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.

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.

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!

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.