatomy is just begging to be incised, dilatated, or ram-rodded with a scope.

In 1920, the eager surgeon went to work on the readily accessible scrotum and implanted a goat testicle in the impotent Farmer Stittsworth. There was no neurovascular connection or fancy anastomosis to the vas deferens; the transplanted gland was popped in and left to hang there like a drunk dangling from a bar stool. A rubber crutch would be more functional.

Soon the farmer was singing the good doctors praises albeit a few ovtaves higher about his new found libido. (The placebo effect of sham surgery is even greater than it's pharmaceutical counterpart.)  When the farmer's wife gave birth to a healthy baby boy who was named after the good doctor, word spread far and wide. Large groups of forlorn men showed up at Brinkley's office eager to pony up with the surgeons goat gland  implant fee of  $750 ( equivalent of $10,000 in today's money.)  Exploiting desperate patients like this was a foul ball of the highest order, but Dr. Brinkley was a master of self promotion with little regard for the welfare of his patients.

What he lacked in respect from the medical community he made up with acquisition of material goods which included a fleet of Cadillacs, an airplane, a yacht and an opulent mansion. Before his medical license was revoked in 1923 on the grounds of unprofessional conduct he performed nearly 16,000 goat/human xenographs.

The man who fittingly sported a goatee throughout his career developed a deep vein thrombus necessitating the amputation of his leg in the early 1940s. His handicaps did little to slow down his huckstering spirit. Perhaps the inspiration of sacrificing goats on the surgical alter led him to the study of theology. His dreams of launching a mega church died with him.

Karma seems to catch up with just about everyone. This gland grafting gooofus died penniless.

Friday, January 31, 2020

A Heminephrectomy and a Stock Tip

I really, really, disliked scrubbing in surgeries that involved partial removal of a kidney. The positioning of the patient  on the OR table involved a number of hacks worthy of a MacGyver  Award.  A side lying position, with a break in the table at the inferior thoracic level was a worthy challenge to maintain with sand bags, chunks of foam egg crate mattress, bean bags sans the beans, rolled up surgical towels, and long lengths of 2 inch adhesive tape which were all  included in the patient  placement armamentarium. Anesthesia was worried about compromised gas exchange with gravity pulling abdominal contents downward on the diaphragm while nurses fretted about a tumble from the table.

Once the procedure was underway the nephrology surgeon began his solemn narrative of all the challenges involved; too much monkeying around near the adrenal glands atop the kidney could blow blood pressures sky high, the renal artery had lots of anatomical variations so it was tough to figure out where it ended and the arcuate artery began, and finally, modifications to the fascia were required to hold what was left of the kidney in place. Old school surgeons just loved to hang the crepe before a difficult procedure because then even a bad result might look OK.

After a lengthy discussion of renal pyramids and poles (I could never make sense out of the difference between the two,)  the surgeon excised the pathologic portion of the kidney that most commonly  harbored a benign tumor or cysts. At least most of the partial nephrectomies offered a cure.

Now the fun part for the hapless scrub nurse begins.  To seal the exposed surface of the incised kidney, miniscule pea sized chunks of fat are sutured in place. This time consuming task requires lots and lots of sutures and by the time about half the job was done my bony fingers were aching from loading endless needle holders.

Fatigue can be the impetus for saying stupid things and my preternatural foolishness didn't help matters as I muttered, "Why don't you just throw a couple of stitches around one big hunk of fat and be done with it."

The surgeon gave me one of those churlish looks and quickly changed the subject to one of his particular areas of expertise, stock marked tips. According to this  financially savvy surgeon,  Abbott labs was a sure fire winner and a must buy stock because the share value had been temporarily  eroded by a contaminated IV fluid SNAFU. As soon as the problem was corrected, the share value would soar. As  he enthusiastically  expounded about this must buy stock, the old Airshields ventilator pumped a potent halogenated anesthetic agent into the deeply obtunded patient.

The case proceeded along uneventfully and I helped gently transfer Mitch, the still anesthetized patient unto the gurney. A nurse was always with a patient like this to maintain an airway on the  open road to the recovery room.  I was carefully making sure his silver metal oral airway (no cheesy plastic throwaways like those in current use)  was in place  as I  guided his mandible forward to keep him breathing.

With unexpected gusto Mitch suddenly aroused, pushing my hand away and yanking out that pesky airway. His first words upon regaining consciousness? "Call my broker. I want in on some of that Abbott Labs stock."

Monday, January 13, 2020

Were You Ever Afraid of Contracting Somthing From a Patient?

  I was almost infected with greed fever
Someone on Quora asked me if I was ever afraid of  contracting something from a patient and a plague of answers began swirling around  in what's left of my ancient cognitive vault. Hmm...was it Hepatitis C, influenza, or step throat? Well, no, something else suddenly came to mind and it did not involve a bacterium or virus. It was pure unadulterated greed. Something all too ubiquitous in today's healthcare world and as contagious as the most virulent virus.

As a novice nurse one of my patients was confined to a self imposed isolation in a private room on one of the nicer hospital units. He had a high forehead with bushy eyebrows and  a prominent jaw line that did not betray a hint of weakness or doubt. He had a definite presence about himself.  His name was Ray Kroc and the McDonalds restaurant empire was his brainchild. Billions and billions of burgers meant big bucks and a lifestyle ordinary folks could only dream about.

 The reason for his hospitalization was weight loss. One too many BigMacs had taken a toll on his waistline and rather than purchase a bigger belt he checked into the hospital for a carefully supervised dietary regimen. Rich people do strange things and a  huge monetary donation reserved his hospital bed. Money can buy anything.

He was very friendly and interested in the workings of a big city hospital. After hearing a few of my tales about hospital experiences he came up with a grand  proposition for me. His business sense told him there was a pent up demand for male nurses and not all that many nurses carried XY chromosomes. According to him, a nursing agency for male nurses could be quite lucrative with careful marketing.

I looked down at my lowly Timex watch and compared it to the gleaming Rolex on his fat wrist. Hmm, I thought, maybe I could swap my Raleigh Super Course bicycle for a motor vehicle. I was just about to contract a very bad case of greed as dollar signs danced in my head.

Then I came to my senses. Greed suppression was an integral component of nursing education. Nurses weren't supposed to have much of anything. The ANA code of ethics even prohibited RNs from endorsing any commercial products. All the nurse influencers of today would be in big trouble as money making was definitely not in the cards for a nurse. Nurses were supposed to be selfless caregivers often at their own expense.

I began to think of all the experiences I would miss if I were worried about my balance sheet instead of the names on a Kardex. Being well off financially disconnects you from the day to day activities  that define the experience of everyday folks. I would have missed out on the warmth and caring shown to me by a homeless person in the ER  when he taught me how to keep warm in a Chicago winter by wrapping layers of newspaper around my extremities. I hoped I would never need the skill, but the kindly way it was explained to me stayed with me. I can still see his warm smile.

When nurses leave a  patient's room after a failed code they seldom look back. Somehow I managed to corral my greed impulse and never looked back. An agency for male nurses sounded like a dubious proposition and, besides,  I always thought of myself just as a plain old nurse. No gender qualification needed.