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.