Friday, November 4, 2022
Saturday, October 29, 2022
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?
Sunday, October 23, 2022
(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.
Thursday, October 20, 2022
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.
Sunday, July 24, 2022
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!
Sunday, May 22, 2022
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.
Saturday, April 23, 2022
Saturday, April 2, 2022
Friday, February 25, 2022
Saturday, February 12, 2022
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.
Sunday, January 30, 2022
Thursday, January 27, 2022
|Physiology pivots on the oxygen pinnacle|
Monday, January 3, 2022
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.