Friday, October 29, 2021

O.R. Poem

 Find me a place

where the overheads shine bright

and the hollering gives fright.

Find me a suture that closes just right

and a patient that awakes without

a pathology that gives a great fright.


I remember a young scrub nurse

hiding from the world.

Find me all these things

And that is where you'll find me.

Thursday, September 9, 2021

Needle Gauge Sizing Explained

Hmm...It's easier for a camel to pass through
the eye of a needle than avoid Miss Bruiser's
painful ministrations!

Sizing of most medical implements made sense, gloves were measured by running a tape measure across the mid section of the hand, the measurement in inches was the glove size. Catheters were measured in Fr. and one French was equal to 1/3 mm. a 32 Fr. catheter was most definitely larger than a 26 Fr.  Endotracheal tube diameters are measured in simple millimeters. Nice and straightforward for foolish folks like myself.

Needle caliber sizing is a horse of a different color. Miss Bruiser, my favorite nursing instructor insisted that physical discomfort (pain) was required for a  student nurse's proper education, so when she gave us a choice of needle size for injection practice sessions it was obviously a trick question. Her beady little eyes shifted like a pinball in play when she asked, "Now which size needle would you like me to use on your tender deltoid when I demonstrate an intramuscular injection technique, A 16ga or a 22ga?" Well a 16ga sounded like the best choice because the logical thought process would deduce that 16 is less than 22 so the needle would be of a smaller caliber  and hurt less when harpooned by a towering Miss Bruiser. Well we were dead wrong and had the bloody aching arms to prove it.

 Every nurse knows that the smaller the gauge number, the bigger the needle, but how in blue blazes did this come about? Up until the dawn of the 20th century there was no standard for needle size other than puny, medium, and jumbo. Thanks to the British wire industry things were about to change.

Needle sizing is a direct descendant of ye ol'  Birmingham wire gauge which was widely used as an industrial standard in merry old England. According to this standard a #1 gauge wire had a diameter of 6.26mm  which was used as a starting point for the measurement of wire diameters. The number of wires that could fit in this defined area was the gauge. It's easy to see that for an area of 6 mm diameter (or there abouts) to accommodate 25 strands of wire they would have to be much, much less of a diameter than say #12 gauge to occupy the exact same area. The greater the number of wires ram rodded into the same sized area, the lesser the diameter. So that's why the higher the needle gauge, the smaller the diameter of the needle. I'll take getting harpooned with 27 gauge needle over a 16 gauge any day!

As time went on, the Birmingham wire gauge was further improved and made more exacting for the sizing of medical needles by meticulously defining the steps between the different gauges, for 7-14 gauge needles the size increased by .025 mm for each larger size needle, to 19 gauge the size increased by .013mm, and lastly with the small needles size increased by .0064 mm. When you think about tiny needles, just a small decrease in gauge can make a really big difference so that's why the steps between gauges are so small.

The year 1955 was an occasion for old nurses to celebrate. Roeher Products introduced the disposable Monoject syringe which allowed for a choice of needle size which was independent of the syringe. The color coding of needle sizes was born and every nurse knew a bright  red needle guard signified a 25 ga needle and a blue guard meant a 21 ga. I never could figure out why a 20 ga needle and a 25 ga had the same reddish  color, although the 20 guage was of a very light shade. 

The needle that gave every novice nurse the tremblors was not a monster 16ga, but rather the mighty 2 inch long.Imferon needle with the purple guard. I shudder to think of the misery Miss Bruiser could inflict with one of these monsters as it bounced off periosteum with a loud clunk followed by an ear splitting shriek!

Tuesday, July 6, 2021

Portrait of the Scrub Nurse As an Artist


Yep...I hijacked the title to this post from that great Irish literary genius, James Joyce, whose near blindness probably enhanced his writing ability by excluding extraneous stimuli. Operating rooms, on the other hand, have loads of stimuli, but they are certainly nothing to look at. The stark, tiled walls and hard unforgiving terrazo floors almost call out for beautification and just about anything  aesthetically pleasing is a huge step forward.

Scrub nurses have a variety of artistic media available to them right on their Mayo stand and  each individual has their own style. My attempts were crude compared to some of the Rembrandt like efforts of today's youngsters.  I'll give a brief account of my lame efforts and then morph into some truly beautiful work by contemporary artists scrub nurses and scrub techs.

My initial  artistic endeavors involved cutting various designs in my sharps bag which was really nothing more than a plain old waxed brown paper container. A straight Mayo scissors was the perfect cutting tool and I began with profiles of hearts on the sides of the bag. After all, any operating room could use a little more love.

 As my skills advanced, flowing scalloped edges inspired by the Rococo school of art adorned the top of my sharps bag. Ratcheting a needle out of my driver and dumping it  in the sharps bag had a new found feeling of artistic fulfillment as I watched it drop past those lovely scallops. Simple pleasures for simple minds.

In the 1970's the hottest new innovation in surgical draping was a material called Vi Drape which was nothing more than a sheet of polyurethane with an adhesive backing. After prepping, a sheet of Vi Drape was applied to the skin and the surgeon made his incision smack dab through the Vi Drape. No cutting corners here!  The idea was to isolate the skin from the surgical site to prevent infection. Vi Drape also provided a sterile platform for plopping an organ down on it without fear of contamination.

Before the skin sutures were thrown in place, the Vi Drape was pealed off and unceremoniously tossed in the ever ready kick bucket. While removing a used Vi Drape from the bucket, I noticed how the overhead lights illuminated it, creating a stunning design. The center of the drape that had been incised glowed like a twinkling star and it was surrounded by a lovely pinkish glow thanks to the retained Zepharin prep solution. Pink tinged Zepharin was certainly more pleasant to look at than the yucky brown Betadine prep which is so ubiquitous today. The speckling added by blood droplets and minitissue chunks highlighted the brilliant center of the design.

How could I display this masterpiece? The answer was no further than an unused light box used to view X-Rays in our break room. I archivally preserved my masterpiece by sealing it in unused Vi Drape and secured it to the light box. There was mixed reaction from my fellow nurses. Some loved it while others thought I was nuts. Art is supposed to get folks talking and asking questions so I fulfilled my purpose.

Now for the good stuff. Orthopedic surgery provides whippersnapperns with a great media for sculpture, namely bone cement. Marjorie RN at bloodgutsandcoffee on Instagram has some really great work displayed on her posts. The sample on the left has even been enhanced with what is apparently Methylene blue and a surgical marking pen. How cool is that.

Orthopedic surgery also provides for brief "time snacks" while portable X-rays are taken. What a perfect time for artistic endeavors. Every moment of pseudo leisure can be put to good use in the OR. Sculpting with bone cement is surely lots more fun than gazing at that yucky blood/bone chip slurry reposing at your feet.

When I was a youngster, surgical marking tools were limited to a tooth pick and a medicine glass filled with methylene blue. To mark an area the tooth pick was dipped in the dye and dabbed in place, a crude method which did not lend itself to intricate designs or sketches.

Today, it's a different story. There are all sorts of surgical marking tools that are not only useful in marking patient's skin, but also function great as a means of artistic expression. The canvas is a surgical towel or mayo stand cover. Surgidoodle on Instagram has some of the most intricate and lovely designs I have ever seen. This "circle of time" is one of my favorites and the way the tips of a pair of Babcock clamps  point directly to the serpents head is really spooky. Maybe someone is about to snag that serpent in the jaws of their Babcock and free that omniscient eye lurking in the center. Who knows!


Surgidoodle also has a simply elegant work on her Instagram page titled SHARK ATTACK. You won't get any of that artsy fartsy sillyspeak from me on this magnificent work. It's simply beyond description. The contrast between the stark line drawing of the attack with the severed lower extremity and the ambiguity  of the bloody mottled background make us consider the complexly entangled lives we lead in the OR. Heavy stuff, indeed.

Shark Attack has all the elements of  a quintessential work of fine art: A life altering event frozen in time, the sometimes random element of trauma infliction, how trauma dissociation is based on evolutionary survival behavior, how invalidated trauma generates silent internal screams,  and an inquiry of the survivability of traumatic injury. The assorted components cohere into an elegant whole that transcends the harsh, unforgiving environment of the tiled temple. Compared with the wan, self involved art (I'm thinking of the Andy Warhol Museum here in Pittsburgh,) which strain for undeserved and unearned profundity, Shark Attack is in a class by itself!


If I have piqued your interest in operating room artists here is a listing of some of the ones I enjoy on Instagram.

ortho_artistry features some very nice bone cement sculpture work

operatingroomart shows us some lovely abstract images created by a urologist with a cystoscope and gel.  Absolutely more colorful than a meatotomy!

surgeryboxcartoons shows what can be done with a surgical head covering container.

And of course surgidoodle which is my all time favorite. Thanks for inspiring me to finally get around to posting something. 

.

Tuesday, June 15, 2021

Downey V.A. Hospital Signage

Dr. Scott Mastores is  a graduate of  Chicago Medical School which was constructed on the Downey VA Hospital grounds shortly after I quit working there. Thankfully, he rescued this sign from the trash and was kind enough to Email it to me to share with all those interested in Downey VA hospital.

There were lots of interesting signs at Downey and this one was on prominent display in the lobby of most of the buildings. I don't think many of the patients bothered to read them and enforcement was lax. Most of the nurses at Downey would much rather have patients lying on the floor than fighting on the wards.

Just about every ward had a pool table and a sign that stated throwing pool balls was prohibited. I broke up an unusually nasty altercation where two patients were bayonetting each other with pool cues and was promptly advised there was no signage prohibiting this activity. "If we can't throw poll balls at one another, what are we supposed to do?" was their response.
 

Saturday, June 5, 2021

Boo Hoo

 Lots of views, but no comments and I'm stuck in a terrible brain freeze. I'm open to any suggestions for a post. Thought about an updated nursing awards post if I can crawl out of this cognitive abyss!

Saturday, May 22, 2021

Stick 'Em Up

 

 
                                    "That's the last Bicillin shot you're ever going to give!"

Monday, May 10, 2021

Professional Adjustments Class

"All right it's time to break up into groups of two. The smokers will demonstrate
 to the non-smokers how to light up and inhale a cigarette. Return demonstration
is required and I don't want to hear any of that gagging or coughing!"


 Every  hospital based nursing school had a class motto. In my school where Miss Bruiser, my favorite instructor presided, the old adage was;  A journey of a thousand miles begins with a single step. Initially, we thought  this slogan referred to breaking down an arduous accomplishment into simple steps to achieve our final goal of receiving  that coveted pin, but after nearly three brow beating  years and constant harassment our assessment shifted. A thousand  miles was along way from home and diploma nursing education transported us to a bizarre new world with strange new rules and customs. Professional adjustments was our very last class and we were going to learn how to conduct ourselves as nurses in this strange new land.

Miss Bruiser, regal and pompous like a queen, strutted around the classroom with her cap serving as a crown. Her edicts were delivered sternly in the same tone one uses to discipline an unruly child or train a dog. It almost felt like she was deploying little bombs in the back of our heads, set to detonate sometime in our future nursing life.

Miss Bruiser  harshly intoned, "The first order of business is going to be the  use of tobacco products. Every nurse should learn how to smoke cigarettes in order to connect and relate to patients, especially on the psych wards where it's an absolute must and I don't want to hear any of your lamentations or sniveling. If the smoke bothers your throat do what I do, smoke menthols or don't inhale!" ( Hmm...I wondered if Bill Clinton was a nurse in a previous life, that "don't inhale" business sounds all too familiar.)

The finer points of cigarette smoking included the proper use of ash trays and cautions about letting the ash get too long. Never aggressively flick an ash or use a cigarette to gesture which might give the wrong impression. I never could figure out the rationale for those two rules, but like many other things, there were many mysteries in nursing. The rule about holding a cigarette between the index and second finger made sense. In Chicago only gangsters held their cigarettes between the thumb and index finger.

The opening lecture about smoking set the tone for the entire course. It didn't much matter what your personal feelings or wants entailed, you were going to be a nurse and it was way too late to question the rules. We got what we set out to get and that was the only thing that mattered.

Money was always a hot button issue in diploma nursing programs as alluded to in a previous post, we were not even allowed to carry money because it simply was not needed. The school met all your needs from food, housing, books, and uniforms.

 The third rail in any nursing job interview was inquiring  about salary or compensation. Instant death to anyone foolish enough to ask. Nursing was not meant to provide practitioners with financial stability, but you won't ever be broke and you do eventually learn to navigate desperate situations with your pride intact.

 Asking for or charging other nurses money for  just about anything will rot your pride. I think that's what makes me cringe when I hear whippersnapperns asking for payment for online education or commercial products. I realize we are in a brave new age but I'll never get used to nurses asking other nurses for financial compensation. It makes me very anxious because it makes me feel like bad things are coming and I can almost hear Miss Bruiser's howls in the background.

Working at a charity hospital highlights the unfairness in the world and careers that earn a good bit of money were seen to exacerbate the inequalities in society. Despite the financial precarity of a nurses salary there was a unique kind of ecstasy in helping those in dire straits. The overly productive lifestyle of folks with money begins to appear pointless. So instead of a class on retirement planning or investing we were conditioned to live with very little.

Although diploma nursing school did have a cognitive constipating curriculum, there were life lessons if you could see past the smoke screen. Miss Bruiser's notion of sacrificing every thing for patient care was not sustainable. A nurse's notion of self care has to extend beyond a break for a Coke and a smoke. I think whippersnapperns have a much more realistic notion when it comes to self care.

The lesson that really stuck with me was that it really doesn't require much money to generate happiness and well being. Some of my happiest days were spent in a crumbling third floor apartment with my Raleigh bicycle parked in the hall.

Lucky for me, I really never got the hang of that smoking business. If I had been a successful smoker, it's unlikely I would have survived to become an OldfoolRN!





Sunday, May 2, 2021

Do Nurses Do Windows?


 Yep! Old school nurses were window cleaning experts and I'll let you in on a secret method to make those panes glimmer brighter than a new graduate's nursing pin. Impress your grumpy old instructor and win brownie points galore. So much more fun than dealing with that balky hopper in the dirty utility room, smells a heck of a lot better too!

Step 1: Sprinkle a dash of baking soda on a gently used and lightly moistened ABD sponge. Rub the baking soda on the window and don't be afraid to add some gusto (just like the nurse in the illustration.)

Step 2: Go over the entire window with a plain, wet ABD. Central supply is usually more than happy to provide ABDs that have reached the end of their service life. One thing that does not work well for window cleaning is old, worn out student nurse aprons. I think it has something to do with all that imbedded Argo starch impeding absorbency.

Step 3: Mix equal parts water and vinegar in a spray bottle and mist the window.

Step 4: Buff aggressively with a dry ABD and stand back to admire your work. Just think what a wonderful world it would be if all things in nursing could be as fulfilling as window cleaning. Instant gratification at it's very finest. Cleaning windows sure beats scrubbing emesis crusted beds.

Sunday, April 11, 2021

The Daring Ortho Patient on The Flying Trapeze

 

"Get that needle outta my leg or that doc on  my right with
the glasses gets clobbered by a flying trapeze!"
                           

  Modern hospitals have become disquieting places without the time worn cues to orient folks to the  type of services available on a particular ward unit.  The ortho wards look naked without beds fully encased by unwieldy traction frames and their sundry attachments. 

Respiratory floors were easy to spot with their huge "U" tanks of oxygen wheeled about by tired looking nurses and orderlies. Now everything looks the same and  the appointments are more expensive than can be easily afforded by the common man.

Fancy in the wall pipes did away with the huge oxygen tanks scattered wily nily about the ward, but lack of orthopedic framework and their ever present trapeze was a move in the wrong direction. Living (if you could call it that) tethered to weighty  traction inside the confines of  an orthopedic bed was an unpleasant patient  experience to say the least,  while outside, in the untethered world, the healthy danced the tune of their small delights. In todays vernacular, orthopedic traction and it's accompanying long term confinement was a huge patient dissatisfier.

The underbelly of the miserable world subsisting below the  ortho trapeze always reminded me of a steaming jungle  teeming with rank smells that bubbled with hot gasses vented from inside an overheated, sweat infused hospital mattress. Patients confined in nasty conditions like this clamored for attention and soon learned a trapeze was better than a call bell for eliciting attention from nursing staff.

It's a sad truth,  most of our nursing forebears had seen way too much suffering to be easily moved by a patient's plight. Patients strung up in restricting traction soon learned that like the porcupine's belly, the weak spot for just about any hardened nurse was a struggling patient.

 So struggle they did. The key to attracting a friendly nurse to the bedside was timing, as the target nurse passed by the always open door, the hapless patient wildly swung by one extremity from the dangling trapeze as if he were about to crash back down to the stench laden  mattress in a fatigue induced heap.   Who in the world could turn their back on a struggling patient?  The "helpless dangler, about to crash gambit," worked on just about every nurse. It was a sure fire way to garner some attention, if even, for a brief moment.     

Wily traction bound patients had the luxury of lots of time on their bedridden hands to come up with more sinister uses for a trapeze. It didn't take much ingenious thought to weaponize an overhead trapeze. Aside from a direct assault by swinging the trapeze at a victims cranium like the poor soul in the illustration above, the pull and shriek strategem was equally painful, but more subtle. 

Nurses tending to orthopedic patients frequently had to work below the dangling trapeze when performing painful procedures like cleaning indwelling  traction pins  with hydrogen peroxide  pins or administering stinging  injections. The ortho patient's  golden hour of returning the painful favor to the nurse was when her cap and/or hair brushed against the chain securing the trapeze bar. A quick downward thrust on the horizontal trapeze would lock the nurse's hair in the trapeze suspension chain. The end result was a hair pulling event upon the nurse's pained departure. I think this is one of the reasons that orthopedic nurses were the pioneers when it came to abandoning the traditional nursing cap. A clump of scalp hair suspended from a trapeze bar was a chilling sight.

Most everything encountered in the nursing world has a yin/yang aspect to it, and trapezes were no different. Trapezes could do good things as well as cause trouble. Orthopedic patients were ordered to wear TED compression hose at all times as a clot prevention measure. Most all life threatening clots formed in deep veins and compression hose only worked on superficial vessels. I could never figure out how such an ineffective intervention could gain widespread use, but that's fodder for a future post.

Patients soon discovered the trapeze was an ideal suspension device for drying newly laundered hose. Just hang the TED hose over the horizontal bar and PRESTO they dried in nothing flat in the steamy hospital environment. Enterprising patients also discovered the trapeze was a great place to suspend photos of loved ones. Having a treasured family member in line of sight worked wonders for patient morale.

The pendulum like back and forth movement of a trapeze was also great for inducing a calming effect. The rhythmic swing tended to induce a peaceful hypnotic sort of state that helped counteract some of the misery induced by immobility.

I recall one patient who discovered a truly novel use for a trapeze. The ends of a trapeze were open and the void made a convenient place to ramrod cigarette butts. Old hospitals were chock full of smokers on both sides of the bedside, patients used the trapeze ends for an ash tray and nurses were known to use the traction support holes in the footboard for cigarette disposal. 

Head Nurse Annie confronted one of the nurses about finding KOOL cigarette butts in the traction receptacle and was countered with a good defensive point, "But I smoke Winstons," the wizened nurse replied.

Sunday, April 4, 2021

Happy Easter

 



I can't believe how many folks are perusing my foolishness on such a Holy Day. I hate to go Dean 
Wormer on you, but life is so very short, go spend some time with your family and Happy Easter from OFRN!

Saturday, March 20, 2021

Nursing Performance Evaluations

 

And furthermore, those black bobby pins securing 
your cap are most unprofessional. Use white pins!

Nothing exploits the fault lines of professional nursing quite like the annual performance evaluation. The assorted dynamics are varied, but always divisive; the young vs. the old,  BSN vs. diploma,  'Mericans vs. foreign born, neat fanatics vs. free spirits, and at the root of all conflict, the nurse office sitter academic/administrative complex vs. the lowly bedside nurse.  

The rigid, authoritarian nurse administrator doing the evaluation was once a member of the bedside nurse cohort but ascended the administrative ladder as a result of being totally unfit for direct patient care and also holding anyone who is good with patient care in contempt. Basically, it's a cabal of malcontented  busy bodies whose primary mission in the nursing world is proving their power and mettle at the expense of the lowly bedside nurse.

I love the optimism of  naive, young whippersnapperns who think it's possible to come out of performance  evaluations with an honest assessment of how they are  doing on the floor. Nurse Buff even has a blog post titled, " 8 Ways to Knock Your Performance Evaluation Out of The Park." Maybe things are different today, but in my experience, the nurse is far more likely to get knocked out of the park in this  nursing administration world of bureaucratic incompetence and legendary bullspin. It's a no win ballgame.

 The fur licking, scratching and hissing so common in nursing office settings is  like a magnet for administrative minded  folks. I once received an evaluation that noted I had zero potential for administrative advancement and considered that a high complement. Sitting in an office with these other worldly creatures  would have been like a prison sentence for me. Not everyone wants to climb the so called ladder of success when it involves joining the ranks of administrators.

One of the inherent problems with nursing evaluations is that good patient care is simply not narratable. Long time bedside practitioners develop a 6th sense based on pure instinct. I've worked with nurses who could smell impending death and could assess blood pressure without a syphgmomanometer by applying variable pressure to the radial artery. Long time neuro nurses can actually visualize that pre seizure aura and take appropriate action to nip the convulsion in the bud.  A good bedside nurse is indescribable, but you know one when you see one in action.

The philosophical bifurcation between administrative nurse and bedside care giver is enhanced by the use of lexicon hijacked from the business world. Office sitters have loads of time on their hands for the black art of word play.  In the age of corporate driven medicine the use of high minded sounding goobledegook has flourished. We have phrases like poor time management, customer service, inappropriate consolidation of resources, best practices, building consensus, core competency, paradigm shift, mission critical, or matrix structure. Wow, talk about a tower of Babel.

Here are few of my time proven strategies for dealing with nursing performance evaluations. The first rule is to simply avoid any specialty or area that has a high density of nursing offices. The operating room was a perfect refuge from office sitting navel gazers and misfits. There were no nursing offices in the OR suite and supervisors, like my long time nemesis, Alice, rarely sat down. Her evaluations carried supreme weight and her theory was "If  you don't hear from me, you are doing a great job."

 It's also good job security to excel technically so that your services are valued by the surgeons. That way you have an advocate from the top of the hospital food chain to back you up when the inevitable hits the fan. My favorite general surgeon, Dr. Slambow would body slam just about anyone giving me the business. I had earned his respect through our late night meetings over some gosh awful trauma that we usually  managed to turn the tide on.

Demeanor counts big when on the receiving end of evaluations, so  never, ever, back someone into a corner who is meaner than you, and that accounts for 95% of nurse administrators. Practice this one in front of a mirror. Your facial expression should assume a beacon of baptismal innocence when the dreaded document is being reviewed. Take some measure of control over the situation by signing the blasted thing and making a hasty exit with a broad smile plastered all over your countenance. This is a game you cannot win. Simply grin and bear it then rapidly forget all about it.

If nursing abomination administration genuinely wanted to improve patient care they would provide units with adequate staffing, pay nurses a livable wage, acknowledge circadian rhythms when scheduling, and maintain supplies of equipment to get the job done. Evaluations are small potatoes when striving for better direct patient care.

Although, I've tried to limit my tales of personal woe, there is one evaluation experience that will always haunt me. I was hospitalized with the mother of all Crohn's disease exacerbations and had not been able to eat for weeks. Thankfully,  hyperalimentation was initiated and as I was surrounded by beeping monitors and several infusion pumps a cheery, young nurse popped up at my bedside with news that there was a piece of mail for me.

How nice I thought, some kindly person from work was sending me get well wishes. Upon opening the envelope, I was dumbfounded, it was my annual nursing performance evaluation sent by Helene, my head nurse. I guess she figured that I was never going to recover and return to work so she might as well get it over with. Nursing can be a cold business and, yes, I did return to work just to spite her.

Wednesday, March 10, 2021

LABELS

 This blog has always been filled with foolishness, it's the underlying theme and glue that holds everything together. Lately, much to my amazement, posts about my experiences at Downey VA Hospital have been the most widely read. Although my tenure at this long term psychiatric warehouse was but a brief snippet of my work as a nurse, it left me with some of the most profound memories of human suffering. The men from Downey were a memorable bunch and will always occupy a special place in my heart.

I felt it was unfair to those with an interest in life at Downey to peruse through a quagmire of other posts completely unrelated to Downey so I set up labels on blogger to categorize my ramblings. I started by categorizing the Downey posts and then got carried away and added some other groupings.  So if you want to see my 1970s paystubs documenting my meager nurse's  salary just view the label "remuneration." If you are curious about the demise of sluice rooms just call up hospital design. You can also learn why old school operating rooms were always on the top floor of the hospital.

I hope this labeling makes things easier for my treasured readers. The labels begin in the right column just below my profile.

Monday, March 1, 2021

Downey V.A. Hospital Was The Home of Polypharmacy and Megadoses

 


Desperate situations often produce less than optimum results. The patient population at Downey V.A. Hospital was an intractable bunch, tortured by some of the most severe psychopathology known to man. My first time passing medications was a real shocker as one pour soul was ordered 2000mg. of the potent major tranquilizer, Thorazine. Nursing school pharmacology taught me that a usual dose was 75-200mg of Thorazine. A ten fold dosage of 2 gms. was out of the ball park.

Another disturbing trend involved patients dosed with more than one major tranquilizer with some dispensed as many as four. When the V.A. administration discouraged megadoses, polyharmacy was haphazardly substituted. I don't know which practice was worse in fueling disabling side effects like tardive dyskinesia, polypharmacy or megadoses.

When I brought this up to our ward physician, Elihu Howland MD, he agreed that it was a less than desirable situation  and suggested that I do a study enumerating the problem and he would see what he could do. Good luck were his parting words which were uttered in a less than sincere manner.

I eagerly went to work and came up with the following.

There are a significant number of patients at Downey receiving  more than one antipsychotic drug or a witch's brew combination of these neuroleptics. Here on Building 66AB I found a patient receiving three different antipsychotic drugs with a PRN order for a fourth neuroleptic agent. This much chemical restraint could be as disabling as the underlying illness.

Many studies evaluating  polypharmacy under controlled conditions demonstrate that there is no effectiveness over monotherapy. There really is no basis in fact for the existence of polypharmacy as a treatment method nor empirical evidence for its continued use as an effective treatment modality. Additionally, polypharmacy creates an added risk, even a fatal outcome, from a combination of drugs with mutually additive effects. With polypharmacy it is nearly impossible to delineate which specific drug is the culprit inducing untoward side  effects.  Many articles conclude that single drugs are the treatment of choice over polypharmacy.

Furthurmore, a recent review clearly shows that  we have a number of patients on extremely high dosages of antipsychotics. Megadoses   seem related to poly pharmacy in that one poor option is often substituted for the other. When megadoses are discouraged, polypharmacy soon fills the void.

Megadoses indicate  we have a large group of chronic patients who have been receiving a very high dose for a long period of time and whose mental status has stabilized, yet no attempt has been made to reduce their dosage to the lowest effective maintenance level. This maintenance dosage should be as low as suitable for retaining therapeutic progress. Dosage should be gradually titrated down to avoid a sudden emergence of symptoms.

The notion of lowering doses is especially important when megadoses or high doses are ordered. The patient's symptoms , drug history, and general physical condition should be considered when the risk of megadoses is evaluated. The occurrence of side effects must be balanced the benefits in the chronic patient who continues to present psychotic symptoms endangering himself or nursing personnel.

Once control of target symptoms has achieved, the dosage must be be adjusted downward as most all patients could be maintained on a lower dosage level.

Perhaps we should start by eliminating polypharmacy and then carefully titrating down on some of the megadoses.

I submitted this report to Dr. Howland with a listing of the patients receiving polypharmacy and megadoses. While there was some success with reducing polypharmacy, there was much resistance to decreasing megadoses. The main argument was the patient was on these doses for a very long time so there was no rationale to decrease doses.

My frustrations working at Downey reached a boiling point a few months later when my head nurse recommended me for a grade promotion, but  it was rejected by the personnel office because I was 4 days shy of the time required in grade for promotion, but never fear, I could apply again next year.

I resigned from Downey V.A. on May 21, 1976 after working there 1 year, 5 months, and 28 days. It was a very long year and a half and made working in the OR seem like a walk in the park. I happily returned to my favorite stomping grounds in the O.R

Saturday, February 27, 2021

Informed Consent Would Have Annulled This Vow!

 

                                                             A diploma school promise

Friday, February 12, 2021

Time Worn Adjuncts to Mechanical Ventilation - The Good, The Bad, The Ugly

 

Proning is the latest modality for augmenting ventilator 
therapy.  Some vintage measures were not so effective


Recognition of acute respiratory distress syndrome (ARDS) in the early 1970s and treatment with Engstrom ventilators was a game changer, with  mortality plunging from 100% to about 40%. As more experience was gained mortality plunged even further. Deducing what worked and what didn't with ventilators was a rocky road.

It's human nature that clinicians faced with an unstable, critically ill patient want to do everything possible to rescue the person. We referred to situations like this as kitchen sink medicine when just about anything and everything was added to the armamentarium. Sometimes, desperation in medicine results in untoward  outcomes. I'm thinking about radical mastectomies for all breast cancers and surgeries like hemipelvectomies. Some pioneering accompaniments to mechanical ventilation bore little fruit, and did little to avert a vegetative outcome, but just about anything seemed worth a try when the clinical situation seemed so bleak.

Early practitioners in the art of mechanical ventilation were not like the experienced critical care medicine experts of today, but surgeons and anesthetists who saw the benefit ventilators made with ARDS treatment. They were drafted into the new role of managing ventilators and much of what ensued was on the job training..  Science was sometimes, in short supply when empirically based notions were applied as we shall soon see.

Everyone takes in a deep breath from time to time, so why not try this with ventilated patients? It was fairly easy to adapt those ancient, chugging, Engstroms to deliver an occasional deep ventilation, all it took was some monkeying around with that gizmo on top of the Engstrom that looked like an expresso machine, and PRESTO, the "sigh" was invented. A sigh was an occasional cycle with increased tidal volume and the frequency was highly variable.

 Intermittent sighs were a source of dread for sedation deprived ventilator patients, imagine having a hurricane force of air, unpredictably, blasted into your chest via a skinny little tube.  A United airlines pilot recovering from pneumonia said, "Now I know what it's like to suck on an engine of a 747." Unpleasant does not begin to describe the patient experience when the sigh cycle kicked in.

Ventilator driven sighs never really caught on in the hospital where I worked.  Surgeons blamed the sigh cycle for putting undue stress on suture lines and in the event of a rare evisceration, the sigh was always blamed. The elevated intra thoracic pressure was also blamed for barotrauma to vulnerable alveoli. 

Positive end expiratory pressure or PEEP evolved to be the replacement for sighs. PEEP entailed maintaining a low steady pressure (5cm/H20) in the lungs just slightly above ambient atmospheric pressure. Some overzealous physicians figured that if a little bit of PEEP was good, then more is even better. Super PEEP was born with pressure of 25 cm and above which was like blowing an automotive tire up to 100psi. Talk about a rough ride!

Super PEEP worked for a time until complications surfaced. High intra thoracic pressure compromised blood flow in the great vessels which caused big problems. A hemodynamically unstable critically ill patient is not a good thing. Renal problems often developed as a result of compromised circulation. Super PEEP was not such a good idea, but did persist when technology for cardiac output monitoring was developed which enabled fine tuning to allay complications. The father of super PEEP at Montefiore Hospital in Pittsburgh was Arnold Sladen MD. He was either a hero or a scoundrel depending on who you talked to.

Endotracheal tubes exert a seal by an inflatable cuff which contacts and forms a seal with the trachea. Sustained pressure exerted by the cuff can limit the amount of time a patient can be maintained on the ventilator before an invasive tracheotomy must  be done. Long term unremitting pressure from the cuff can cause problems.   Intermittent endotracheal tube cuff inflation was thought to be a way a kinder gentler way of sealing an airway. The cuff was inflated only on inspiration.

Intermittent endotracheal cuff inflation required some complex additional equipment and lengthening the inflation tubing  increased dead space and exacerbated the  potential for  leaks. There was also the ever present risk of aspiration when the cuff was deflated. This overly complicated  modality was usually abandoned with much haste as it just didn't work very well.

There is that old joke about anesthetists passing gas, but in reality, they are passing gases. Fiddling around with the inspired mix of gases was second nature when novice anesthesia folks began overseeing ventilator therapy. Traces of helium mixed with the FiO2 were thought to aid in alveolar dispersion, but in the long run seemed to make little difference. 

Life on a ventilator was unpleasant at best. Before propofol came along, anesthetists would sometimes  "trace an agent," or install an in line vaporizer to sneak in a whiff of halothane to settle things like "bucking" down. Progress in IV sedation put a halt to anesthesia  vaporizers on ventilators except, of course, in the OR.

Ventilators are an unforgiving entity and that ominous click...hiss...pause  always overshadowed the cheerful cacophony of melodious alarm tones, quickly becoming  the dominant noxious noise in the ICU. Ventilators really strummed a different sort of tune that frequently foreshadowed impending doom.

In the rapidly gathering storm leading up to intubation and subsequent ventilation, impending consequences were often conveniently overlooked. Rendering someone mute with an endotracheal tube and lashing them to a machine forcefully converting air into breathe has all the grace of getting clobbered by a linebacker on steroids.

Late at night, numbed by fatigue induced hopelessness, strange thoughts percolated through my mind when caring for a poor soul on a ventilator. We all want a nice linear, progressive, and predictable path from illness to health. Sometimes, though, ventilator patients are too far along on their journey to the other side. If  I'm ever in this predicament, I hope my caregivers reconsider my path and don't interfere with my final journey.

When I'm on that peaceful river journey to the other side, I better not come across a ventilator masquerading as a life boat!

Friday, January 29, 2021

Diploma Nursing Students Learned Procedures the Hard Way

 

Needles could turn a smile into a grimace, lickety split


Procedures were the alpha and omega of diploma nursing programs and the ultimate way of measuring a student's progress. Like just about any other trade school, academic accomplishment took a back seat to providing a free source of  hospital labor. Procedures performed without concern for remuneration on unsuspecting patients were the currency used to pay for  "free" books, housing, uniforms, and food. There was no such thing as a free lunch.

Student nurses' mindsets were carefully groomed  to maintain a calm, confident, omniscient  bedside demeanor despite the fact that this was our virginal attempt at thrusting a 2 inch Imferon needle into a fellow human's vulnerable flesh. We were acutely aware that the procedure was likely inhumane and excruciatingly painful. Student nurses also carried the burdensome  knowledge that any flaw in their Z tract injection technique would be visibly advertised by that ugly, dark brown Imferon staining the surrounding subcutaneous tissue. An ear beating public  dress down from my favorite instructor, Miss Bruiser was sure to follow. I found it ironic that her name reflected the very nature of the Imferon staining complication, a big old brown contusion that looked a mess.

As a general rule of thumb, any procedure performed above the waist line, was done to a fellow student, affectionately known as a procedure pals. This relationship always reminded me of a cat vs. groundhog fight, one minute the cat is chasing the ground hog and the next minute the rodent is baring his formidable front teeth at the feline. The nurse and the victim patient in subsititutus  had to be very wary when dealing with  one another, she who injects and skedaddles  might live to inject another day, or the next minute, become the hapless recipient. Like so many other aspects of nursing, a classic no win situation.

 Performing painful treatments on each other was thought to be a vital component of nursing education, a real boon to developing empathy and the proper "attitude," what ever that was. Thank heaven we were not studying neuro surgery.  I shudder to think about the mess a bunch of first time amateur  craniotomies would look like.

When it came to performing uncomfortable downright painful procedures there were two student nurse  personality types involved. The most dangerous, in my humble opinion, was the eager beaver, overly enthusiastic student who would stop at nothing to be the first one administering the tormenting treatment. 

These were the novice nurses who thought the blood dripping from their fingers after a botched venipuncture was a badge of honor or that  it was appropriate to celebrate doing post mortem care for the first time. Miss Bruiser usually was able to take the wind out of their sails by insisting the eager students "volunteer" for her to insert a NG tube down their dainty little porboscus. Her ram rodding technique combined with her "demonstration" of a sulcus at the base of the tongue would humble anyone. The manipulation of the tube at the level of the epiglottis was guaranteed to provoke a hacking, gagging fit that would turn one's stomach while simultaneously bring tears flowing like a fire hydrant. A memorable experience that was sure to temper the gusto of the most aggressive eager beaver.

At the other end of the student nurse spectrum were the reluctant, overly sensitive types who were preoccupied with the uncomfortable nature of their ministrations. I was, without a doubt, a member of this tribe and frequently found myself biting my cheek when it came time to do just about anything associated with inflicting pain.

Mrs. Viotto was the kindly, grandmotherly nurse that was assigned to us who were not so eager beavers when learning painful procedures. Her constant reassuring smile resembled the exaggerated expression a pantomimist would use. Her typical discourse followed the theme  that we were there to help patients recover and in order to accomplish the end goal we would sometimes have to do things that were "uncomfortable." Pain was not part of her vocabulary. Everything from dressing changes on burn patients to bicillin injections were just "uncomfortable."

There was a reassuring smoothness in the way Mrs. Viotto conducted herself when demonstrating procedures. Rather than the stabbing and jabbing of the over eager student nurse clan, she stressed gliding a needle into position or threading a catheter in place. I learned more from her than any other instructor.

There was a very short window of opportunity for student nurses to master procedures and if by junior year a deficit was identified big trouble ensued. That dreaded yellow dismissal form with the dream shattering message, "unsuited for the practice of nursing," would soon find it's way to your mail box

. It was like an amputation in the days before anesthesia; painful and irreversible. Although, sometimes, the students who persevered envied the one's who left, especially when the ex-students would return to nursing school for a visit with tales of menial jobs paying more than a nurse could ever  hope to earn.

Friday, January 22, 2021

Not on My Mayo Stand!

 One of my most popular posts from the  past was about items I never, ever want to see on my OR back table. https://oldfoolrn.blogspot.com/2017/01/not-on-my-back-table.html. Scrub nurses work  at ( or least  they did 50 years ago) from two horizontal surfaces. A large  back table at the foot of the patient which is loaded with just about anything and everything  needed for the surgery and the Mayo stand placed over the patient just below site of the surgery. This stand  is solely for the instruments in immediate use. I've seen some illustrations of Mayo stands that really flustercate my fragile foolish faculties, so here are some thoughts about the care and feeding of Mayo stands from a perspective of many moons ago. (I had to put that disclaimer in because some folks compare my ramblings to contemporary standards and I get harshly critical emails.)

Side hanging  instruments as shown in this illustration desecrate one of the most basic of  OR commandments - Thou shall not let any instrument dangle over the edges of your Mayo stand. The outer ridge of the stand acts like a fulcrum sending your instrument flying if you inadvertently drop an elbow during a critical moment. Flying instruments, depending on where they land, are never a good thing in an OR. A nasty surgeon once lobbed  a Haney clamp at me and then in a Karma driven moment, dropped a weighted speculum on his foot. Yes...there is a flying instrument god in every OR.

I started this post out thinking that maybe I should do the ten commandments of Mayo stands, but that sounds cliched and besides, what happens if I can't think of ten? Maybe it's better if I just ramble  on in in my typical foolish manner.

When in use, Mayo stands should always be at the scrub nurse's waist. A uniform height helps establish muscle memory so that when you go to grab something, your hand goes to the intended spot without thinking. Many nurses need some altitude enhancement to reach the correct height and I went out of my way to construct elaborate altitude enhancing arrangements.  oldfoolrn: Scrub Nurses Flying High

Yikes! When it comes to just about any sort of tubing or cable, be it suction line or Bovie, it's much neater to keep them on the back table until needed. Think of your Mayo stand as fly-over country and pass the long  tubing or wiring directly from the back table to the surgeon. This Mayo also has a towel clip and a Metz scissors hanging over the edge of the Mayo waiting to be dropped or take flight. I do like the way the scrub nurse lined the top of the Mayo stand with a couple of honest to goodness cloth towels. Disposable paper Mayo stand covers and towels generate that raucous rustling noise that really grated on my nerves. It reminded me of opening presents on Christmas morning when I was often stuck in the OR.

Old scrub nurses were real sticklers when it came to keeping all your instruments on one level while they were reposing on your Mayo stand. The only high-rise object tolerated was a stack of 4X4 sponges because when it comes to anything bleeding you can't be too careful. I vividly recall the dressing down a new resident received from Dr. Slambow when he took a loaded sponge stick and  swiped instead of a dabbed at a small bleeder. "You meathead!@#&, you are wiping the clots away." The good surgeon did not tolerate fools well, except for me. 
 
This Mayo stand illustration should be captioned double trouble. A scrub nurse is like a mama bear protecting her cubs when it comes to guarding and maintaining the sanctity of her Mayo stand. Here we see more than one set of lunch  hooks...oops I mean mitts on a Mayo stand. Fifty years ago a stunt like that would merit a knuckle smack with the business end of a scrub stick, especially if my nemesis, Alice, was standing behind that Mayo stand. Alice was an equal opportunity knuckle buster, surgeon or nurse, it didn't much matter. The other faux pas  here involved a specimen jar filled with a likely toxic solution like formalin. Mayo stands are restricted from any liquid that could be toxic. Methylene blue and lidocaine are just fine, but biopsy fixatives are a big no...no. 

Noah was right, everything is better in pairs. When bringing up ratcheted instruments from the back table always grab two at a time. There should be an even number of hemostats, needle drivers, kochers, mixters and babcocks. I never did like the way grabbing a babcock. registered in my ear  when spoken.  Picking up a pair of babcocks always sounded more civil, so don't grab a babcock, pick up a pair. Avoiding odd numbers of instruments on your Mayo stand  helps avert that dreaded foreign body mishap. Thank heaven  this never happened to me (I pray.) .Avoiding some mishaps is  a matter of luck as much as skill. Surgery is a high wire act with lots of distractions and bad things do happen. It was well known that any nurse involved in a foreign body incident would be fired on the spot. We were scared straight.

Some nurses delighted in adding artsy fartsy touches to their Mayo stands and I'm not sure if this is a good thing or not. I'm not very artistic so maybe I have a dog in the manger attitude when it comes to fanciful touches to Mayo stands, especially when the artist is a much more accomplished scrub nurse than me. My friend, Janess, liked to craft lovely designs in her  wax paper sharps bag by cutting designs along the top border of the container. She was an artist with a straight Mayo scissors and I think her flower designs were the very best.

Elite scrub nurses were a very special breed that certainly excluded me with my size 9, hubcap sized hands. Fleet of foot with nimble fingers and a fast firing central nervous system, always totally relaxed, but ready to strike at a moments notice. Probably the ultimate paradox was their narcissism coupled with unyielding selflessness. You have to love yourself if you are going to  do just about anything for another with such blatant disregard of your own needs. 

I'll always remember my favorite scrub nurse mentor, Alice, harping about some Mayo stand minutiae and when it came time for self-evaluation her only fault was having to deal with low motivated sloppy dolts like me. Old OR nurses like Alice were different from the rest of us.


Thursday, January 14, 2021

WHAT IS A NARCOTIC PRESS?

 There are many vintage nursing terms that are unheard of in these modern times: Johnnies for hospital gowns, snaps for hemostats, monkey bars for orthopedic framed beds or hypo for any drug administered by a needle, regardless of route. Some of these names, at least, made sense in that their origin was pretty easy to figure out. One term that really through me for a loop, even in my younger days , was "narcotic press." I tried to learn what was behind these obscure terms in a foolish attempt to appear smart or wise, but, like they say, you can't make a silk purse out of a sow's stomach.

A narcotic press was not a newspaper about the perils of addiction or a device for squeezing the exudate from the papaver somniferum  poppy. Narcotics were secured in a double doored locked  metal box prominently located smack dab in the middle of the nursing station and frequently referred to as the narcotics press.

I used to love the way Filipino nurses called it a nar-koe-tiks press in their lovely melodic way of speaking, so different than the harsh, Chicago midwestern dialect that sounded like a Stryker saw hacking through bone in the morgue. Native nurses had rather inelegant terms for this storage  device like locker, cabinet, or box. Narcotics press had a nice ring to it.

Since most Filipino  nurses used the lovely narcotic press term so freely, I wondered if it came from their native Tagalog language. After learning the term had no roots in their native language, I set off on a mission to learn where the narcotic  press term originated.

Old nurses, having seen it all and done it all, were not very tolerant of nursing terminology cognoscenti like myself. Well seasoned nurses were intolerant of foolishness regardless of source, patients, colleagues, or whatever, it didn't much matter. It was a tough battle liberating information from these hard core characters, unless it was a direct matter concerning patient care, but young fools can be highly motivated when the quest for esoteric information is on the line.

I got quite a few answers regarding the narcotic press nomenclature inquiries. One aging bat thought it had something to do with triggering a red warning light located above the medication room door. Regulations required a visual indication whenever the narcotics press was open. Newer narcotics storage areas had a switch automatically linked to the outside door that triggered the warning light, older boxes required manually PRESSING a button and thus the term narcotic press was born. This explanation seemed a bit far fetched, but I guess anything is possible.

And finally, the best answer, verified by more than one aged nurse is the following revelation. The narcotic press nomenclature is a coinage born of frustration with securing the double doors of the contraption. Rules from the grand nursing poobah upon high specified that  narcotizing drugs must be stored behind two locked doors. closing the first, inside door was easy, but to get the outside door securely latched, you really had to press on the margins to get it shut. A narcotics press was born!


Wednesday, January 6, 2021

The Doctors' Dining Room

 

Old school hospitals offered lots of special treatment to their esteemed  medical staff. Free front row parking with valet service on demand and an ornate dining oasis which was far removed from drab, utilitarian hospital environs were the more obvious perks. Physicians were the alpha predators in the hospital food chain, far removed from nurses and ancillary staff. There were no "mid level providers" in days gone by. It was just the doctors and everyone else.

Doctors' dining rooms were entered through a solid wood door conspicuously marked PRIVATE. Inside the door was a room paneled in dark mahogany with fancy brass grills covering the radiators. Maroon Karastan carpeting covered the floor. Pictures of the institutions hallowed great healers from the ages adorned the walls with an occasional pretentious bronze  bust tossed in for good measure.  Genuine white table cloths with a fresh floral arrangement salvaged from one of the many bouquets  left behind by departing patients added to the ambience. Fancy light fixtures illuminated these deluxe digs and sculpted plaster potentiated the high brow ambience of these over stated  eateries. A two year old with a plate of spaghetti could do more damage to an over adorned room like this  than a hurricane 

General practitioners and internists served the role of personal physicians and  asserted complete control over the care of their patients spending  many long hours in the hospital.  A readily available source of nourishment was essential.  These dining areas were a feeding lot open 24/7, serving snacks like Good Humor ice cream bars, bagels, donuts, and crackers laden with cold cuts or liver pate' during off hours. Normal operating hours featured  food from the hospital cafeteria embellished with little sprigs of parsley, ripe olives or whatever else the colorful characters known as hospital cooks could whip up. A distinctive touch to our hospital dining room were  bottles of hot sauce smack dab in the middle of every table.

Doctors'  dining rooms were the consummate private place for the boys to raise questions about care and explore  solutions to ethical dilemmas. Operating rooms were fertile ground for  mishaps and screw ups when  minimally trained general practitioners were  granted surgical privileges. Thankfully, they were prudent in restricting their services to simple procedures like vein strippings, tonsillectomies, and D&Cs. 

A ham fisted G.P. might ask an ENT specialist if it was OK to with hold information about a patent's uvula  that had the nerve to get tangled up in an errant tonsil snare. The ENT doc usually advised it was best to be truthful since the first time a patient looked in the mirror he would notice that little thingee hanging down in the back of his pharynx was AWOL. It's best to be honest when your mistakes are obvious.

Wrong site surgery was an egregious error but could be easily explained away by claiming that the errant surgery was necessary and not a simple minded mistake. Circulating and scrub nurses would likely be fired for wrong site surgery or  foreign body oversights, but the surgeons remained unscathed except, perhaps, for an admonishment to be more careful next time.

Doctor's private dining rooms were doomed by hierarchy busting youngsters and the welcome influx of women to the medical field. Most women did not take kindly to putting their own needs ahead of patient welfare when covering up mistakes, an issue frequently addressed in all male forums like doctor's dining rooms.. Corporate healthcare had a significant role in shuttering doctors' dining rooms because of their negative cash flow. Any use of space that failed to contribute to cash flow was history.