Healthcare Paradoxes

  Wake up! It's time for your sleeping pill.

Go Lytely...This stuff is like a Mount Vesuvius eruption purge in a bottle! Not exactly lightly about anything.

Lifesaving surgery...Red Duke, the famous Texas trauma surgeon, debunked this one many moons ago. "When God punches your ticket, he does so with profound authority, without regard to human intervention." 

Soft code...When the notion that CPR was good for all surfaced, the concept of a muted code emerged: walk, don't run, pediatric compressions for 300 pounders, etc. There really is no such animal as a soft code.

Bathroom privileges... This is a biologic need. Do we have room air privileges for patients to breathe?

Therapeutic milieu... I learned the fallacy of this one early on at Downey VA hospital. A nurse office sitter was orienting me to my psych unit announcing that this was their "therapeutic milieu" as she opened the locked door to the ward. A pool ball sizzled by my head like it had been launched from a mortar and 2 patients were bayonetting each other over in a corner with a cue, while a third was struggling to remove an impaled rack from his head. Therapeutic???  I don't think so.

Normal saline...How normal is an IV solution when it can cause metabolic acidosis and renal function changes?

ILL health...Health is health and there is nothing ill about it.

Pressure ulcer... Nope, if pressure caused ulcers, divers would be one giant bedsore. It's the shear forces that cause decubitus ulcers.

Confined to a wheelchair...As an occasional wheelchair user, this one really grinds my gears. Wheelchairs provide mobility and freedom!

Fun With Artificial Intelligence Image Generators

 

Since my native intelligence has been flumoxed by brain numbing complications from my knee replacement surgery, I've turned to artificial intelligence image generators for some foolish amusement. I typed in Old fool RN on "Stable Diffuusion," an open source image generator and my prompts produced this appropriate image. Maybe I should replace that rather dated blog profile photo of me standing under the overhead lights in the OR. Hmmm...I love how that under the overheads lingo sounds. It doesn't take much to amuse a fool.

If you have an opportunity check out Stable Diffusion. It's easier than a camera or paint brushes to construct images. Hopefully artists and photographers won't be data based out of an occupation, but who knows?

Institutional Misogynism: The Women of Downey VA Hospital

At the height of the Viet Nam War, Buddhist Monks doused themselves with gasoline and immolated themselves near U.S. facilities to protest America's involvement in the conflict. Two Army nurses rushed to the aid of a monk who set himself ablaze near a remote Army field hospital. A Viet Cong sniper fired on one nurse, killing her instantly. The second nurse, for obscure reasons, was ignored by the sniper and survived. Screaming hysterically and subsequently lapsing into a mute state, the sole survivor eventually found her way to a long-term ward at Downey VA Hospital, a warehouse for the mentally ill. The slain nurse was hailed as a heroine and awarded several posthumous medals and an honorary promotion to Major. A street at Fort Sheridan Army Base was named after her.

(A snippet of Downey V.A. Hospital folklore)

I  worked as a nurse at Downey V.A. Hospital for several months before I was aware there were women veterans confined amidst the 1600+ men. One evening I received a frantic phone call from a nurse in Building 135 asking if I could come to their ward and start an IV on a patient who was seizing. My recent medical background was an anomaly among Downey nurses. Most nurses employed there had worked on the back wards for decades, allowing their med-surg skills to atrophy. Eager to be accepted in this strange new land, I let it be known if there was an emergent medical problem, I was available to do what I could.

I furiously jammed my bit key into the worn slot on the heavy solid steel door on ward 3A, Building 135 and the portal opened briefly and ominously clicked shut. I was shocked to see an emaciated young lady seizing away on the dayroom floor. I should have suspected that any women patients at Downey VA were sequestered in gender segregated silos. At the time, womens' roles in the military were restricted by gender. It was a male dominated world with tentacles that extended to the V.A. psych wards.

I learned there were two locked female wards at Downey in Building 135 and they were the only ones available in the entire health system. Everyone here was seriously mentally ill and a danger to themselves or others. This arrangement concentrated the most acute patients in one facility while separating them from family and community resources. 

The wards at Downey VA were touted for their therapeutic  milieu, but it's a real strain to deduce what could be gained by such profound isolation. There was an on-ward dining room where meals were served to avoid comingling with the young bucks in the communal chow hall. Washers and dryers were also available to reinforce that matronly obligation of wash day duties. The place was a tour de force of isolation  and womanly perspicacity.

Surfacing from my IV start and a hastily administered bolus of Valium, it was readily apparent that the wards in building 135 were much newer than my native Building 66 which was constructed in the 1920s. These contemporary quarters were straight out of the aseptic construction of medical surgical units. The gleaming terrazo floors and ceramic tile walls were more appropriate to an operating room than a place of comfortable lodging and recovery.

I had the notion that psychiatric units ought to be constructed in the architecture of theaters; not operating rooms. There was no shortage of high drama at Downey V.A.  In lieu of a stage, the television assumed the focal point  with the viewers numbly looking on like a brace of zombies. The TV came on at seven AM and droned on until bedtime.

I heard rumors that pregnant women gave birth on the unit and indeed there was an exam room eqipped with a table that sprouted stirrups from it's distal end. Hopefully mothers were carefully screened to delineate complicated deliveries, but you can never assume when it comes to VA care. The facility was loathe to having patients treated in community hospitals and had medical surgical units on site so the men did not have to venture off base for care. Pregnant patients flayed by desperate life circumstances giving birth on a psychiatric unit made me wonder what chance the infant had for a normal life.

As I eyeballed and wondered what a lone mattress was doing  on the dayroom floor, an attendant enlightened me. "We do takedowns differently here. I know you guys over in Building 66 like to countdown and have everyone grab an extremity to apply full leather restraints, but here we just force the unruly patient into a corner using the mattress as a shield and hold them there until they calm down. Visions of a mattress held vertically and used to pin down a patient reminded me of the Chicago Police in their riot gear and shields at the 1968 Democratic Convention riots.

Walking back to the hallowed halls of building 66 I thought of a cat driven high in a tree by a pack of dogs. Safe at last, but completely isolated like the women in Building 135. Maybe it's time to call the fire department.

Yep...I'm Still Vertical, Part 2

 I encountered a tsunami of post-op complications following my total knee replacement surgery in August, but am starting to feel a return to my foolish baseline.  I received a fascinating email from Anna Pivoras, Executive Director of the Boone County Museum of History in Belvidere, Ill that got me back to thinking about this much neglected blog.

Anna read my posts about Downey VA Hospital because she has an amazing collection of journals from a woman who was a patient at this facility. Janet L. was a college graduate who played the organ for several churches and was very ambitious and active in her community. She joined the Army from 1942-1945 and taught kindergarten after leaving the service. She gave the appearance of being highly functional as she was engaged, had a nice car, and apartment.

After the death of her parents Janet decompensated and was sent to Downey for 3 months in 1967, where "they just wore her out." She became physically ill and was treated and sent back to her ward while still suffering from bouts of nausea. Unfortunately, this was fairly common at Downey. One of my saddest memories is of an elderly man suffering from psychosis as a result of an extended period of time on cardiopulmnary bypass placed in with young psychotic Viet Nam veterans.

The journals from 1971-1974 document a sad and troubled life with paranoid ideation, She chain smokes, a habit of just about every Downey patient because "GI" cigarettes were free and if you had funds, sold for 27 cents in the canteen. She has constant nightmares about shots, needles, hospitals, and psychiatrists. 

This sad story awakened my memory of the 2 womens' wards at Downey VA Hospital which were pretty much isolated from the rest of the facility. As soon as I can organize my thoughts, (HA...HA) not an easy task in my shape, I hope to get a post together on this forlorn topic.

Yep...I'm Still Vertical!

 I've received several emails recently from folks concerned about my health as a result of the dearth of posts on Oldfoolrn.blogspot.com. It's heart warming to think that you care enough to shoot me an email. When I started this blog, I made myself two promises. no politics and no belly aching about personal health issues.

I made the mistake of posting one topic that could be construed as political and learned my lesson; no more politics. My immobility problems have worsened as a result of a combination of osteoarthritis and Crohns disease induced poly-arthropathy. Thankfully the intestinal Crohns nonsense has been quiet lately. In 2009 I had both intestinal symptoms and multiple joint arthropathy, not a good combination when you have to double time it to the bathroom! 

Anyhow, I'm finally having a left total knee replacement on August 3rd so I can hobble about my little hovel.  I've been occupied with lots of pre-op testing and clearances from a plethora of medicos and everything seems to be all set!

Meanwhile, I hope some of you can enjoy some of my old posts. The 2 all time most read posts are "Not On My Backtable" and the one on that dreaded operating room nemesis, perineal fallout. You can be sure the first thing I'm going to check out when I'm wheeled into that OR is that rubber bands are in place around the distal portion of everyones' scrub suits. I'm also having this done under spinal anesthesia so I can keep an eye on the goings on!

Name This Mystery Equipment

 

I just love hospital mysteries, so I was delighted when a nurse emailed me these photos of a vintage device found in the ER at a Catholic Hospital, St. Vincents, in Cleveland, Ohio. The folks there were unable to identify it and it didn't ring any bells with me so I was thinking (a rare event for me) that maybe someone from my vast readership could lend a clue.

My first guess was that this was some sort of contraption from the hospital laundry. After sheets were dumped from a gigantic steaming cauldron, they were run through rollers to squeeze off excess water. Those rollers were a serious entanglement hazard for the poor folks toiling in this hell with the lid off environment. I had a special place in my heart for the Hispanic crew that worked the hospital laundry. I would practice my lackluster Spanish with these friendly folks and marvel at how happy they were in such an oppressive environment. I had life easy compared to their hardships!

My next speculative theory involved the radiology department. Before the advent of automated film processors where raw exposed film was inserted in one end and a finished X-ray slid out the back, roller film processors were used to conserve developer and fixer. The exposed X-ray film was loaded into the roller processors in a darkroom and chemicals introduced by a light proof port. The drum rolled which sloshed the entire film with chemical. You did not need any signage to find the radiology department, just follow the pungent smell of fixer with your proboscis!

My next brainstorm (more likely a brain fart) was this was a dispenser for the giant rolls of paper used to cover exam tables. Handling these giant rolls of paper always reminded me of octopus wrestling-get one end secured and the other end would pop up.

I did contact Oldfoolette. a central supply queen, from the dark ages and she could not identify it as any medical device. So perhaps the notion of this being a piece of hospital equipment was a cognitive disruption entity. We did have some whacky things in our ER that came in with patients and stayed behind in the ER.

We had a Chicago CTA turnstile from the Ravenswood El station that ensnared a fare jumpers lower extremities as he tried to vault over it and save 35 cents. Chicago's finest brought him in turnstile and all. I have a previous post about a poor soul who froze to death in a Chicago Park District garbage can. We kept the can and every time I read that HELP KEEP CHICAGO CLEAN slogan my heart skipped a beat. We kept the tunstile and trash can. Don't ask me why.

Any guesses about the identity of the above object would be most welcome!   

Selling Tenormin

 

What's that old Madison Avenue advertising axiom? If I remember correctly, it's "sell the sizzle not the steak." Sure, every nurse is aware of drug reps acting as poseurs for selling pharmaceuticals with their usual give aways of pens, stationary, and assorted bunk, but when Tenormin went off patent the good folks at Astra Zeneca went bananas with marketing ploys in an attempt to keep the big bucks coming for their name brand gold mine. Tenormin was consistently in the top 20 most frequently prescribed drugs and no doubt brought in gazzilions of dollars which brought smiles to stockholders while cash strapped seniors wolfed down their only affordable meal, Alpo suppers. I knew that trouble was brewing when I learned Alpo only made canine specific meals!

An entire culture was invented to persuade physicians to prescribe the brand name Tenormin in lieu of dirt cheap generic  atenolol. Drum roll please...Wellspring was an entire civilization with Tenormin at the apex, invented by clever marketing gurus. There was even a Wellspring magazine with healthy lifestyle tips centered around consumption of this pricey beta blocker. I perused one issue and I was struck by the well tanned healthy youngsters frolicking around a beach. Not a single geezer  with a tremulous manner and spreading jowls!

The give aways promoting Tenormin were top notch, not your usual cheap pen and stationary give away.  Astra Zeneca was well aware that lots of drug company swag found it's way to the circular file, but who in the world would toss a pair of priceless  collectible coins?  Most physicians were not numismatists and were not aware that the wheat penny featured in the Tenormin collectible coin set was valued at 30 cents and the nickel was likely not worth much more than 5 cents. The fancy encased (I was going to say entombed, but came to my senses,) coin set likely displayed in a prominent place on the good MDs desk as a constant reminder to prescribe Tenormin.

For nurses there was the lovely Wellspring wrist watch complete with a lovely red heart smack in the middle of the dial. Internet websites for advertising were far in the future, but Astra Zeneca had a WATS telephone line number (800-937-4027) where you could listen to a prerecorded message touting the benefits of Tenormin. A sweet sounding starlet rambled on and on how Tenormin did not induce depression, so common with other Beta blockers, because it did not cross the blood/brain barrier. Heck, I used to ring her up late at night just to stay awake. There was something about that melodic voice that kept me going. Dr. Slambow was aware of my tricks and when my scrub nurse skills were hampered by fatigue, he would say, "Fool it's time to call that Tenormin lady!"

Nursing crises of one sort or another could really shiver your timbers and leave you feel like you were walking a high wire with only cunning and a parasol with the chasm  chanting it's siren call way down below. Leave it to Wellspring to come up with a unique antidote for these forlorn times. When the real sh*tstorms rained down on the hapless practitioner. They sprung a genuine Wellspring umbrella as a freebe. My Wellspring parasol lasted all of a couple of hours. While strolling back to my apartment after a late night in the OR, a classic Chicago wind blast destroyed my Wellspring give away. They don't call Chicago the windy city for nothing.

There was something about this tour de force of  pharmaceutical marketing that shook me in some ways I wasn't even able to name. Wellspring just seemed wrong. Most nurses had a less than favorable view of drug sales folks and likened them to vultures, but I had a different avian vision of these proud hucksters of pharmaceutical wonder drugs. I envisioned drug reps as having all the charms of an old country goose: ordinary with a pleasant demeanor, but an irascible beast that will peck your eyes out when it came down to the hard sell.

I Had The Stew Beat Out Of Me at Downey VA Hospital and All I Got Was This Lousy Letter!

                                                              

         Veterans Administration Hospital

                 Downey, Illinois 60064

              December 4, 1974                                  

Mr. Old Fool R.N.

Nursing Service  118

Dear Mr. Fool:

I am sorry to learn of the injury you sustained from a patient's assault. It is regrettable this incident occurred and I am hopeful you have recovered by this time.

I am aware that working in a hospital such as ours must be conditioned with a recognized possibility of occasional physical and verbal acting out by patients. Due to the nature of some illnesses, certain patients periodically lose control of their emotions. It is only through the contribution of such as you that the hospital is able to help these patients through their difficult periods and eventually restore them to a fulfilling life in the community.

Although you have a positive responsibility to protect and conserve all Federal property, including equipment, supplies, and other equipment entrusted to you, personal remuneration for the broken window you were thrown through will be waived,

I want to personally thank you for your assistance as part of the hospital team in carrying out out mission of service to veterans under our care.

                                                                                     Sincerely yours,

                                                                                      Paul K. Kennedy

                                                                                       Hospital Director

Post script: The VA system has changed quite a bit since this letter was delivered to my mailbox in Building 66 at Downey VA. The official VA seal was updated to replace the anchor and rifle scene with a hodgepodge of images including flags, an eagle, gold cord, and five stars. I think I like the old school seal lots better. There is something to be said for simplicity.

Patient assaults on staff were so common at Downey that a slew of these letters were written. The VA has subsequently ceased apologizing for assaults to limit their liability. In the 1970s, not a soul would even think about litigation, especially against one's employer. Times have changed.

If you're interested in the gory details of the assault here is the link; https://oldfoolrn.blogspot.com/2015/08/knock-out-punch.html 

Last Night in the OR

 

Routine scheduled surgery during daylight hours always reminded me of church services on Easter Sunday or Christmas Morning, packed with posers and pretenders making a show of strutting their stuff.  Members of the administrative office sitter bunch taking advantage of a new day to spread their feathers like a peacock on parade. The more routine the procedure, the more garish the display.

 Midnight surgeries were of a far different persuasion and akin to a mid-summer church service during vacation season where only the true faithful showed up. The daytime pretenders were a totally different breed from the passionate middle of the night doers. It took a determined personality to crawl out of a warm bed on a frigid Chicago night. Owing to a phobia of authoritative administrators, a craving for an adrenalin boost or a youthful naiveite (choose whatever works for you), I'd rather crawl in for a midnight trauma than scrub for an 8AM vein stripping.

Dr. Slambow, my favorite trauma surgeon had lots to say about these late-night adventures and with his jowls dangling below his mask like a giant croissant he would often bellow. "Everyone here believes in life...so let's get this done before the daytime herd heads through the door." Sometimes he would expound at length as to why the only valid surgical intervention was for serious traumatic injury. "Things can only get better from here, but so many elective procedures invent new surgical complications. When was the last time a radical mastectomy or Whipple really cured anyone?" I could see his point. Thank heaven contemporary surgery with its repair and replace mentality has taken place of the old -ectomy for all free for all's. 

Middle of night surgeries often began with a call to the honeymoon suite which was actually a repurposed vintage operating room at the end of the hall in the oldest part of the hospital. There were 2 sets of bunk beds and a wall phone midway off the floor so it could be answered by upper or lower occupants of the bunk beds. The room's light switch was permanently taped in the off position with autoclave tape, so entrants did not arouse those at rest. Call rooms like this were gender neutral and the only prerequisite for use was being bone tired.

Shenanigans were a great way to pass the time and deal with late night tensions while awaiting that phone call to hop to it. I always tried to set a positive tone for our late-night ministrations and frequently started my dialog with the prep and  a lengthy description how I just loved the radiant pinkish glow of Zephirin scrub solution.

 Janess was a frequent partner on these late-night traumas and I usually bunked on the top bed while we awaited the call god's page. When the call abruptly awakened us at 2AM, a shocker awaited me. I glanced down to put my battle tested Clinics on, and lo and behold, my toenails were painted that lovely pink shade of Zephirin prep solution. Janess just grinned from the lower bunk and admitted she had been busy with nail polish while I was sound asleep.

Janess and I had a long history beginning with a procedure partner pairing in nursing school where we bloodied each others arms attempting IV starts. Like so much that happened during our on call trauma . rendezvous, Janess's presence was a paradox. She presided over emergency surgeries like an angel watching  a cemetery. She was monumental in a demure sort of manner.

The call gods could be an unpredictable lot, but everyone knew to pay close attention to the lunar calendar posted in the light just outside the door. Most nurses did not even bother to rack out when there was a full moon, action was imminent.  

I never gave a thought to circadian rhythms or the pitfalls of staying hyper alert for late night surgeries when I was young and foolish. Trauma surgery was a mission and I had always sensed that I would be completely lost without it. Looking down at blood spattered shoe covers at the end of a rough trauma, I could never imagine not being a part of this mission. This was timeless. 

Later in life looking down at varicose veins and arthritic knees, I came to realize I could be just as lost as a result of it. The very thing I thought I needed the most was the thing that drew the shroud of futility around my soul. Helping others while ignoring self-wellness never has a happy ending. and thankfully, most whippersnapperns are more aware of self care than the Oldfoolrns of days gone by.

A High-Flying Patient Returns to Earth

 Usually it's a good sign when you  hear a patient coming through the ER with their shrieks echoing off the green tile walls, but with this one, there was a twist. The disheveled, emaciated gentleman was chanting, "I'm breaking a record. get me back up there." Strange indeed.

As I approached him, a strange combination of olfactory stimuli assaulted my prominent, sensitive beak, a sweet-sour miasma of cigarette smoke and Old Spice cologne to mask the imbedded dirt that made his skin look like a Jackson Pollack work of abstract art. The combination of different colored dirt and a panoply of greenish fungal lesions was a sight to behold.

 I checked the skin turgor on an atrophied bicep and the little mountain of skin generated by the gentle pinch had the staying power of a member of the nurse academic/administrative office sitter complex ensconced in a Lazy Boy recliner. This poor soul was severely dehydrated.

Of course, in pre-EMS days, the Chicago Police were responsible for most patient transfers, and it was prudent to pay heed to the officer's admission commentary for a history of the patient's injury or treatment insights. The jolly young officer presenting us with our latest challenge had an unusual warning that really piqued our curiosity, "You better be able to rehabilitate this one or you're going to have to order a sitting 'em up coffin for him." Sure enough, the unveiling accomplished by an Abra Cadabra top sheet removal revealed some of the most severe lower leg contractures I have ever seen, with his knees flexed at a 45-degree angle so that a conventional flat, horizontal coffin would never accommodate him. This patient was a poster boy for the hazards of immobility.

No, this was not a nursing home patient. It was obvious from the poor soul's wrinkled, weathered, and deeply tanned skin that he had spent considerable time communing with the natural world in the good old outdoors. His well tan, wrinkled extremities had the color of tobacco juice and upon removing his tee shirt emblazoned with the slogan "ANGER MANAGEMENT PISSES ME OFF," a few scraggly chest hairs emerged from a chest that looked like the color of skim milk.

Perhaps a hiker who experienced a mishap on the trail or a construction worker? The patient was strangely nonverbal when queried about his plight, and as the mystery deepened, we decided that treating his dehydration would be a good place to start. His serum osmols were sky high and poor skin turgor cried out for hydration. 

We lacked that clever whippersnappern vernacular back in the day, but the new fangled  term "fluid resuscitation" described what was acutely needed here. Unfortunately, a cursory review of his arms revealed that finding a vein was going to be like looking for a black cat in a coal mine. I corralled the friendly resident to place a central line. He opted to place it in the subclavian vein running just below the clavicle. He punctured the big vein with ease and after verifying a good, nonpulsatile flow began threading the guide wire through the needle. After sliding the catheter in we were in business.

It didn't take long for our efforts to bear fruit and the poor soul began relating his adventurous, but misguided tale. He had been hired by a newly established whiskey distillery on Lincoln Avenue to set a flag pole sitting record as a publicity stunt. This activity, popular in the 1920s and resurrected in the 1960s was exactly as described. Our patient had been confined to a whiskey barrel platform erected on the very tip of a 60 foot flag pole. He was planning to break a 30 day record but was retired after several weeks when his ground crew could not communicate with him and called the Chicago police who delivered him to our ER. 

What goes up, must come down

Before internet advertising, business had to invent a number of  whacky schemes to promote their ventures. Oscar Mayer company had a vehicle resembling a hot dog on 4 wheels aptly called the wienermobile and it was piloted by none other than Little Oscar. Car dealerships used high voltage floodlights to illuminate the night sky and bring in customers. Like the emaciated flag pole sitter some of these promotions ended in a trip to the hospital. Lincoln Mercury had a genuine Cougar on hand at Chicago's Ampitheater auto show and all was hunky dory until the beast attacked his trainer.

It's a good reason that hospitals were not allowed to advertise or I suspect misguided CEOs would have considered a nurse for flag pole sitting duty. They expected us to perform just about any unsavory or unpleasant task imaginable.

'  

The Gas House Gang

 

Who knew a nitrous oxide leak could lead to so much fun??

Life Before Piped in Oxygen - Tanks A Lot

Physiology pivots on the oxygen pinnacle

I thought those gigantic "H" cylinders of oxygen, not to be confused with their lesser sized brotherern, would be with us forever in the hospital. Oxygen delivered to wall outlets in patient's rooms seemed like a pipe dream because we had enough problems with our common old ordinary plumbing. There were steam leaks from autoclave pipes that resembled Old Faithful and recurrent problems with clogged drains. Pipes and problems went together like tweedle dee and tweedle dumb. How in the world could this ever work with a gas under high pressure?

I couldn't imagine oxygen pipes being exempt from similar pipe problems and, of course, I was an ace with the skills necessary to course these massive green cylinders around and about hospital wards and halls. Who needs fancy piped in O2?  A weak mind and a strong back were the only prerequisites for being an oxygen delivery boy, and of course the eager nurses and cyanotic patients were always overjoyed to see me with my life sustaining cargo. Just what a fragile adolescent male cast adrift in a sea of estrogen needed for an ego boost. I was really doing something worthwhile! This is why I chose nursing as a career instead of an auto mechanic.

Oxygen tank storage rooms were special places and out of bounds for most of the fairer sex. Green monsters chained to 2X12 wooden planks and weighing in at over 150 pounds required some muscle and lots of practice to safely handle. I used a trusty dolly to transport these bemouths and once they were set in motion inertia took over. Stopping these rolling monsters was akin to putting the brakes on a battleship.

The other tricky part was maintaining the correct incline while tipping the dolly into position. There were dollys with training wheels for the more cautious, but the tiny caster like wheels used on the trainer support system were prone to gyrating like a belly dancer and slowing the entire delivery process. It was no fun pushing these bruisers down a hospital corridor with those tiny wheels doing the watutsi.

Training wheels also impaired the ability to maneuver the tank into position at the patient's bedside. It was possible to fine tune the position of the tanks when it was released from the dolly by carefully rolling the base of the tank which was all fun and games until you rolled an "H" cylinder over your toes. I preferred the dolly sans training wheels.

Alas, all good things must come to an end, and the conversion of cavernous hospital wards to semi-private rooms was a game changer. Wrestling a colossal "H" oxygen cylinder into the cramped confines of puny 2 bed hospital room was akin to stuffing an elephant into a phone booth, these green monsters longed for the circus big top of a spacious ward where there was ample room to roam.

The construction required to section off individual rooms from the big tent arena of a hospital ward provided an opportunity to run pipelines for the bedside delivery of oxygen, and an end to wrestling with the big green monsters.

Endings like this are usually bittersweet. Yes, piped in oxygen was very convenient, but the bedside delivery of something as life sustaining as oxygen afforded the delivery boy an entire cosmos of goodwill. It was heartwarming to witness the relief and gratitude of patients and nurses alike, while I quickly switched out regulator yokes and twisted my oxygen wrench to the on position and noted the swing of the needle on the pressure gauge from near empty to full, good for another few days of life sustaining oxygen. I was transformed from lowly delivery boy to a genuine care giver and that was good enough for me.

Roller Clamps Were Pioneers in IV Fluid Regulation

                                         

The past is like a foreign country where things are done differently, before the extravagant complexity of intravenous pumps and controllers, simple little roller clamps ruled the roost when it came to IV regulation. I was totally fascinated by these clever little gizmos and even had a collection of vintage roller clamps that I recently unearthed from my nursing archives basement junk hoard. 

These unsung heroes of the IV therapy universe deserve further study as they are not as simple as they appear. An injection molded cage with wheel guides molded into the sides to accept the axles of the adjustment wheel is the most obvious feature. When the wheel is positioned at the top of the housing an uncompromised flow of IV fluid ensues. The device must apply just the right amount of friction to the plastic tube to remain stationary while leaving the lumen of the IV tube wide open, not an easy task. The device then had to regulate the flow of IV fluid by changing the lumen of the IV tubing as the nurse turned the adjustment wheel.

There was strict dogma delineating the correct position of the clamp on the tubing.  Our rigid, uncompromising diploma school instructors insisted on having the roller clamp positioned about 2 inches below the drip chamber so as to be able to locate it in the dark. Old nurses never, ever flashed on blinding overhead room lights at night. Sleep was revered as a healing agent. Having the clamp just below the drip chamber made it easy to locate at night.

There were 2 methods of establishing a flow control region within the clamp housing and one entailed the wheel traveling along an inclined ramp molded into the bottom wall of the device. The other entailed a clamp with the base parallel to the open wheel access port, not a ramp in sight!  The wheel guides were inclined so the wheel traveled at an angle to the base of the clamp whereas the wheel was much closer to the bottom of the clamp when rolled down. The pressure on the IV tubing was varied by the up and down movement control wheel as it moved along the inclinations in the wheel guides.

Some really fancy roller clamps were dual action in that both a ramp and a variable inclinable control wheel changed the lumen of the IV tube. Some things in nursing made no sense and one of the most common places to find these over engineered, exquisite roller clamps was on clysis sets that were used to give fluids subcutaneously. Drip regulation on clysis sets was not a big deal, so why the fancy roller clamps?  Some mysteries are never solved, especially in nursing, but that's a topic for another day.

 Clysis sets were really old school and not subject to medical supply companies seeking to maximize profit margins by making cheaper roller clamps. Travenol clysis sets with dual action clamps even had metal axle spindles on the control wheels. I'm sure it would have been more cost effective to injection mold the wheel and axle in one piece. No cost was spared in producing these roller clamp gems.( For more foolishness on clysis:  https://oldfoolrn.blogspot.com/2015/07/down-quart-hypodermoclysis-to-rescue.html . )

One of the problems with roller clamps was a phenomenon called control point drift which occurred when the control wheel spontaneously moved to a region of less pressure increasing the lumen of the IV tube resulting in increased flow rate. Definitely not a good thing, especially when titrating vasopressors. The dual action clamps with metal control wheels were rock solid once adjusted. The increased  friction exerted by the metal spindles effectively attenuated control point drift.

Another problem with roller clamps involved the properties of the PVC intravenous tubing itself. After adjustment a phenomenon known as cold flow creep sometimes occurred. The lumen of the IV tube would decrease even though there was no movement of the control wheel. Lengthening the control zone on the clamp helped control this problem. Generally speaking, the longer the roller clamp the more stable the infusion rate. Short, stout roller clamps could be a real bear to regulate, some nurses even resorted to taping the control wheel in place.

The labor investment required by manual IV control was considerable because roller clamps needed frequent adjustment, but who would you like to see standing at your bedside, a concerned nurse or a noise barfing electronic poseur? Roller clamps also limited the number of IVs that could be managed on a ward. On a 30 bed unit the maximum number of  running IVs was abour six. Roller clamps are long gone, but not forgotten.