Writng on Bed Sheets

Spotless white sheets were perfect for bedside note taking

I'm a diehard aficionado of the esoteric little nuances present in hospital culture. Before  I begin writing (if you could call it that,) a Google search is usually in order. If the topic I had in mind fails to show, I have a winner. I googled nurses writing on sheets and up popped, report sheets, hand off sheets, ICU cheat sheets, and brain sheets. Ahh...perfect, nothing what so ever about nurses and doctors physically writing on hospital linen. 

Seasoned, well past their prime doctors and nurses scribbled on hospital sheets all the time in vintage hospitals. The usual weapon of choice was a ball point pen, but a fine tipped felt marker would do in a pinch. Pencils simply did not cut it for sheet writing and were usually in short supply. Some physicians are inventive and I have witnessed sheet scribbling done with a broken applicator soaked with  Zepharin  solution which added an artsy fartsy touch to their scribbling  due to it's bright reddish/pink color.

Anesthetists in the OR loved to keep track of things like units  of blood or dosages by scribbling hatch marks on the sheet near the patient's head. Procedures calling for an intraoperative position change would frequently throw a monkey wrench into linen record keeping systems. The vital hatch marks could all to easily relocate to an inaccessible position. Another SNAFU was keeping simultaneous tallies such as one for units of blood and the other for ventilator settings and then confusing one recording for the other. This could lead to strained conversations such as, "Those markings are for the units of packed cells and this one over here is for tidal volume...or is it the other way around??"

Orthopedic surgeons were frequent sheet scribblers and left notes for the proper positioning of traction equipment. Before Campbell's Operative Orthopaedics became the dominant textbook, closed reductions with traction ruled the roost. All those weights, slings, and pulleys just called out for sheet side illustration.

Pioneering total hip replacements were affectionately referred to as low friction arthroplasties and required complex post-op nursing care. Hemovac drains required constant attention to maintain patency and Pehr splints to prevent abduction generated lots of twiddling. Putting an octopus to bed would have been small potatoes compared to caring for total hips.

Arthroplasty patients were to stay flat on their backs for 7 days and could not be turned side to side to make a typical occupied bed. The arduous procedure entailed suspending the hapless patient over the bed while making the bed from top to bottom. Many students sought to avoid the linen change ordeal by carefully maintaining the condition of the bottom sheet. Miss Bruiser, my favorite instructor, was always one step ahead of her intrepid students. She would make a tiny mark on the sheet in an unobtrusive spot and then check back to see if the sheet was changed by observing for the absence of her mark. If the mark was observed after the student finished morning  care a tongue lashing and demerits were liberally issued.

An  unusual sheet writing adventure occurred in the OR just prior to an induction. One of the staples stocked in our break room was canned sardines which were opened by inserting a special key into a slot and unrolling the top of the tin. The discussion among the surgical residents was how to open a can of sardines without the key. A diagram of a sardine can was scribbled on the top sheet covering the patient and the explanation ensued. "The first step is to center a knife over the crease (in the can) and make a fist around the knife. Next strike the top of your fist until it pops open." The patient thought the good doctors were discussing operative technique and let out a shriek of horror. It took several minutes of explanation to restore order and calm the patient. You can never be too careful when patients are awake in the OR!

Wagensteen Suction - Elegantly Simple Without Electricity

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Wangensteen suction in action during the 1930s. The water level in the top bottle
drains by gravity into the lower bottle to the left generating negative pressure. 
A glass drinking straw inserted to the top of the top bottle conducts suction to the patient.

Whippersnapperns  don't give a second thought to the equipment  needed  to suction a patient. Intermittent Gomco, straight tracheal suction, or low pressure Wangensteen, just plug that suction  regulator into the handy dandy wall socket and go to town. Like everything else in today's high technology world, handy dandy wall suction is a convoluted, complex system masquerading as something  simple. Hospital  centralized suctions are anything but simple. Bright  young whippersnappern are  tapping into an over-engineered, overpriced  pipeline connected to hidden pumps, vacuum reservoirs, traps, filters, regulators, sensors, and alarms. I shudder to think of the resources required to maintain this complex hodge-podge of exorbitant  components.

There is an easier way to maintain GI  suction on  a post - op patient suffering from a paralytic ileus. I'm not talking about those plug in "portable" machines that weigh 1/2 as much as your patient. There are few pieces of medical equipment that generate a more annoying buzz saw  noise than portable suction machines. A bone saw in action might sound worse, but at least the patient does not hear it.

Electrified  suction machines in action remind  me of the time a yellow jacket flew inside my full coverage motorcycle helmet while cruising on Lake shore Drive. You can't turn off a buzzing suction machine when suction is necessary and you can't remove  a helmet in heavy traffic. Meanwhile that persistent  buzzing is driving  you  nuts.

In old diploma nursing schools, instructors like Miss Bruiser, my all time favorite, frequently said that we should learn how to do something "just in case."  Students were required to "learn" how to smoke cigarettes so we could better relate to psych patients. Other various hacks were part of the "just in case" curriculum like using sterile finger cots to perform procedures in the event we ran out of gloves.

We were also taught how to construct a do-it-yourself Wagensteen suction using 3 large glass bottles, rubber tubing and a glass drinking straw "just in case" of a power failure. Old hospitals had no backup power supplies.  The  principle underlying manual Wangensteen suction was Boyle's gas law which stated there was an inverse relationship between pressure and volume. As the water flowed out of the glass bottle on top, a negative pressure was created by the increase in size of the void within the bottle. A glass drinking straw inserted through a hole in the stopper served to harvest the vacuum created by the falling water

The clothesline pulley on top of 

the stand facilitated bottle exchange

There were a couple of ways to suspend one large glass water filled  bottle above another. The easiest way was to hang it  with a canvas sling suspended on the rail for the bedside curtain, but this required lifting the bottle on the floor when it had filled upon completion of a cycle. A big glass bottle filled with water requires the arm strength of Magilla Gorilla to heft back into position.

 A more elegant system involved a pole outfitted  with an ordinary clothesline pulley which according to my notes could be obtained at any hardware store. A length of rope about 7 feet long was attached to each bottle and threaded through the clothesline pulley  assembled at the top of the pole.When the bottles needed exchanged after draining, a nurse could swap their position  with a  not so gentle tug on the connecting rope. As the bottles made their up and down journey continuous suction was maintained as water continually drained from top to bottom. Dr. Owen Wangensteen, the inventor would have been most proud.

There is something to be said for simple devices cobbled together with a nurse's two hands. Wangensteen suction was a breakthrough discovery in the 1930s that reduced operative mortality from 44% to less than 20%. Owen Wagensteen should have received the Nobel Prize for medicine in 1931, but they gave it to someone who discovered an esoteric enzyme. Simple, silent devices like this suction engender those immersive, visceral feelings old nurses experienced from directly helping someone feel better even if the nurse  was too busy yanking on the clothesline to take a break for a Coke and a smoke.

The Disappearance of Needle Stylets

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A thing of beauty is a joy forever. A stylet at home in the bevel of a needle

New fangled disposable injection needles with their cheap looking plastic syringes were just beginning to show up on wards at the beginning of my nursing journey. I just love that "journey" vernacular so common in today's healthcare lingo. See, I can talk just like a whippersnappern if I try really hard.  Anyhow, old school nurses had lots of laments about disposable equipment of any permutation because it  went against the grain. We were taught to reuse just about everything. Throwing away Monoject disposable syringes was bad, but the elimination of stylets was even worse.

Reusable injection needles always had a stylet running the length of the needle bore that terminated at the beveled business end of the needle. Whippersnapperns might start out their day by logging on to a computer, but their predecessors started out by sharpening injection needles. The stylet was a vital component to reusable needle maintenance and sharpening. Ramrodding a stylet through the needle served to clean the bore of any residual debris. When sharpening was completed the stylet served to clear the needle bore of any residual micro shards from the grinding process.

Stylets also served as a template to maintain the appropriate angle of the needle bevel during the sharpening operation. Minimalist minded nurses could sharpen a dulled needle on an ever present match book striker. Needle sharpening was one of those rare instances when a nurse was off her feet and the matchbook was a cue for a quick smoke. Smoking and sharpening needles went together like peanut butter and jelly. Mechanical devices for needle sharpening were most commonly hand cranked gizmos where the bevel of the needle was rocked back and forth by a cam while pressed against a rotating wheel all the while an indwelling stylet maintained the bevel angle.

Every nurse's station needs a needle sharpener

Biopsy needles with their very shallow bevel always have a stylet as a stiffening mechanism and as a control over the cored tissue sample. When sampling liver tissue from an obese patient the stylet is left fully engaged during it's journey (oops..here I go again with that "J" word) through the subcutaneous tissue. When the final liver destination is reached the stylus is withdrawn to snatch a core of tissue. Stylets are also needed to expel the cored tissue from the biopsy needle.

When performing spinal taps or removing fluid from a body cavity, the stylet is also necessary to control the flow of fluid. No stop cock can halt the flow of fluid through the lumen of a needle like a trusty stylet.

Inventive nurses discovered that stylets have  unintended uses that have loads of utility. When the hinge screw mysteriously disappeared  from my ever present eyeglasses a quick fix was needed. I discovered that a stylet from an 18 gauge needle was the perfect diameter to fit the void left by the missing screw. With the stylet in place, it was a simple matter to bend it in the shape of a horseshoe with a needle holder. A perfect fix. It was also common knowledge that a stylet was the perfect instrument to pierce ear lobes for those nurses that liked to decorate themselves with earrings.

It's nice to know that stylets have survived into the present age with spinal tap and biopsy needles, but once upon a time every needle worth it's jab had a stylet.

Hospital Signage

Yesterday's sign was a model of stark simplicity

Today a ridiculous hodge podge of word jugglery. What a mess!

Cyclopropane Anesthesia - A Blast From the Past

Inhalation anesthesia was dominated by ether until cyclopropane made it's debut in the late 1930s. This new agent was potent and did not induce the unpleasant nausea and vomiting associated with ether. Those operating room scenes from Ben Casey or Dr. Kildare where the patient is asked to count to 10 after the anesthesia mask hit their face were classic cyclopropane inductions. Most were sound asleep by the count of 3. Cyclopropane was like magic pixie dust in an orange steel cylinder;  inhale it and almost instant anesthesia, back on room air, and presto... near immediate emergence. There was only one problem, cyclopropane was explosive and had the potential to turn just about any cysto room into a wiener roast.

Every old time operating room suite  had a cyclo room that was heavily modified to avert cyclopropane detonation. I always liked the way cyclo room sounded when pronounced, it had an eerie Alfred Hitchcock feel to it because it sound so much like "psycho room." Indeed these were different sort of rooms where strange rituals and  happenings prevailed.

Cyclo rooms persisted until the early 1970s. Any new OR suite constructed post 1970 lacked an explosion proof room. The first line of defense against exposions was the elimination of statuc electricity discharge by grounding everything to a terrazzo floor which was interlaced  with conductive copper dividers. A gleaming terrazzo floor lined with glowing copper dividers was a beautiful sight.

Everything in the room was supposed to be grounded to the conductive floor. Operating room personnel wore shoes that were modified by a metallic plug smack dab in the middle of the sole and shoe covers had a conductive strip running from toe to sole. First order of business upon entering a cyclo room was testing shoe conductivity by stepping on a small bathroom scale like device. A green signal meant all was well and it was OK to proceed. The shoe testing requirement also served to exclude rubbernecking snoopers and busy body administrators. Only the personnel that really needed to be there were present. An anesthetist, 2 nurses, and a surgeon with an assistant could handle just about anything that came along.

Equipment in the OR was grounded to the floor by tiny metal chains that jingled  when the furniture was moved about. Old operating rooms were always furnished, never equipped. The anesthesia cart which was always a repurposed Sears Craftsman rolling tool chest  had double chains. Why take chances?

The other approach to explosion proofing the room was a bomb squad containment mentality. Potential sources of explosion were shrouded in a heavy steel housing. Operay overhead surgical lights had a particularly robust containment chamber that I thought resembled Russia's Sputnik satellite. I'm not so sure I would like to be laying on the table with that ominous black orb hovering  overhead. It looked spooky to me.

The electrical switch for the Operay was covered in a heavy leather boot that looked like the covering on a Mack truck gearshift. Every time I turned the overheads on, I imagined the carefree life of an open road trucker as opposed to facing up to the stressful work ahead. Oh well...at least I did not have to worry about unannounced visits from my favorite nemesis, Alice, the all knowing supervisor, always steered clear of the cyclo room.

Working in the cyclo room was always the best part of my day, and then later on, the best part of my night. On call, high risk emergency trauma surgery was the perfect venue for cyclopropane because it actually elevated blood pressure to improve perfusion. A good question was; If cyclopropane is so frequently selected for the high risk trauma patient, wouldn't it be good for the healthier patient? The limiting factor was the risk of catastrophic explosion.

I loved the peace and quiet in the cyclo room. There were no Bovies  buzzing or power tools whirring, just the quiet swish as the anesthetist went about  breathing for the patient. The brisk snip sound of straight Mayo scissors cutting ligature after ligature was almost hypnotic.  Occasionally while in the midst of a messy trauma surgery you could actually hear a vessel bleeding.

 Cyclo also had a very pleasant, gasoline like smell that always reminded me of one of my favorite high school courses, auto shop. No matter how carful the anesthetist was with holding the mask, a tiny bit of cyclo always seemed to pervade the room.

Attending anesthetists often told the residents that cyclo was to be   handled with the finesse of a violinist, not with the banging of a kettle drum. Anesthetists were also advised to keep in physical contact with the patient at all times to keep the electrical potential balanced.

Whenever I see a modern operating room furnished with enough electronics to land a 747 in a whiteout and multiple OR personnel milling about it shivers my timbers to the core. To heck about worrying about the finesse of a violinist, these rooms are the equivalent of a symphony orchestra complete with a grand piano. Cyclopropane R.I.P.

Bed Scale Blues

It's easier to push a stalled '57 Chevy than a bed scale!

I made the mistake of reading some of my old posts and some of them resemble a distant ping from a satellite knocked out of orbit. Tales from a far away planet where bedside care was the only currency that mattered and what little money there was flowed away from nurse's pockets. It sounds paradoxical, but the more interface I have with "modern" healthcare, the more I miss the old days.

Oh well, Nero's circus must go on so here's my take on vintage behemoths that were part Hoyer lift, part ironing board, and finally part piano mover's dolly with enough free weights to open a gym. Bed scales were the hospital version of battleships, difficult to change direction when in motion, fraught with danger and best left alone.

The illustration above shows an intrepid  young nurse in transit for her mission; to weigh a bedridden patient. The ironing board part of the scale is hinged so it's vertical when in storage or moving  struggling down the hall. It's visible on the right side of the scale just inside the counterweights. After an arduous journey to the bedside, the ironing board like platform was tilted to a horizontal position. The patient is pulled, pushed, or glided onto the awaiting platform. You know, that old count to three and grunt routine.

The platform is elevated like a not so magic carpet by way of a hydraulic Hoyer lift like pump. Now for the fun part -  where the rubber meets the road. The patient is suspended inches above the bed while the nurse turns her attention to balancing the counterweights. A potential  hazard included becoming distracted by the precarious position of the patient and dropping a 20# weight on your foot. Clinic nursing  shoes did not have a safety toe so that's really going to leave a dandy bruise, if you are lucky. The not so fortunate will see the ortho clinic with compound fractures of the metatarsal bones.

One of the great nursing debates involved the question of including peripherals (How about that? I managed to hijack a term from the computer industry.) like Foley bags or surgical drains in the bedside  weight. The free spirit nurse simply tossed the Foley bag or drain apparatus into the mix and included it in the final weight. Dangling Foleys and drains were always at risk for unintended extrication during the transfer or elevation process so I usually left them be and subtracted a pound for the tare at the conclusion of the procedure.

One of my most colorful nursing instructors, Miss Bruiser had a favorite saying, "Work smarter; not harder." Every nurse hated bed scales with a passion and looked for a smarter procedure when it came to patient's weights. In nursing research there are methods for assuring interrater reliability so that results are consistent. Nurses weighing bedridden patients took a lesson from carnival weight guessing hucksters and followed suit. Before the bed scale weight was determined, the nurse took a guess at the patient's weight. When her guestimate came within 5 lbs. or so she became a certified patient weight confabulator. Leave that massive bedside scale in the clean utility room and bring in the certified nurse weigh approximator. These nurse's were also trained experts at clairvoyant counting patient's  respirations.

What happened to Mop Swinging Nurses?

"That spot you missed will cost you 10 demerits"

Nurses from my generation knew their way around a janitor's closet as well as whippersnapperns know how to monkey with a Pixis. Mopping floors was an integral part of any diploma school nursing education curriculum. Just when you thought nothing could top scrubbing mucous/emesis stalactites from bed frames, mopping madness was introduced.

The swabbing the deck curriculum began with an orientation to perhaps the most important and critical cog in the hospital hygiene world which was the lowly slop sink. These marvels of plumbing technology consisted of a square, slightly elevated receptacle just inches off the floor. They were marble back in the day, but toward the end of my nursing days they were (gasp) fiberglass which definitely  lacked presence and looked cheap. Slop sinks close to the floor were a real boon to a nurse's back because the massive 30 liter buckets could be filled and emptied with minimal lifting. Filling buckets was lots more fun than emptying the bacterial/blood/stew medley that frequently accumulated after a mopping session.

Home base for the RN mop crew was a trolley consisting  of two 30 liter buckets on a mobile platform.  Bucket # 1 was filled with 19 liters of hot water and a foul smelling witches brew of ammonia compounds and an overpowering  detergent that really meant business. The ratio of solution was 10:1 and this factoid was always a question on just about any test. Bucket #2 was equipped with a wringer and Miss Bruiser, my favorite instructor, claimed that aggressive mop wringing was good for the bust line. I don't know about that, but my signature move was twirling the high modulous cotton/rayon mop head as it settled into the wringer which really got the juices flowing (the mop's, not mine) when the wringer mechanism was actuated.

Alice, my favorite operating room supervisor was equally  adept at mop swinging as sponge stick loading. My mopping abilities were honed to perfection by lessons from Alice. She  said to always pull the mop toward you while moving backwards. I modified her technique to a sideways  stance after backing into a kick basin and nearly breaking my neck in a free fall to the floor. After that episode I often referred to them a trip basins.

I actually enjoyed mopping operating room floors. The rhythmic swinging of the mop had a meditative component to it and I loved seeing the immediate results of my labors. After dealing with verbally assaultive surgeons and aching fingers from loading needle drivers, mopping was  a refreshing oasis complete with the soothing sloshing of water. A gift.

In the sunset years of my work in the OR, young nurses were surprised at my love of mopping and suggested there might be a better use for my skills. I was far too compliant to question mopping duties and too foolish  to refuse, after all, I was doing it for the patients. Old nurses would do just about anything for their patients.

Today on my frequent visits to hospitals as a patient, it's as though I'm entering the Twilight Zone. I don't know which is worse, carpeted floors or the total absence of moppers of any permutation. Modern hospital have descended to a hellscape of ubiquitous beeping and bleeping electronic doo-dads with nurses caring for computers on wheels. I would much rather be wheeling around something of substance like a fully loaded mop trolley.

Clandestine Patient Restraint Techniques

Nurses providing ambulation assistance 

for an afternoon nap.

Restraining patients is probably one of the most unsavory elements of nursing practice and old school practitioners were masters of obfuscation when it came to forcible restriction of movement. Even office sitting nurses of the academic/administrative complex eschewed patient restraints. Everyone did their very best to find ways around outright restraint of those under their care.

Memos from on high regarding patient restraints were filled with officialese and gobbledygook in an attempt to camouflage what was really  going on. I found a VA restraint and seclusion Professional Services  Memorandum that illustrates this point: VA Form 10-2683, Report of restraint and seclusion.  "The doctor's orders (SF508) will be initialed by the GS9-11 ward nurse. The nurse will copy the prescription (form 10-2913) on the nursing notes (SF510) indicating the type of restraint and 24 hour report of patient's condition (VA form 2915). The nurse in charge of the ward during each tour of duty will maintain a record of each application of restraint on VA form 10-2683. After the last day of the month, the nurse will sign this form and forward it to the Registrar Division - 114A."  Some head nurses referred to the monthly reports as the "Funny Papers" because restraints were not always used according to Hoyle with the frequency of use almost always understated.

Downey VA Hospital, the long term psychiatric hospital I worked at in the early 1970s made extensive use of full restraints that consisted of heavy leather cuffs secured by robust belts. My ways of caring for these patients were unique and foolish, but averted some  of the unpleasantness associated with 4 point restraints. I began a patient enlightenment program that involved patients recognizing when they were beginning to escalate and request restraints before anyone was injured. A veteran of the Viet Nam war summed things up quite  nicely, "Restraints are just like an Asian civil war-much easier to get in than get out." I couldn't have said it better myself.

This illustration clearly shows the time tested maneuver aptly called "let me hold your hand...DOWN. Whether inserting nasogastric tubes or assisting with  excruciating procedures like the removal of Jackson-Pratt surgical drains, every old nurse had experience with this one. Initially, good intentions entailed holding the patient's hand for support, but soon evolved  into a vice grip not unlike the panic induced squeeze on the overhead bar of the Ravenswood EL train as it rounded an acute bend. Hold that patient's hand like a trapeze  artist grips the bar while the good doctor gives that J-P drain one final yank.




Distraction is another useful tool in the nurse's position inhibition  armamentarium   (please note, I did not use that dreaded "R" word.) This trick procedure does not work well with painful ministrations about the head and neck, but is very effective for procedures below waist  level like bedside urethral dilitations or removal of orthopedic external fixation devices. The nurse elevates the bed so that the patients eyes are close to the height of the nurse's ocular orbs. The patient's  head is immobilized between the hands as the nurse locks eyes with the hapless patient. Extreme eye contact seems to slow things down  and put a damper on some of the unpleasantness.

Children are especially vulnerable and the isolated snippets  in my mind of pediatric restraint have long sense departed. Whew! Am I ever happy for that. There is a harrowing  pediatric restraint device known as the  Pigg-O-Stat. Google it if you dare. This thing looks like a blender with the lid off and the youngster is dropped into it for X-ray procedures. It's no wonder so many people have claustrophobia later in life. They were probably popped into a Pigg-O-stat as a mere youngster.

 One of the more humane child restraint devices is a take-off on the old Trojan Horse idea. The restraint device is a toy rocking horse that lures it's young patients by whimsical looks, not brute force. While the child plays horsey, an X-ray plate is slid into position and the exposure made before anyone is the wiser. An elegant restraint solution! I wish they all could be so easy.

Show Me the Money and I Will Show You Why That CVP Line Stopped Transducing

It really grinds my gears when entrepreneurially minded nurses seek to monetize assorted tutorials for learning clinical skills. Theoretical nursing in an academic environment is ridiculously overpriced and I understand the plight of whippersnapperns facing exorbitant school loans, but bedside procedures should be passed along  with a sense of pride and  respect for the history of nursing. The sense of well being gained by seeing a young nurse confidently perform a procedure you showed her how to do is priceless. It's your extension in time and will bring a warm feeling to your foolish heart when you are old like me.

Image courtesy Maklay 62

Diploma schools were big on ceremony and pageantry with ascent through the nursing hierarchy. Youngsters today may have dollar signs in their eyes, but for us, the ultimate reward was that coveted pin. Dreams of walking down the aisle  with our Nightengale Lamps leading the way to receive our pins were what we thought of in troubled times. Thinking about money was distant in our minds and any mention of financial gain earned you a speedy exit from the program. It was just palin wrong headed thinking and an egregious example of putting your needs before others.

How do you unite nurses from different generations with different values? One  way was  passing on  clinical skills from experienced nurse to novice. The scrub nurse tricks of the trade that I learned from my nemesis, Alice, are precious beyond any means of monetary compensation. I didn't learn how to load a sponge stick one handed or count out ten 4X4s in a nanosecond by paying money to watch a video. No, she never smiled or encouraged me like the glad handing  nursing procedure hustlers selling their videos. Humiliation was a powerful motivator.

I shudder to think of the consequences incurred by  offering a Greatest Generation nurse money for procedure tutorials. They could survive on next to nothing because working as a nurse was a reward in of itself. Their  notion of self care was a 15 minute nap in the lounge after being called in for a middle of the night case and working 9 hours the next day. Life was meant to be difficult and nurse's were destined to a life of poverty. I admired them with unbounded abandon and was a mere sissy compared to their resolve. I wish a few of them were around to deal with today's nurse monetizers.

CVP lines were in their infancy when I was practicing and I made it my mission to learn all I could about central line procedures. Obtaining a central pressure involved a carpenter's level, a three way stop cock, and a manometer. Connecting them to a transducer opened up a Pandora's Box of problems and involved endless fiddling for a reading of dubious value. They were a real pain to deal with. I was thinking of producing a video explaining some of the pitfalls of CVP lines and possible solutions. Of course this is going to cost you, but, in all honesty, I would rather sell a kidney than profit from teaching the next generation of nurses. We are all in this together so let's pause and think about the needs  of novice  nurses before whoring out something sacred like the mastery of bedside procedures.

Overhead IV Racks Done in by IV Pumps and Controllers

An overhead IV rack in it's safest position-on the ground

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Imagine a device that would take advantage of unused vertical space above the patient's bedside and free up congested floor space. Sounds too good to be true?  Well, it was.  In the early 1970s a new fangled device came to our fancy new state of the art ICUs. Designed by architects with decades of office sitting experience, but loathed by nurses at the bedside, the wonderous new creation was overhead  suspended IV hangers.

The ceiling was equipped  with tracks that ran around the periphery of the bed in a semi-circle or as a single diagonal running from the foot to the head. A looped hook with ball bearing wheels roamed the confines of the track. The IV rack  had a pigtail like structure at it's upper most  point  that was carefully threaded through the hook and you were in the  business of IV bottles in the sky.

These clever contraptions utilized a release button that dropped the rack down to working level that just happened to be the height of the average bedside nurse. It was fun and games for all until  a spontaneous release that dropped the loaded rack in a nondeviating  path on the top of a vulnerable cranium below. Talk about Excedrin headache #47, that really smarts. I think overhead IV racks may have been the impetus for semi-private rooms. A nurse was concussed by an overhead IV rack and rather than open another hospital room, an additional bed was wheeled in for the traumatized practitioner.

Another problem with overhead racks was a phenomenon known as "uplifted bottle drift." My recollection of high school physics is a bit fuzzy, but one of the facts of inertia included the notion that once a body is set in motion, it stays in motion. A sudden lateral adjustment of the heavy glass bottles position in the ceiling track sometimes meant the contrivance flew past it's intended stopping point resulting in a most unpleasant crash/bang with light fixtures or anything else in it's path. Twin overhead racks over a single bed were an accident waiting to happen. If both loaded racks collided, a shattered glass shower was inevitable as the bottles self destructed. If you think cleaning up glass IV bottles from the floor is bad, you haven't seen anything, as an occupied bed full of injurious glass shards glass was far worse. A two for one deal of the supremely noxious variety as both nurse and patient were potential laceration victims.

Gravity was a dependable vector to deliver IV fluids, but there were lots of variables when the only controlling mechanism was a roller clamp. This necessitated endless fiddling and adjusting as vascular resistance varied or the fluid level in the bottle dropped. See-sawing IV drip rates were always explained by that ubiquitous "P" word. Positional covered lots of possibilities from the position of the IV catheter to the movement of an extremity.

A revolutionary development appeared in the mid 1970s. Fancy little IVAC machines with glowing electric eyes plastered to the drip chamber began appearing. This clever little apparatus accurately controlled pre-set drip rates. Older nurses thought they would never catch on due to their expense, but to me, they were magic in a box. IVACs and the even more sophisticated pumps that followed required an IV pole for support. IV poles meant the death of overhead IV racks. We did keep a couple of the flying IV racks on the unit because a few of the patients enjoyed posting family photos or inspirational slogans on the overhead racks. It was a genuine boon to patient morale to look up and see a reassuring image and some of the hazards of these racks was mitigated by the absence of heavy bottles.

If you are interested in acquiring an artefact of nursing/hospital history, there are loads of these fickle firmament flying fixtures for sale on EBAY. Just don't forget to duck!

A Vintage Operating Room Table

A classic Amsco O.R. Table. Turn one big wheel for elevation, the other for tilting

the head up or down. Grab the gear shift handles to activate breaks. Shift into first

gear and use the stirrups for gyne and urology procedures.

Old time operating rooms were furnished, not equipped like today's technological marvels. The focal point of just about any OR is the table because that's where the all the action happens. Vintage surgical platforms were crude, but effective pieces of furniture that could function without electricity. No complicated owner's manual  necessary. The adjustment wheels applied torque to gigantic screws that moved the table.

One of the design flaws was locating the position of the exposed screws with their inclined plane below the table.  Accessing the controls of a draped table required a trip down under for the circulating nurse. Circulating nurse was one of those new fangled terms and fools older than me called them "hustle nurses."  I was a frequent volunteer for this duty because I relished the serene environment  under a draped OR table while all that noise and fuss emanated from above.

During my under table sojourns it was all too easy to allow for some foolish daydreaming. Those big shining control wheels looked like they belonged on a yacht and sometimes I  imagined myself at the helm of a pleasure vessel on peaceful  Lake Michigan or driving a race car in the Indy 500.  A break from all the drama above always refreshed.

The exposed screws were also in a vulnerable spot when it came to collecting fluids from above. Blood would clot and dry on the surface of the adjustment screw so that subsequent rotations would produce a colorful rooster tail  of flying red flecks that reminded me of those spinning fireworks shooting sparks. The mini pieces of dried blood flying about would also refract the light from the big overheads creating a miniature light show that was a sight to behold

Surgeons had no direct control of patient positioning and were at the mercy of nursing and anesthesia to adjust the table. Positioning attempts were initiated immediately after the one...two...three... count  transferring the patient from a cart. Kindly surgeons like Dr. Slambow would always help lifting and transferring patients from the cart to table. Non verbal, cold as ice stares awaited less helpful surgeons who soon learned the up side of team work.

There were no specialty OR tables back in the days of one size fits all surgical platforms. Sand bags, rolled towels, airplane belt restraints padded with egg crate, and whatever else we could scrounge together made up our somewhat barbaric positioning armamentarium. (I just love that A...… word because it sounds like I might know what I'm talking about!) When we applied a restraint belt to a conscious patient the party line was always, "Since the table is so very narrow we use this for safety." There was no mention of the fact the belt helped keep them on the table if an abrupt anesthesia emergence occurred giving an alternative meaning to ambulatory surgery.

When The KARDEX Was King of Communication

Glen from Texas emailed me with a suggestion to write about my experiences with the nursing KARDEX which he advised is disappearing. I had no idea. How could something with so much utility just up and disappear?

Christians have their Bible, Jews have the Torah,  and nurses from a bygone era had their KARDEX. Named after a company that specialized in using index cards for data storage, KARDEXES  were the center piece of any nursing station. Patient charts come and go with whoever snatches them up, but the KARDEX is always front and center at any gathering of nurses. Change of shift report without this wonderful collection of data would be impossible.

The front and back of  a vintage KARDEX was a solid sheet of gunmetal grey steel with a piano hinge through the midsection. When you opened this hefty collection of vital information an audible, metallic  CLUNK would echo around the room. That harmonious sound reminded me of a church bell announcing that something important was about to happen. The flipping through the KARDEX index cards  made a gentle rustling sound like the wind blowing through a Midwest cornfield just before the combine moved in for harvest. What a contrast to the contemporary clicking, bleeping, and clacking of a computer keyboard. I loved this bit of KARDEX  acoustic candy because it was an auditory sign that my shift was over and more peaceful, restful times were ahead.

What information was included in the KARDEX?  Everything a nurse needed to know when providing patient care: demographics, treatments, medications, allergies, consults, code status,
 urine reductions, diet, surgery, I&Os, IVs, and  IM injection rotation sites (everyone received these painful ministrations and rotating the  sites distributed the pain over a larger area).  The patient's name and physician was written in ink, but everything else was written in pencil and unlike the medical record, subject to erasure. The Kardex was not a formal document and when the patient was discharged, the cards were ceremoniously tossed in the circular file. No HIPPA - No shredding.  Identity theft was unheard of.

From my blogging foolishness, I can attest to the fact that people say different things under the cloak of anonymity and the KARDEX was no different. I was a quiet and reserved scrub nurse and just look at the blowhard  I've become  with an anonymous blog.  Notations in the Kardex were not signed and nurses perfected a generic form of printing to avert handwriting analysis. This cloak of secrecy  promoted blunt and sometimes crude KARDEX entries.  KARDEX notations often liberated many a nurse's free spirit and foolishness was not too far away.

Nurses who came  before me often had to administer painful and unpleasant (to say the least) treatments and never took "no" for an answer. Rather than write that it was necessary to restrain or hold a patient to the bed for a treatment, code words were used. "Patient needs assistance maintaining proper position for enemas," sounds better than "restrain his arms to prevent fighting to dislodge  enema tube."  In pediatrics the youngsters often needed "help" to receive painful injections or treatments. Those old school nurses were a force to be reckoned with and their KARDEX entries sometimes bordered on fiction. I vowed to never cultivate a mean, sadistic nature present in these hard core care givers.

As I was thinking about the KARDEX, a stream of odd ball and memorable entries returned to my obtunded consciousness. Every student nurse remembers their very first patient. Mine happened to be a pleasant, young Hispanic man recovering from a heroin overdose. Prominently displayed on his index card was a very good suggestion: No heroin on discharge.

Downey VA could be a very dangerous place to work and assaults were an unfortunate occurrence. A night  nurse pulled from the medical side of the facility left an ominous warning taped to the front of the KARDEX: Unsafe to be in attendance here  at ant time. DO NOT ask me to cover this ward again. I heartily concurred but could not do much about my situation. Building 66 was my permanent assignment.

Folks addicted to drugs had a very difficult time in vintage hospitals and old school nurses seemed to delight in social engineering to make their stay as miserable as possible. The old "That'll learn ya" attitude on steroids. A frequent entry on a drug addicted patient's Kardex was: Known drug abuser-no pain meds of any kind.

Floor is slippery. Patient expectorating giant phlegm globs.  Enough said.

If patient is experiencing difficulty voiding, have him blow through a drinking straw. Along with running the sink, this trick really worked.

On the post-partum unit: Remind patient to pull inverted nipples out. Ouch..as if the delivery experience wasn't bad enough.

A patient, Dudley, that I cared for as a student nurse smelled of urine no matter how carefully I bathed him. A perusal of the KARDEX offered an unusual explanation of the pungent odor.  Remove patient's prosthetic leg  from the room on PM shift. He awakens at night and fills it with urine.

Have footwear at bedside for AM pulmonary function testing. We all knew what this entailed.  PFTs were conducted in the stairwell at the end of the hall. If a patient could ascend  2 flights of steps with a  resident encouraging him from behind, he was deemed an acceptable surgical risk. Just be careful not to slip on the giant pools of phlegm/mucous left behind on the steps.

Some patient families are prepared for just about any contingency. I remember well the family that brought a 3 piece suit to the hospital with a dying patient. The KARDEX notation:  Make sure the suit in the clean utility room goes with the undertaker when he comes for the body. Yikes!

KARDEXES were the hospital equivalent of a jungle telegraph and revealed information that you were afraid to ask about or never knew existed. I think rigid and permanent forms of medical record keeping, electronic or paper, can block nursing inventiveness that drive holistic care. The old KARDEX unleashed the nursing free spirit by delineating what really worked for the patient.
                                                                                                                                                                                                                                               

Fun With Operating Room Kick Buckets

My recent visit to Pennsylvania Dutch Country rebooted a long dormant memory of an unfortunate incident  with that wheeled dervish, an operating room kick bucket. The Amish eschew internal combustion engine powered transportation devices in favor of things like foot powered scooters. One foot remains firmly planted on the scooter platform while the opposite lower extremity propels the device with intermittent kicking motions. As we shall see, that mode of propulsion is not exclusive to Amish scooters.

Kick buckets in the OR are similar to Amish scooters in that they share the ability to move through space on wheels and are about the same size. My tale begins as another long case comes to a conclusion and I am involved in the usual post-op prattle with Janess, the exhausted scrub nurse. As she descended from the artfully OFRN designed scrub nurse  platform her foot landed smack dab in the middle of a carelessly positioned  kick bucket. The wide opening at the bucket top guided her foot into the much smaller base firmly entrapping and immobilizing her leg in the contraption. Luckily the bloody sponges had been removed from the kick bucket or the situation could have been rather messy.

The ensuing commotion soon aroused the attention of our hypervigilant supervisor, Alice, who added to the cacophony with one of her bitter diatribes. "Look what you've done now you clumsy little goofus. I've got a mind to teach you a lesson that you won't soon forget," shrieked Alice.

Janess was now a hostage of her sympathetic nervous system which activated the flight or fight instinct. Alice was a contentious character with a military background so the only viable option was flight without further ado. With one foot entrapped in the confining but mobile kick bucket, Janees used her free extremity to propel herself through the open door with all the skill of an Amish scooter driver. Alice was not up to speed with her arthritic knees so Janess was able to open up a substantial lead and soon disappeared into the locker room. The ensuing laughter soon took the wind from Alice's sails and we all lived happily ever after...sort of. Folks that work together in stressful environments like operating rooms often transforms themselves into one big dysfunctional family. It did not seem like much fun at the time but in a strange way, these were some of the best years of my life.

Ring Stand Challenge Racing

An official makes last minute preparations to the race course.

Old school operating rooms were brimming with an assortment of unsavory, unpleasant and downright dangerous tasks; from unclogging floor drains occluded with who knows what to running test firings on  hissing and sputtering behemoths that passed as autoclaves. Who cleans up the room after a trauma case and who tends to the patient?  We used to draw straws with discarded suture for the equitable assignment of these nasty tasks. For the athletically inclined, the alternative to games of chance like the drawing of straws  was ring stand races with the winner awarded the undesirable  task of their choice.

Ring stands were a piece of operating room furniture designed to hold large basins of solutions used during the case. Before the advent of modern  disposable surgical gloves ring stands were used to rinse talc off reusable gloves. This ubiquitous piece of equipment was a favorite plaything for old school OR nurses. Contests of skill involving the tossing of various objects through the ring stand gradually evolved to attempts involving the passing of  an entire nurse's entire body up from the base of the stand and out of the elevated dastardly top disc that served as the finish line. The contest obviously favored the petite, lithe, thin contestant. Since I met none of these criteria, I was an almost certain loser and frequently found my self with a ring stand stuck on my ample waistline. My buffoonery quickly transitioned to outright embarrassment as the laughing of my colleagues crescendoed .

An official race began with 2 nurses facing the race course ring stand. On the "GO" command the nurses slid down to the floor like a limbo dancer and contorted their way up through the opening in the ring stand. The next stage of the contest was the hard part and involved slithering your body all the way through the ring stand with the victor emerging free of that confining circle. Older nurses always positioned the ring stand parallel to the OR table and leaned against it for assistance. Lithe youngsters could use their upper arm strength to rise above the confining circle. Victory was sweet with the winner having a justified sense of power knowing the choice of unsavory tasks was their choice.

For my next post, I'm thinking about another piece of OR furniture that could be more fun than a barrel of monkeys - the kick bucket.

Glass IV Bottles - Breaking Bad

Breaking a  glass IV bottle was the stuff nightmares were made of. There were three elements to
consider with shattering  old time glass IV bottles. The glass bottle, a liter of fluid (D5W took the prize for making the biggest mess due to it's inherent stickiness,) and an air gap. The air in the bottle served to amplify the crash of the glass breaking so as to sound almost like a rifle shot. Hearing that booming "CRACK" followed by a piercing scream alerted the entire floor of the mishap and summoned a legion of gawkers for the messy clean up. It was an unwritten rule that the clean up was the sole responsibility of the unfortunate breaker of the bottle - don't even thing about calling for a janitor, oops, I mean housekeeping person. An empty Cardboard IV case was placed on the floor close to the broken glass which was gingerly pushed  into the enclosure with a portion of the box top. The procedure always reminded me of catching a piranha  with your bare hands, a slippery mess with a laceration or bite close at hand.

Glass IV bottles were at risk for breakage because their girth made them difficult to grasp. When CDs were designed one of the goals to make them easy to handle. Designers of glass IV bottles were not concerned with ergonomics and the diameter of the glass  container expanded to fit the volume of the fluid. Thank heaven there were no 2 liter  IV bottles.

Another common mechanism of bottle breaking was undershooting the hanging notch on the IV pole. That thin wire hanger was difficult to see especially under bad lighting conditions and many an old nurse thought the bottle was about to nest safely on the pole only to have it come crashing down. A good luck/bad luck conundrum occurred when the rapidly descending bottle came crashing down on the nurse's foot. The bottle, cushioned by the nurse's toes remained intact but hobbled the hapless nurse. Maybe nurses should have worn steel toe shoes like heavy construction workers.

Miss Bruiser, my all time favorite nursing instructor had a favorite tactic for dealing with bottle breaking students. After haranguing and berating the student during the clean up she insisted the clumsy student carry a glass IV bottle with them for 24 hours. A unique combination of public humiliation and learning how to perform daily activities with an ever present glass IV bottle was an excellent deterrent.

Finally the rolly polly crash and break was another way to reduce the glass bottles to glistening shards.  Everyone was acutely aware that there was only one safe position for a glass IV bottle and that was vertical. Inadvertently setting a glass bottle on it's side resulted in it rolling away and crashing at some distance from the nurse. Nurses frequently turned the bottle to this vulnerable position to apply a timing strip or write a note on the bottle label. This unfortunate event almost always occurred at times of great stress when there was an unforeseen complication or unexpected event. An acute hypoglycemic crisis required an immediate IV and if that gigantic ampule of D50 rolled and shattered it was like having a bull in an IHOP restaurant with all those syrup bottles; sticky, gooey syrupy stuff everywhere.

Despite the potential for breaking, nurses hated to see those glass IV bottles morph into those silly looking flexible plastic bags. If the complaints and derisive comments about heavy duty enema cans being replaced by flimsy bags was bad, the ill will directed toward IV bags was even worse. Veteran nurses used to joke  ( I hope it was in jest)  about using those newfangled flexible plastic IV bags for enemas because that was about all they were suited for.

When and Why Glass IV Bottles Disappeared

Glass IV bottles were all fun and games until you dropped one.

Up until the early 1970s you could receive your IV dispensed from any container as long as it was a gleaming glass bottle. These time tested and trusted  vessels had been the workhorse of infusion therapy for decades and possessed a sense of inertia that suggested  they would be around almost forever.

Having been raised  with glass IV bottles, older  nurses had a special reverence  for them. It was easy to view the level of remaining fluid and  glass was inert to allay any worries of interactions with the fluid contents. A strip of ordinary adhesive  tape could be easily applied to the side of the bottle with the time marked for the fluid levels. Pumps and controllers were nonexistent so we counted gtts/minute (gtts is a Latin abreviation for "gutta" meaning drops.) It  always amused me how health care folks  used  Latin to obfuscate the issue, but alas, that's a post  for another day.

KCl  and B&C vitamin supplements could be added to bottles without even using a needle, just plug that naked syringe into the air vent and inject away. I used to relish the visual treat of the deep yellow vitamin solution as it merged and mixed with the clear IV fluid in the bottle. Inject the colorful solution rapidly and a model of a spinning water spout could be replicated. I've heard the term "lightening in a bottle," but a miniature water spout was even more impressive.

 Nurses mixed all  IV fluids  on the patient care  floors, no need to involve the pharmacy with all those superfluous phone calls or redundant paper work. The air vent had another feature nurse's came to know and love. As the air bubble gurgled it's way through the fluid in the resonant glass botle to equalize  pressure, the soothing noise  was an auditory cue that all was right with the infusion. Infiltrated IV sites never produced the  gurgle. Glass IV bottles had a special place in every nurse's heart. We never gave a thought to their disappearance. What could possibly replace such a dependable and familiar piece of equipment?

The beginning of the end for glass IV bottles occurred in July of 1970. Outbreaks of hospital acquired sepsis by the bacteria  Entrobacter cloacae  were linked to Abbott Labs newly designed glass IV bottles with screw caps. The decades old bottle cap was pealed off to open the bottle similar to a pop tab on a can. Occasionally the metal would peal off unevenly resulting in a problem opening the bottle. A new screw on cap was designed to eliminate the opening problems. There were also problems with spiking the old design caps. Sometimes a tiny portion of the black stopper would break free and float freely in the IV solution. We were always told not to worry about it, but foreign bodies like little black flecks of stopper made every nurse nervous. Who in the world would want something like that coursing through their veins?

The newly designed threaded cap was easy to use and the problematic  black stopper was retired. We all liked the new design, but problems were waiting in the wings that would spell the end for glass bottles.

Viable bacteria gained access to the IV fluid while it cooled following the autoclave procedure which created a vacuum drawing bacteria in through the threaded interstices of the newly designed  screw- on cap. The end result was 412 known infections among hospitalized patients and 50 deaths. All of Abbott Lab's intravenous solutions in glass bottles  were withdrawn from the market in March, 1971.

On May 29, 1973 a Federal grand jury indicted 5 corporate officers from Abbott Laboratories. Investigation revealed the Abbott IV plant in Rocky Mount, N.C. was contaminated with a variety of pathogenic bacteria. The proliferation of bacteria was exacerbated by glass bottles of D5W falling from the assembly line and breaking ( a problem nurses knew all too well)  which provided the bacteria with an ample supply of growth media. This was one of the initial cases of health care officials facing criminal charges.

Hospitals were desperate for a supply of IV fluids and Baxter Labs had just introduced a novel product - IV fluids in a flexible rectangular configuration featuring a plastic container that collapsed as fluids infused. The flexible IV bags were tagged with the clever  name "Viaflex" and the revolution had begun. These bags could be stored in any position and touted a completely closed system-the bags collapsed as the fluid exited. No venting required. With the old bottle system it was risky to piggyback antibiotics into a primary line because drugs like Keflin came in 2 gm. bottles requiring a vent and connecting a vented secondary bottle to a vented primary line could allow for air embolism. Small plastic bags of piggyback medication eliminated the air embolism risk. Baxter acquired a pharmaceutical company and began selling premixed drugs in small 100cc plastic bags. The IV piggy back was off to a running start with the closed system mini-bags.  Soon many drugs administered by IM injection were being given IV and fancy new fangled notions of determining peak and trough levels of drugs evolved.

For a brief time period (1976-1980) Viaflex bags and glass IV bottles assumed  a tenuous coexistence. Vented IV sets were bicultural so to speak and could be used with either Viaflex IV bags or glass bottles. Using  nonvented  Viaflex IV tubing set up on a glass bottle was strictly taboo. Hapless practitioners that pulled this stunt found that without a means to relieve intrabottle pressure the drip chamber collapsed like a lung in a punctured pleural cavity. If the problem was not promptly corrected the negative pressure could begin to draw venous blood through the angiocath producing a tell tale red streak of blood in the IV tubing. Spooky indeed and guaranteed the nurse a prominent position on the wall of shame and vulnerable to endless gossip..."You would not believe what Suzy did with her IV last night...yada..yada," nurses only made this mistake once.

By 1980 the intravenous therapy world was ruled by Vialflex like flexible bags and glass bottles were gone for good. Abbott even began producing their own IV bag that had an unusual feature that nurses disliked. The port for adding medications was a blue bull's eye  target about 3 inches up from the bottom of the bag. When adding drugs to an IV, nurses were used to holding the port in one hand to steady it while injecting with the other hand. There was nothing to grasp on that blue bull's eye and nurses in a hurry were known to poke a hole through the opposite wall of the bag resulting in much cursing and  general unpleasantness.

This transition from glass to plastic  was difficult for seasoned old nurses who by  nature of their basic constitution were resistant to change. Glass bottles had prominent labels and were easy to identify; bags were produced with an over wrap that obscured the label. Drip chambers on glass bottles hung perfectly vertical; on bags the drip chamber was often hanging at an angle. Patient transfers with a bottle always required the careful use of a pole to maintain the positioning of the bottle. Nurses were appalled at the occasional  practice of tossing the IV bag on the patient's lap or chest during brief transfers.  Bottles would roll off and break if this crude trick was attempted. It was easier to thread a solid object like a bottle through an opening for an arm when changing patient gowns. Those IV bags were like getting a grip on a handful of Jello.  Finally, hanging those flimsy bags could be difficult. It was necessary to free up the folded vinyl hanger and thread the small opening over the hook on an IV pole.

I am truly impressed by the variety of realistic sounds produced by electronic devices like that camera shutter clicking noise on cell phones or that  "whoosh" noise when sending an email. The Oldfoolrn  medical equipment design institute has come up with another innovation. How about an electronic IV pump or controller that emits a skeumorphic noise replicating that gurgling noise as a bubble coursing through a vented  glass IV bottle. Lots of old nurses would  truly love hearing  that reassuring noise again.

Blood Bag Blues

It's been a very long day. The somber cacophony of suctions sucking, Bovies burning, Airshields ventilators chugging , instruments clanging, and surgeons bellowing has decrescendoed to a strange and rare moment of blissful silence. Those weary legs wobble like Jello as they acclimate to an absence of weight bearing stress. The impending fatigue unleashes a contemplative frame of mind so different from the acute attentiveness  required of a scrub nurse busily loading needle holders and delivering the exact required instrument at the exact right time. My mind sometimes fixated on the remaining flotsam and jetsam scattered about the tiled temple as I planned my clean up activities.

Drained of their miraculous magenta contents, empty blood bags are neatly stacked sit on the anesthetist's  gas machine awaiting their round trip journey back to the hospital blood bank. The few remaining droplets of blood form an intricate spider web design visible through the transparent container that always reminded me of stained glass. The drained bags are now a component of the detritus remaining as an artefact of the previous surgical adventure with their own tale to tell.

Artefacts and relics mean different things to different people when their intended function has ended. I thought many times how strange it sounded to keep blood in a  "bank," but then I began to figure it out. Some of my very best insights occur when fatigued and sleep deprived as that caffeinated jolt works it's magic.

Blood bank CEOs and commercial bankers have much in common. Blood banks rely on the innate goodness of volunteer donors  whose reward might be a glass of orange juice and a stale cookie. Bankers of money pay paltry sums of interest to the hapless savers and charge exorbitant fees to credit card users. Blood bank CEOs and bankers reap their massive  salaries and stock options on the backs of little people just trying to do the right thing. In nursing it always felt as if large sums of money flowed  right around me much the same as the  blood in a suction tubing. Nursing and donating blood is a waste of time if you are doing it for the money. It may sound strange, but I always felt a sense of pity for the greed consumed CEOs lounging in their administrative playgrounds. They probably never had the warm feeling that comes upon you when really helping someone at a critical time in their life.

Blood had almost magical qualities when transfusions went well and the source of blood loss could be corrected. Used blood bags always had redundancy in miniscule sticky labels with an identification number. There were always plenty of these little stickers left over even when all the documentation was complete. I tried to keep the good juju times a rolling with these little stickers by sticking them on the back of my name badge or wrapped around the earpiece of my trusty stethoscope. I don't really know if they helped, but when times were tough, I could cheer my spirits with a quick glance at the back of my name badge.

Finger Cots - Minimum Coverage Saves Vintge Hospitals from Bankruptcy

"Here is your daily allotment of gloves. Use them judiciously and I better not here about one shift hogging them - remember they have to last 24 hours."

Finger cots substitute for gloves in budget minded hospitals

This was the warning issued by one of those stern nursing supervisors as she reluctantly surrendered a box of one size fits all gloves. A box of 24 latex (nobody was allergic to this substance in the good old days) gloves was supposed to suffice for three busy wards inhabited to the gills with patients vomiting, excreting, and  oozing every bodily fluid known to mankind. At least these fluids were organic, the Cidex based cleaning solutions we used on hospital equipment would make unprotected skin boil and bubble up like a dousing with boiling water. We always tried to handle cleaning solution soaked rags with forceps, but sometimes the volatile fumes were enough to accelerate skin lesions. Nasty stuff indeed and don't dare get caught wearing a precious glove on an ordinary cleaning mission.

Old school nurses eschewed gloves for reasons other than the negative impact such extravagant expenditures had on hospital budgets. Nursing was a hands on affair and this meant bare hands  with skin to skin contact. Gloves imposed an unnatural barrier and were viewed as an offense to the patient.

I was conditioned like Pavlov's dogs when I had gloves on. This was just not right and my shoulders hunched over with a strong sense of self consciousness. Even when using gloves appropriately, I was anticipating that cranky old nursing supervisor in the background  hollering and belittling me.

Finger cots came from the supplier in boxes and were clean (hopefully) but unsterile. Sterile finger cots like Montgomery straps and scultetus binders were produced in house by cantankerous, past their prime nurses who toiled diligently in central supply. Three finger cots were oriented in the same direction and placed in a glassine finished envelope which was then autoclaved. A piece of autoclave tape sealed the envelope and verified sterility by proudly displaying diagonal black stripes.

You could do lots of fun tasks with sterile finger cots such as dressing changes or Foley catheter insertions without bankrupting the hospital on  exorbitant expenditures like sterile gloves. Donning sterile finger cots took lots  more practice than  sterile gloving. After carefully opening the sterile packaged fingercots with your ever present bandage  scissors, place them business end down on a bedside stand. Judiciously apply a very small dab of tincture of benzoin to the tips of your thumb, index, and second finger with an applicator  and blow dry with a couple of puffs. Smokers (which compromised 95% of all nurses) with their comprised tidal volume might need three puffs.  Press your thumb into the very center of the rolled finger cot and let the tincture of benzoin work it's adhesive magic. With the finger cot firmly stuck to your thumb slowly and carefully unroll it with your free hand while touching only the inside surface of the finger cot. Rinse and repeat for your index and second finger.

Now that you're all  gloved cotted up it's time to rock 'n roll. To maintain sterility it is essential that you curl up your bare naked  third and fourth fingers. For the time being just pretend they don't exist (I used to make believe  they were burned off in a Bovie mishap.) You do not want them flopping about contaminating the sterile field or the catheter.  You can now use your finger cot festooned fingers to make like a forceps and guide that Foley home to pay dirt. When you're in (urine) haha, its time to peal off those finger cots and hook up the drainage bag.

Finger cots have limited surface area compared to gloves and can be predisposed to slipping off your digit at inopportune times.  The no finger cot left behind doctrine incorporates several measures to prevent in vivo loss of cot custody. The tincture of benzoin trick helps ameliorate wandering finger cot issues when sterile technique is used. For the more common everyday uses of finger cots  the keyword is restraint. Discretion is definitely the better part of valor when exploring any internal orifice with a finger cot. Never ever inset the finger cot into anything past it's cuff. If you poke that finger cot in deeper past the cuff all it takes is a sphincter contraction to strip it off faster than  a chimp can peal a banana.  It's a real challenge to gain purchase on a retained finger cot and the best course of action is probably benign neglect while hoping that it works itself out.

A tenaculum  grasping cervix and a cot on
the index finger. Note the 3 exposed fingers
providing traction on the tenaculum. Gloves optional.

Are Patient Lifting Devices Inhumane?

Cecil, a 26 year old quadriplegic reclines in bed waiting for a pair of nurses to transfer him to his waiting mobility device, an electric wheelchair. Standard operating procedure calls for the nurses to wrestle him to a sitting position with his legs dangling over the bedside.  The nurses then assume a position on either side of Cecil with their muscled arms hooked under his armpits.  A  Cape Canaveral countdown commences and at the conclusion we have a lift off as the stalwart  nurses heft Cecil's limp body into the wheel chair. A solid plop down completes the mission. The source of that ominous cracking noise is a toss up - a nurses back or shoulder joint popped.

The sensitive nurses recognize Cecil's vulnerable state of affairs and take measures to minimize the progression from helplessness to hopelessness by understating the difficulty of the manual transfer. No complaining or grunting and groaning by the nurses when the critical lift is at the peak of their muscular endurance. Pseudo smiles mask the aching backs and burning biceps. Cecil replies with a heartfelt "thank-you," as the nurses ignore their wounded backs and secure him to his electric chariot of a wheel chair.

When hospital administrators could reward nurses with service pins and non-monetary tokens there was little concern about nurse's damaged intervertebral discs or wrenched shoulders sustained while lifting patients. Angels in white were there to serve without concerns for remuneration.

Change was about to come when nurses had financial benefits like workman's  compensation and paid sick leave. Nurse's manual efforts to overcome gravity for their patients suddenly became an expensive commodity and red ink on hospital balance sheets demanded immediate action.

Hospitals began to institute a no lift policy and resorted to devices like the Hoyer mechanical lift for patient transfers. This handy dandy device had a hydraulic pump much like a car jack to lift patients. Straps or a sling were applied under the patients arm and legs and the operator initiated the lift by pumping a lever which resulted in having the patient suspended in mid air.

Cecil and most all patients that were accustomed to human lifts hated these mechanical monsters and pronounced them "inhumane." The herkey - jerkey movement of the Hoyer was offensive to some patients, but there was more to their aversions. Cecil related that here was nothing to hang on to and the feeling of being suspended in mid air was frightening.

I tried to understand Cecil's objection and related the lift experience to my climbing adventures as a foolish youngster. Climbing open structures like fire towers was indeed much more terrifying than scaling a solid rock face. Having a fixed object in front of you  as a reference took some of the fear out of the elevation. It's the  reason that mountain climbers don't necessarily make good workers on cell phone towers. The tactile presence of the nurse lifters added a measure of security to the precarious gravity defying adventure.

Old time nurses like me were falsely advised we were capable of lifting just about any patient if  "proper body mechanics"  were used.  Keep your back straight and let your legs do the work was the mantra. Science does not support this whacky notion. The spinal vertebrae can take only a limited amount of stress and damage to their fibrous structure is cumulative. Nurses have one of the highest occurrences of musculoskeletal injuries of any occupation.

The only inhumane aspect of lifting is  the high injury rate of manual lifters.