Looking Good - Feeling Bad

Back in the late 1960s  cures for serious illness were few and far between. Undaunted by bodies mutilated by serious illness, old school nurses were true artisans when it came to making sick, debilitated  patients look good. That old adage, You can't make a silk purse out of a sow's stomach, did not apply to these embellishment minded nurses. Cachexia never looked so gorgeous.

Every bedside nurse was a master when it came to the quick shave. A wash cloth heated in the blanket warmer served to mollify the most robust beard. A few deft strokes with a prep razor produced a dapper looking patient despite the paroxysms of sustained DTs of an alcoholic in the process of sobering up.

Shaving had one well known complication. Intubated patients always had  that pesky pilot balloon dangling in the razor's path and slicing into that tiny little bubble resulted in lots of excitement. A massive leak around the deflated cuff of the endotracheal  called for a STAT reintubation, but, at least, the patient looked nice if you could overlook the terrified expression elicited by a crash intubation..

Another trick in the looking good procedure manual was fooling  around with the lighting. Jaundiced patients always looked much worse under incandescent illumination, so open the drapes and turn off the overheads in the room. Avoiding yellow bedspreads helps too. Patients with an elevated bilirubin of 4 mg/dl  never looked so good.

Out of sight, out of mind was the philosophy of wound management and the bigger the surgery, the bigger the dressing. Abdominal surgeries incorporated another layer of obfuscation, the scultetus binder. A patient might feel as though their belly lost a battle with a chain saw, but hey, they can't see a thing until that dreaded dressing change.

The importance of accessory items such as eyeglasses and wrist watches in the looking good gambit  is illustrated by the sad tale of a 47 year old man suffering from terminal heart disease. Haskell Karp of Skokie Illinois was the first recipient of an artificial heart. Famed Texas heart surgeon, Dr. Denton Cooley made quick work of the situation and in a 47 minute surgery the artificial heart was in place. The device functioned for 3 days when a transplant became available, but death came 2 days later from operative complications.

It was especially important that a patient  fortunate to receive  doomed by the first totally mechanical heart to look attractive. This was international news and lots of folks were watching. Nurses went all out  to convert what was a terminal event to a flattering photo op. The illustration below shows Haskell fresh off the operating table awaiting the return of consciousness and the delivery of The New York Times. Reading glasses in position for a cursory perusal of the business section. Looking good!

Haskell Karp   Circa 1969

Student Nurses Misappropriate Birth Certificates to Imbibe

Vintage diploma nursing schools had rigid, authoritarian  rules for just about everything  that could be construed as fun. From restrictions on outside visitors, especially men, to strict study hours, all recreational outlets were meticulously managed with onerous regulation. The rules regarding alcoholic beverages were especially strict and came from the hallowed chambers of  The Hospital  Board of Trustees. This mysterious and often cited governing body was a force to be reckoned with because just one measly slip up of their regulations could get you expelled from the nursing program.

According to the esteemed board, alcohol was the ultimate in forbidden fruit, especially for stressed out and underaged nursing students. The notion that imbibing in the magical elixir of alcoholic drink was wrong, made it all the more appealing. Diploma nursing students were in the same boat as Eve in the Garden of Eden.

By the time nursing specialties: pediatrics, psych, and obstetrics, rolled around, nursing students were feeling the pressure of their chosen vocation. I was going to say chosen profession, but we were brain washed into submission and nobody really believed we were worthy of such a lofty title. I'm just a nurse was our mantra. Doctors were professional-nurses were not.

All nursing specialties were difficult and stressful. Cures for seriously ill children were few and far between. Leukemia of any variety was a death sentence. Our clinical psych experience was on the back ward of a state hospital and it was your lucky day if your patient wasn't homicidal. I don't know which was more trying on your soul,  psych or pediatrics. It was a toss-up.

Obstetrics was different, especially post partum where the exuberance of young mothers was uplifting. Our time in OB was rotated in monthly intervals through delivery room, nursery, and post partum. Everyone had their particular favorite, but delivery room duty was the highlight of just about any young student  nurse's  training. The miracle of birth was something that stayed with you and served as an antidote to all the pain and suffering in the rest of the hospital. Birth and death were the ultimate Yin/Yang experience.

The delivery room had another up side. Stashed right next to vials of silver nitrate which was used prophylactically in  babies' eyes to prevent blindness from contact with gonorrhea was a stack of blank birth certificates.

The unwritten rule was that each student nurse was entitled to one blank birth certificate at the conclusion of their delivery room rotation. Students treasured documents from their various specialty rotations and I still have a plundered birth certificate along with a sponge count record from the OR and a restraint and seclusion record from psych.

I first learned what could be done with a blank birth certificate from one of my fellow students who had been released from Cook County School of Nursing as being unsuited for the practice of nursing. That "unsuited" business was a catch all phrase that covered a multitude of sins and was a step up from academic failure because some of these students were able to transfer to another diploma nursing program after "maturing." Transfer students were a valuable resource when it came to surviving nursing school because they knew many of subtle ins and outs of getting through the madness of three years of torture.

Light fingered nursing students knew exactly what to do with a poached birth certificate. "All you have to do is fill in your own name with a birthdate of more than 21 years ago and the document becomes your ticket to freedom from the evil clutches of the sanctimonious "dry" hospital environs," explained one of these wise transfer students. Time to unleash the libations.

Barkeepers found the neighborhoods surrounding hospitals as fertile ground for their trade. There was no shortage of stressed out workers that had pay checks to support their bar tabs. These taverns often had clever names like "Recovery Room" or "Barborygmi." The bar of choice near our hospital was "Ratzos" and the barkeep would just wink and pour when presented with a birth certificate with freshly inked infant footprints. This little charade had been going on for a very long time and was one of the dirty little secrets of old school diploma schools. Cheers! as Sue  would say.

Euphmistically Speaking

I overheard a group of whippersnapperns discussing the advantages of rewording the term "terminal wean" to "compassionate extubation" when discontinuing mechanical ventilation and  allowing nature to take it's course in a critical care unit.  Over the years lots of terms were changed: Directoress of Nursing is now Chief Nursing Officer, Hospital Superintendent is now CEO, Janitors are Environmental Engineers, and Personnel became Human Resources.

All this got me to thinking, which is always a dangerous proposition. I'm  in the midst of a midwinter brain freeze when my thoughts are too incoherent for a typical post. Anyhow, here are some terms that could be reworded to be more politically correct or incorrect, depending on your perspective.

Suicide to euthanasia from unbearable emotional pain.

Bathroom privileges to free range bathrooming?  That sounds dumb, but anything is better than B.R.P.

Doctor's orders to physician's proposals.

Physical restraints to boundary maintenance aids.

Near miss to near hit

Drug addict is a label loaded with lots of pejorative connotations. I've never really had to deal with this issue because old school discharge criteria mandated that a patient be relatively pain free upon discharge. There were very few legal narcotics outside the controlled environment of the hospital. So..lets start referring to those poor souls addicted to drugs pharmaceutical aficionados

I'm saving the best for last. An oldie but a goddie; Emesis to feedback. The simplest ones are always best.

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.

Teaching Student Nurses - That'll Learn Ya

"The next time Miss Bruiser gives me the

business, I'm gonna let her have it."

Crime and Punishment was more than a great Russian work of literature. To a lowly diploma school nursing student it was an integral component of the educational  training process. Mishaps, oversights and downright mistakes were all dealt with by mean spirited instructors out to teach a lesson that usually incorporated humiliation and the infliction of discomfort if not outright pain.

A bulletin board in the lobby of our nursing school was referred to as the wailing wall or the wall of shame. It publicly proclaimed the scores on NLN proficiency exams with the less than stellar results underlined in red and accompanied by cryptic notations to see Miss Bruiser for further review or report to so and so for remediation. The "reviews" were not pleasant and "remedial" usually meant painful and/or humiliating of the highest order.

My scores in obstetric nursing were not up to snuff and as a shy, 19 year old male I was ordered to teach a post partum mother's class. "Fool," Miss Bruiser intoned in her most somber voice, "I've got something special in mind just for you. You  are going to teach new mothers how to care for their infants." It was as if Bozo the Clown had been put in charge of a manned spaceflight to Mars.  I had to demonstrate with a baby doll how to bathe and care for a new born infant. My "students" were all experienced multigravadas that did more laughing and chuckling at my ham fisted, clumsy attempts than an audience at the Comedy Club. I think it was probably the most embarrassing episode in my entire life and I have a special knack for putting myself in embarrassing situations.

My procedure pal Janess was very busy with passing meds and was late turning one of her patients. Miss Bruiser caught her in the act of being 20 minutes behind the turn schedule and had that look in her eye that shivered our timbers to the core. We knew something was up the next day when a bed from the nursing practice lab had been wheeled front and center in the nursing school  auditorium. Before the day's lectures began, Miss Bruiser ordered Janess to hop into the bed and with her usual brusque mannerisms proceeded to "position" Janess with the entire class as a captive audience. When all the bending and twisting of extremities was completed, Janess found herself in a side lying knee-chest position with her head canted at such an acute angle that  her mandible was parallel to her clavicle. "You will remain in that position for the duration of today's lectures," barked Miss Bruiser as she ram-rodded  the siderail up with enough force to elevate the entire bed. The entire class witnessed Janess's contortionist like  punishment  that went on for nearly 4 hours. When she was released from the surly bonds of the bed she could barely walk and all she ever wanted out of life was to be a nurse.

Thankfully, the operating rooms were out of bounds for Miss Bruiser, but Alice, my favorite nursing supervisor was a perfect stand in with a bag of punishments  honed over decades of service. She had a real obsession with finger nail length and would approach nurses at the scrub sink with her millimeter ruler at the ready. One millimeter was the specified nail length and any deviations were treated with a subungal curettage with the business end of a mosquito hemostat. I learned the hard way that the subungal space is highly innervated when Alice began carving away on me while I was a novice OR nurse. I learned how to shave  my nails to half a millimeter length  for an extra margin of safety.

Alice had a thing about tucked in scrub shirts because she claimed leaving them out provided an escape for sub-axillary micrcocci which she affectionately termed "pit fallout" not to be confused with perineal fallout. She  also claimed that lose dangling scrub tops were at risk for inadvertently contacting a sterile field. Alice's cure for untucked scrub tops was an aggressive manual tuck in followed by a practiced upward yank of the scrub pants. I believe the street name for such a maneuver is a "wedgie" and it was something to be avoided at all cost.  I always carefully tucked in my scrub top to avoid this pitfall..

Getting caught wearing gloves for anything but a sterile procedure was a serious deviation from accepted hospital practice. The punishment for wearing gloves was usually a cleaning assignment that involved hospital beds encrusted with a variety of dried on excrements and don't even think about donning gloves.

In the old days things were done in a different way. Nurses scraping by on a subsistent wage faced a wild, chaotic hospital work environment where there were few cures for some very dark illnesses. In this entropy rich culture rigid rules and their subsequent enforcement provided a twisted sense of security to hardened old nurses. Of course, things are different today...I hope.

I'm Going to Give You something to Think About! YEOWW

I stumbled upon this old image and it made my knees feel weak and my knuckles throb. It's a spitting image of my old time OR supervisor, Alice, who could wield a sponge stick with all the force of a burly cop swinging a billy club. This photo shows her assessing the severity of the infraction which will determine the location of the fulcrum to swing her weapon sponge stick from when it impacts the knuckles of her hapless victim. Swinging the sponge stick from the distal tip would inflict the most pain.

It looks like she is about to wail away with the fulcrum in mid position near the instrument's hinge. This was for relatively minor offenses  like passing an instrument to a resident rather than the attending surgeon, even though the resident was in the proper position to deal with the problem. Rules were rules-always provide the attending surgeon first.

The most brutal knuckle cracks were for any offense, real or imagined. that broke aseptic technique. Alice was an equal opportunity knuckle basher and residents were fodder for her cruel ministrations as well as nurses. She caught a young resident with his nostrils protruding over his mask and he received a double punishment, Cracked knuckles and a set of dental rolls plugging his nose. I think there might be an old post about that Aliceism somewhere amidst my foolishness.

Nursing Diagnosis - An Aimless Pursuit

Your patient suddenly loses consciousness, blows his pupils with a narrowing pulse pressure and
has the beginnings of decerebrate posturing.   What's your diagnosis nurse?

"This patient is experiencing hypovigilance secondary to disruption in the flow of energy resulting in a disharmony of the mind, body, and/or spirit." Say what nurse? Old time diploma students never dabbled in this high minded, academic  activity of  the modern  nurse diagnosticians, quite the contrary, we were sternly advised, "Nurses do not diagnose."  This resulted in many deferrals to "Ask your doctor."

We were well versed in acute clinical contingencies (Ha..Ha...I can talk just like you smarty pants nurse diagnosers) and knew exactly what to do if the patients under our care had problems.
Verigo on arising-back to bed...A hemorrhaging arm laceration-slap a blood cuff on while the resident scrambles for hemostats...Hypoglycemic..Have some orange juice...A sluggish chest tube-milk it.  It's really just plain old common sense.

A bona fide diagnosis is based on objective and measurable data, not the whim of a nurse wordsmith spouting off gobbledegook. The evidence supporting the diagnosis would enable different practitioners to come to the same conclusion. I think that those folks a lot smarter than I call it inter- rater reliability.

Nursing diagnoses grant objective status to subjective information. When subjectivity is confused with fact and treatments based on unfounded assumptions are implemented, bad things can happen such as that infamous 1-10 pain scale.

When nursing transitioned from a diploma based hands on education training to an academic setting, office sitter, nurse big shots had to come up with entities to differentiate themselves. They came up with three humdingers that are indeed, unique to nursing. Nursing research, which, more accurately should be called clinical research if the purpose is to improve clinical care. We don't have doctor research. Nursing theory of which I have written jabbered about in a previous post and finally nursing diagnosis.

These discursive disciplines have one thing in common. They are unique to nursing and difficult for other healthcare entities to understand. If the end game is to be a valuable, contributing member of a collaborative, team effort they fall short. Lots of nurses, especially old fools like me cannot comprehend them so maybe we should drop the nursing from nursing diagnosis and work toward a common goal. Diagnosis that is based on objective fact and guides healthcare workers toward effective treatment.

Nursing is all about common sense and using what you know to directly and appropriately helping patients. Having a nursing life that involves only intellectual and down right incomprehensible material is not a good way to live. Some folks think that mastering complex linguistic feats  and fancy talk is going to make them look smart and sophisticated. Truly smart nurses have a high sense of humility and plain talk that really does help patients overcome illness or mishaps.  .

Foolishness...Sparks....Sputters

I've been experiencing one of my mid winter brain freezes and had difficulty coming up with a coherent post so I stuffed a bunch of  3X5  index cards into my pocket and wrote down thoughts as they jumped into my  head. These were some of  the  nursing related thoughts that came to mind. Please don't ask about the non- nursing thoughts. You really don't want to go there!

A nurses (often twisted) sense of humor is inversely related to their proximity to mayhem, misery and tragedy. Utilization review nurses are a dour, unfunny bunch. OR nurses especially after a long messy case will have you laughing like a  hyena. By the way, have you heard the one about the surgeon's daughter and the itinerant autoclave repairman?


Any dropped needle or sharp object will roll or slide to the most inaccessible location with the bevel or sharp side up.


I probably mentioned this previously, but it bears repeating because it's a very reliable prognostic indicator. If the overhead lights are adjusted more than 3 times for a surgery on the same site, the prognosis is grave. The rule is invalid if a technical problem occurs such as a burned out bulb or the light fails to maintain position.

The likelihood of a glass IV bottle breaking is directly related to the stickiness and/or messiness of it's contents. Albumin and plasma are prime candidates for breakage.


Alcohol causes more pain and suffering than cancer and heart disease. Alcohol, gun powder and gasoline do not mix.


Why is the dying process so similar to a birth?

If you are working just for money all the fun and rewards of life are gone.

The higher up the nursing hierarchy you ascend; the worse clinical nursing skills become. A new highly educated nursing supervisor was bragging to us in the OR  about her credentials and one of my co workers hollered out "Yup, you are educated, but can you load a sponge stick with one hand?"
Nope she could not. That put an end to some of the BS.


No sales people are needed for a truly effective drug. When was the last time you heard a sales pitch for penicillin or digoxin?


Hospitals today are loaded to the gills with a plethora of personnel that never touch or directly help a patient. Office sitters and self proclaimed big shots in every department with computer geeks interacting exclusively on  flat screens. If you want a graphic  indicator of how many superfluous people are employed in hospitals observe the difference in how many cars are in the parking garage on weekdays vs. weekends. VA hospitals are the most dramatic.


Regardless of personal religious views, always bow  your head when a patient asks you to pray with them.


You will never know how much it meant to that patient you stayed over past your shift to do something special for, and that's the way it was meant to be.


Never force an intramedullary fixation device into position - use a bigger mallet

"Twas the Night Before Surgery"

'Twas the night before surgery when all through the OR
Not a Bovie was smoking, not even a bipolar
The drapes were assembled on the back table with care
In  hopes that Dr. Slambow would soon be there

The patient was all narcotized and snug in his bed
While floor nurses insured that nothing was fed
And his roommate in a cast and him on a snooze
They just settled down like a drunk on cheap booze

When out on the expressway arouse such a crash
Bodies thrown from vehicles became  victims of a bash
Away, away, to the hospital they were hustled in a flash
Patients off to St. Profit's to be stripped of their cash

 Half their blood volume lie on the new fallen snow
Not a great thing for hemodynamic flow
When, what to my wondering eyes should appear,
But a  young paramedic with an 18 gauge  spear

With a little old tourniquet so lively and quick
I new in a moment he  would feel a big 'ol stick
More rapid than a sump pump in a flood
They pushed in more of that red stuff called blood

Now volume expanders! now lactated ringers!
Pump that fluid in 'til we see color in his fingers
Raise that bag to the top of the pole
Pump away..Pump away.. til his vitals roll

And then in a twinkling straight up to the OR
The elevator cliked and clanked from floor to floor
Wheel him right up next to the table
Call in the nurses and transfer if able

He was covered in blood from his feet to his face
Better lay out a morgue pack just in case
A sucking chest wound was making such a sound
If we don't tube him really quick he'll be moribund

Tell that elective patient all narcotized in bed
His gall bladder has to wait, we have a trauma instead
The scrub nurse and surgeon are fatigued and half dead
Better wait on that cholecystectomy till the nurse gets a bed

I'm Thankful for Autoclaves

If you are working anywhere near an OR and have access to an autoclave all you need is a turkey for the festivities to begin. Thanksgiving  was one of the best holidays to be on call for because traumas were not so common. It used to be rare to shoot or stab some poor sole while a turkey sat  on the table, but perhaps times have changed. Anyhow my featured post is an oldie but a goodie about autoclaving our thanksgiving meal while on call in the OR. You cannot beat an autoclave for cooking up moist, delicious turkey.

What is a "TRUE" Medical Emergency?

Whatever happened to the time when physician's office phones were answered by a friendly, caring person instead of  today's  ominous recorded voice intoning: "If this is a TRUE medical emergency hang up and dial 911? " I suppose this is a lame-brained attempt to limit liability, but it does raise some interesting questions.

There is so much emotional leakage from the medical office worker making these recordings. Everytime I listen to my gastroenterologist's phone menu, a new negative emotion becomes apparent. I get the stressed, pressured, burned out  feeling backed up with a generalized malaise and lack of concern. I don't think this is what the good doctors want to communicate to their patients, but back to the TRUE medical emergency questions.

What if a no good, lying, sociopathic pharmaceutical company executive crashed their corporate jet and was sprawled out on the tarmac like a pile of road kill?  Is this a "TRUE" emergency even though the victims were not truthful and  filled with falsehoods? I don't know. I guess it's time to call the doctors office again and run through that gauntlet of phone prompts to make a determination. If we do manage to get through to the good doctor, how can we respect his assessment skills or diagnostic acumen if he is too lazy to even find someone to answer the phone?

Although obscured by the abrupt interruption of life, trauma always presents opportunity for redemption and renewal of life even if it is radically different from the pre trauma persona. Hopefully, a taste of suffering will enable the pharma big shot to imagine the suffering of others and the evils of cashing in on the pain and vulnerabilities of others that happen to be less fortunate. (So sorry for my crude editorializing, sometimes I get carried away. Blame it on the aging process.)

What happens if a false medical emergency transitions to a true medical emergency while the listener is occupied with the multiple phone prompt choices?  I tried to answer this for myself by dialing 911 when I was about 6 phone prompts into the menu and all I got was that annoying high pitched screech of electronic mayhem. It was then that I realized that in my shock and illness induced fogginess that I neglected to hang up as the uncaring smart alecky voice instructed. OOPS... my bad.

In the good old days we had a better way of classifying emergency cases. The really TRUE emergencies were called "Ambulance Cases" and even had a dedicated entrance to the hospital that was actually a big garage door with a big sign above that cleverly announced: AMBULANCE CASES.  Yesterday's paramedics were ambulance drivers. There were no trauma bays or fancy electronic gizmos standing by, just a group of doctors and nurses that would do anything to save  a patient's life.

Does that ambulance case need blood? If his type matches mine, we will get a direct transfusion going STAT. Here is my arm and that antecubital vein is ripe for harvesting so stab away with that 16 gauge  needle. I'm glad I could help and no I could care less what insurance carrier the patient has.

The many TRUE emergencies that did survive back in the good old days is truly astounding. Sometimes the caring and dedication of the doctors and nurses worked miracles and no we did not have any of those new-fangled telephone answering systems. Thank God I was a nurse back in the dark ages before TRUE medical emergencies were even thought of.

The One Man Band Concept Comes to the OR

I simply love one man bands. The notion of one person or one object having more than one function is fascinating and has led to things like Swiss Army Knives and the Shop Smith woodworking tool that is a drill press, lathe, router, bench saw and who knows what else all in one. Unfortunately, the operating room is an area of specialization. Each instrument and person has one specialized purpose. It's time for a new paradigm in surgery where doctors, nurses, and instruments take on more than one function. Here are a few possibilities.

Too much perfectly good product (I learned that term from those smart alecky business types that run hospitals today) gets tossed. It seems like we had to set up suction on just about every case and then throw it out regardless of condition. On some minor cases the suction container was empty at the end of the case. It just so happened that these minor cases had the most frequent episodes of nausea upon emergence from the anesthetic. It's tough to work up much of an emesis after being NPO, but I have seen it happen. I think that raw gastric content without food to act as a buffering agent can be even nastier than the usual garden variety of emesis mixed with an assortment of foodstuffs.

Now grab that  empty suction container and proudly present it to your upchucking patient. This trick worked like a charm until the end of my career when some genius designed a closed system suction bottle. Bring back the old school coatainer that you can zip the top off and you have a dual use product. Not exactly the equivalent of a one man band, but at least we are back on the right track.

A nobel prize awaits the inventor of a truly functional combination needle holder/scissors. This device would have marvelous utility and could free up a harried scrub nurse for important things like counting sponges and cleaning bloody instruments rather than assisting with the actual surgery. I can't tell you the number of times I have been happily buffing up  a Babcock  with a 4X4 so it shines like the bumper on a '57 Cadillac, only to be rudely interrupted by the surgeon bellowing: "Fool get down here, I need you to cut suture for me." There are now combination needle drivers (as you whippersnapperns are so fond of calling them) that are capable of cutting suture. The present  design greatly limits their usefulness. The scissors part of the instrument lies inside the needle driver making it necessary for the surgeon to work with essentially 2 instruments of different lengths. Muscle memory is a powerful mistress and if you want  to drive a surgeon totally nuts, supply him with instruments of differing lengths. There is never a happy ending with this type of muscle memory confusing instrument and the end result is an outburst of swearing. Hey, maybe we could repurpose that suction container as a cuss bank.

What we need here is a needle holder with the gripping jaws exactly the same length as the scissors part. I am thinking of something with a dual head design akin to a bicephalic creature with both the scissors cutting element the same length as the needle holder jaws.

An old school hybrid anesthetist / circulating nurse was sometimes called into duty on late day or  emergency call cases when there was a shortage of personnel. I am certain this would not be tolerated in today's regulated health care world with all the electronic monitoring devices behind that ether screen, but with a BP cuff and precordial stethoscope these were much simpler times. Once a case was under way the anesthetist would call the circulator over and ask for coverage while he attended to an induction in another room. Once surgery was underway he would scamper back to the original room. This did not happen often and once a sleepy resident was aroused to cover it was back to business as usual.

I was scrubbed once with a novice circulator who seemed anxious about her newly found role as an anesthetist. The attending anesthesia doc ran out of the room for an emergency, but offered succinct instructions for the newbie anesthetist: "Every time you take a breath squeeze that big black bag."

I know nothing of laproscopic surgery, but this discipline seems fond of multifunction devices. I recall a few years back, Olympus announced the Thunderbeat a  combination ultrasonic tissue cutting tool and bipolar cautery. Maybe something was lost in the English translation, but I would be plenty nervous if someone wanted to insert a device named Thunderbeat near my spleen or pancreas.

It does seem like a good idea and in retrospect, I wonder why someone never came up with a dual purpose Metzenbaum dissecting scissor and bipolar cautery. It could be named the "Smokeysnips." If someone could figure out how to add a smoke evacuator to this instrument it could serve several needs; a cutting device, a cauterizing device, and a smoke evacuator.

Here is another 3 in 1 device. We used our trusty Mayo scissors to snap the metal band off multidose vials so the contents could be poured into color coded medicine cups on the scrub nurse's Mayo stand. Unfortunately this really dulled a good pair of sharps so a dedicated multidose vial remover would have great utility.

Since our ORs were on the 7th floor, the windows lacked screens. Occasionally a Chuck Yeager of the insect world would make his entrance to the OR. We did have flyswatters, but you could never find one when you needed one. Combine a multidose vial opener and a flyswatter with perhaps an Oxygen tank wrench and Presto, a multi function instrument of unprecedented value.

I'm saving the best for last. After a long case the first thing I loved to do was tear off my mask without untying it. That ripping noise of the attachment strings separating from the mask was down right satisfying. Next on the agenda was a quick eyeglass clean up. Blood, prep solution, bone chip residue and unidentified material had an affinity for eyeglasses. If an enterprising mask supplier could add a strip of microfiber to the part of the mask, it could be used to clean eyeglasses post ripping off shenanigans. I really could have used something like that.

Dr. Dog on Duty

Thanks to Karl for emailing this lovely photo. It's too good to keep to myself.

Obesity in the OR - Problems Beyond Your Wildest Dreams

Everyone is acutely aware that obesity is unhealthy and can compromise recovery from just about any illness from cancer to cardiovascular problems. Dr. Slambow frequently quipped that surgery on obese patients is like changing the spark plugs in your car engine while standing on a ladder. Some risks of obesity in the OR are subtle and not well known. Here are a few of the obscure risks.

Obesity dramatically increases the depth of that well known lint trap the umbilicus. The deeper that belly hole becomes the more area to accumulate lint, oil, and down right nasty,  foul smelling dirt. The depth of the hole not only increases the volume it can hold, it also further isolates it from oxygen in the atmosphere. Anaerobic bacteria have that characteristic foul smell that any sewer plant worker knows all too  well. Doing a surgical prep scrub on one of these deep, foul holes dislodges sludge that has probably been there since childhood. Unfortunately the patient is 38 years old. That belly button sludge has been fermenting longer than fine, aged cheese. I don't think that I will ever see Roquefort cheese in the same light after doing a prep on one of those coal mine belly buttons.

I'm not on the skinny end of the spectrum and when I required abdominal surgery one of my main fears was of those oversize instruments. My last memory before the Brevital clouded my consciousness was of those foot long pick-ups and how they would look buried in my sore belly. They looked plenty threatening from a patient's perspective and reinforced the humane practice of keeping instruments out of sight until the patient is asleep. I made a note to myself to keep that back table covered whenever the patient was awake in the OR.

 It's not those retractors that are big enough to hold the Grand Canyon open or those very long pick up forceps. Its the mindset they induce in the operative team. Surgeons and nurses see these huge instruments and then subconsciously adopt a Dr. Hulk or Nurse Bruiser mindset. Just because people are big doesn't mean their tissue is tough as nails. An obese patient's pancreas is just as friable as a beanpole patient. Bigness does not translate to toughness. A light, gentle touch benefits all surgical patients. Don't go roughly yanking on things like gall bladders and liver beds. "See with your fingers and lightly touch with your eyes." as Dr. Slambow often said.

Anesthesia personnel seemed to favor spinal anesthesia in some obese patients and after witnessing difficult intubations I can appreciate why. I once witnessed an intubation of a bull necked patient that involved attaching the laryngoscope handle after the blade was inserted. The patient's neck was simply too large to accommodate the laryngoscope handle and blade while it was assembled.. The problem with spinal anesthetics is that while sensory nerves are blocked, pressure sense remains intact. That poor patient can feel the hapless surgeon leaning against him with all his might while he is tying off that bleeder deep down in that wound. Anesthesia always seemed hesitant to heavily sedate obese patients and being awake while the surgeon takes out his frustration on the scrub nurse and leans into me would not be my idea of a good time.

About the only positioning aids available to us in the good old days of big open surgeries were 3 inch adhesive tape, bean bags, sand bags, and assorted permutations of rolled up towels and wash cloths. Lateral positioning of obese patients always scared the devil out of me because wherever that big belly went, the patient was sure to follow. That table was so narrow and that massive belly preparing to slide off was the stuff nightmares are made of. One of the safeguards  I used was aggressively taping the patient's  arm on top to the ether screen. Anesthesia always hated this maneuver because that giant ham hock of an arm could partially  obscure their view of the patients chest. Before all the fancy electronic monitoring aids were available, anesthesia constantly watched the patients chest rise and fall. Flexing the side lying patient's legs and running another course of 3 inch adhesive around the ankles and thighs was added security.

Distractions in the operating room are not a good idea. The surgeon and circulator often begin the "How are we going to get this guy off the table?" discussion just before closing the wound begins. They should be more concerned with sponge counts than who can bench press 150 pounds or more or how many people will be required to complete the table to litter transfer.

Even a dolt realizes that it is much more difficult to properly illuminate a surgical site that is essentially a valley in the middle of 2 mountains of fat. After carefully positioning the lights for optimal illumination of a deep wound things might not look quite the same as they would in a lean patient.. Dr. Slambow was an amateur photographer and had this mystery solved. The yellow fat tissue that surrounds the surgical site was actually changing the color temperature of the lighting. Instead of that nice, neutral white color the lighting had a yellowish cast.

Here is another way obesity may be a boon to the surgeon at the expense of the patient. While the patient is in the consent signing stage, the nurse is certain to mention that obesity confers additional risk to the procedure. This can be used to the surgeons advantage to explain almost any complication of the surgery. Instead of saying something like "That tie was not secured well enough on your cystic duct," the surgeon can dodge the issue and blame everything on the obesity.

This post has really stimulated my appetite and there is a cold Big Mac in the refrigerator. I am so old that if Big Macs were lethal that they would have certainly killed me by now.

Secret Hiding Places to Avoid

I tried to think of a catchy title for this post, but had one of my frequent brain freezes. Oh well, clarity is better than smart alecky titles. I really meant to include this with my last post, but better late than never.

With the corporatization of health care, I suspect it is getting more challenging to find a suitable secret hiding place (SHP)  to renew your  nursing spirit. These contemporary hospitals view every square foot of space as a money maker and have little in the way of wide open spaces.

Old hospitals had many unused areas. One hospital I worked with had an entire floor of patient rooms that had been abandoned in the 1940's. It was a really cool place to visit. The thing I liked best were the ornate old wooden wheelchairs with the big wheel in front and the tiny pivoting wheels in back. Maybe they could not cure anybody, but the wheelchairs sure were classy.

Nurse's lounges sound like an appealing secret hiding place, but they are actually terrible places to hang out. If the dense cloud of cigarette smoke doesn't kill you, the endless jaw-jacking and mouth flapping will. Supervisors used to plan their personal attack strategies after their nurses' lounge visits. I once heard one of the meanest of them planning an assault, "Let's go after that nurse Jan on the ortho ward, she had the temerity to secure her cap with black bobby pins instead of the required white ones." Stay out of the nurses' lounge at all cost.

Meetings sound like they might be a nice break, especially in the Summer when the only air conditioned section  of the hospital is the administrative wing. As a naïve  young nurse, I volunteered to represent the operating room at the head nurses meeting. It was one of the worst mistakes of my nursing life. Imagine a cage at the zoo filled with angry howler monkeys at feeding time and you are locked in. That head nurses meeting was simply unbearable and I quickly deduced which head nurses would make good bar fighters; all of them. As a general rule of thumb for bedside nurses; AVOID  MEETINGS AT ALL COST.

Medication rooms are readily available on all patient care units and at first blink might appear to be suitable for a SHP. Med rooms are poor choices for secret hiding places for a couple of reasons. When they asked Willie Sutton, the notorious bank robber why he robbed banks he quickly replied, "because that's where the money is." When they asked a nurse with a drug problem why she was always in the med room, the answer was, "because that's where the drugs are."

Another issue that makes medication rooms a poor choice is because every nurse knows that med rooms are ground zero for releasing embarrassing intestinal gas. I really don't like crude language but one med room I worked in had a huge sign reading "The med room is not your personal fart box."  We all ignored the signage, but some foolish jokester posted an additional sign cautioning "NO OPEN FLAME"  It was advice well worth heeding. The best policy regarding med rooms was to prepare the medication, pass gas, and quickly depart while slamming the door shut to contain those nasty vapors.

Unoccupied patient rooms might look like a tempting SHP. The problem is that every hospital department from dietary to housekeeping environmental services knows the location of every vacant patient room. These hiding places with a tempting bed to stretch out on are not very secret. Every loafer in the hospital knows about these not so secret hiding places. This SHP quickly surrenders it's charm when you come to the realization that you might have to give a big burley janitor the boot before you can use the room for a SHP.

Although somewhat different than the SHP strategy the mental reframing of the hospital sometimes works if you really dislike your job and need to buy some time before finding something different. I really disliked working in psych and came to view the psych unit just as a place to rest between bike rides. It worked well in the Spring and Summer when I could bicycle to work and when Winter came I was back to the OR which was my first love.

Thanks for indulging in more of my foolish tales!

Keep Those Bedside Cut Flowers Vibrant

A nice bouquet of cut flowers was a pleasant bedside diversion for the frequently long hospitalizations of yesteryear. Decades ago bedside flowers were a very common occurrence. We used to stack them on top of  Gomco suction machines which had a perfectly sized flat surface for this purpose. I used to love viewing the beautiful, fragrant  flowers perched over a huge glass bottle filled with offensive, purulent drainage on the suction machine. It was the hospital version of Yin and Yang.

Care of the cut flowers was frequently  in the hands of nursing staff and with lengthy hospitalizations it was important to preserve them as long as possible. From the Old Fool RN whippersnapper enlightenment institute I am going to reveal an old time trick that really preserved those beautiful bouquets. This may sound whacky,  but much like my Thanksgiving autoclave turkey trick, really did work. The proof is in the pudding as they say.

This is a very wise young student nurse. Notice how carefully she is arranging her patient's flowers in that shiny metal vase. That  fancy metal vase is actually a male urinal (before the advent of those abominable plastic ones)  and yes, it's filled with that magical flower preserving liquid, urine. This is a proven technique that really is science based. The urea found in urine contains nitrogen which is a real boon to plants. Urine also keeps those plant stems patent so the nitrogen nutrient in the urea can move up the plant. This is not another one of those cutsie  hacks that nurses confabulate for amusement. It really does work.

I have seen hospital bedside bouquets last for up to a week when their stems are submerged in that golden yellow miracle excrement. Perhaps with the ultra short hospitalizations and outpatient procedures this is not so important but it's always good to keep in mind when you have an extended hospitalization.

Look Out Below

Florence Nightingale  envisioned hospitals as one story structures that had large windows for both lighting and ventilation. The fresh air was thought to have a healing benefit. Old hospitals had windows that easily opened and closed. There was no mechanical ventilation with a HVAC system and positive pressure rooms were in the distant future. Rooms were heated with radiators and windows were usually wide open in the Spring and Summer.

There were no high altitude flying insects in Chicago, so the windows above about the 4th floor lacked screens. There was nothing between the hospital interior and the good old outdoors.

This direct connection to the outside world presented a temptation too great for some nurses to resist. After working a harried evening shift with normal inhibitions dulled by being too tired and seeing too much misery the unthinkable suddenly seemed like a good idea.

The thought process went like this; "Hmm.... there are 8 Foley bags on this ward that need emptied.. I'm already behind schedule and it's 10:50PM...Over in the corner is a janitorial bucket with impressive capacity...Now lickety split I'll drain the urine bags into the bucket.. Now for the real stepsaver, DUMP THE BUCKET OUT THE WINDOW."

Now, I'm not saying that I've ever done this, but I know for a fact that it was practiced. One old nurse said the hospital planners even allowed for this practice. "Why do you think the sidewalks are located a good 40 feet from the building?" she asked. I don't know if this was true, but I made a mental note to keep a safe distance from any hospital building.

I noticed another tell-tale sign of the window urine dumping syndrome; the grass below selected ward windows was a dead brown color. The high nitrogen content of the urine had effectively killed the turf. I also noticed that upon venturing off the sidewalk (not a prudent thing to do without a raincoat) the unmistakable odor of urine was present. This smell could have wafted out the open windows, but it seemed to always be there which was further testimony of urine dumping.

Miss Bruiser, my favorite nursing school instructor, once asked the class for an explanation of gastric dumping syndrome which often occurred after a gastrectomy. One eager student quickly replied, "The dumping syndrome occurs on the detox wards when a patient vomits out a window." Miss Bruiser seemed puzzled by the student's response, but vomiting out an open window did indeed occur on the 6 bed detox ward.

I think it was a conditioned response with seasoned alcoholics to hurl their gastric contents out a window. The detox ward had that peculiar blend of olfactory insults as a result of the paraldehyde, stool, and emesis coexisting in a small area, so the windows were always open.

It is much easier to vomit out an open window than

trying to hit one of those tiny emesis basins. "When I

open the window, let it rip."

To a detoxing alcoholic the window looked like a perfect place to vomit.  The bed placement also encouraged this tactic. Two of the beds had the head of the bed aligned perfectly with the open windows.    As one old booze hound explained, "I've pucked out my car window many times, it's a lot easier to drive drunk, than clean vomit off the interior." I guess it's called projectile vomiting for a reason. This provided an added incentive to keep your distance from the hospital exterior. I don't know which would be worse to have dumped on someone, urine or emesis. They were both nasty.

There was no positive pressure ventilation in our old operating rooms and with our positioning on the 7th floor the windows were frequently open. Old time anesthesia machines were rather crude and sometimes leaked anesthetic agents. Even on cold days, Dr. Oddo would start hollering, "I'm getting sleepy, open the window."

Not much refuse was ever thrown out the OR windows as there were plenty of witnesses. Hospital window tossing of garbage or effluent  was usually a solitary act. The one exception would be an orthopedic case done in a regular general surgery room. This occasionally happened with a trauma patient and left the circulating nurse with a cleanup dilemma. The only sanctioned disposal location for casting plaster was way down the hall in the ortho room. The stuff could not be poured down a sink as it totally gummed up the plumbing.  After a long trauma case, the window could be a tempting place for plaster dumping. I always wondered what that stalagmite looking mass was on the ground below the general surgery OR. Now I knew, it was casting plaster, that stuff lasts forever.

With Lady Bird Johnson's keep America beautiful campaign in the late 1960's littering and dumping really had a pejorative connotation attached to it. I think most of this unsavory activity ceased. Of course if a nurse was working late at the close of a stressful shift, who knows what might happen. It's always prudent to maintain a safe distance from open hospital windows.

April Fools 2016

I was having one of my usual brain freezes this April Fool's Day and decided to Google medical pranks and foolishness suitable for the day. The best trick that I found was to put Surgilube on stethoscope earpieces which I thought was kind of cute.

Here is an unintentional, but true prank that I was an unwitting victim of. In nursing school our uniform inspections were very detailed and Miss Bruiser, our instructor always found some fault to humiliate a lowly student. We were always supposed to have our clinic shoes buffed up to a gleaming shine, but sometimes the white laces were neglected. I can hear Miss Bruiser's shrill voice, "You forgot to bleach your shoe laces and have just earned yourself a demerit." Shoe laces could be bleached in dilute Clorox solution several times with acceptable results.

My roommate had been called on this issue and was carefully bleaching shoe laces in a plain old drinking glass. Someone saw the glass filed with dilute Clorox and white shoelaces, thought it was milk (we used to smuggle milk back from the cafeteria like this all the time using this method.) The proper place for a glass of milk was the refrigerator which is where it went.

I saw what I thought was a glass of milk in the refrigerator and being half-awake dumped it on my cereal the next morning. The bubbling and gurgling of the cornflakes in the cereal bowl should have been a tip off, but not this time. I stuffed a big spoonful into my mouth. My tongue started to sting and a smokey substance erupted from my nose. I suddenly realized that I had ingested a toxic substance and quickly spit it out. The "milk" was actually a  solution of  the shoelaces bleached clean of hospital grime . After a few aggressive rinses with Listerine, I was fine. I will never forget that noxious taste and always viewed Clinic shoelaces in a different light after that episode. Maybe it was actually a boon to my immune system because I never got sick in nursing school.

Foolish Memories

I have been perusing the many nursing blogs and they all seem to be posted by youngsters who are very bright but perhaps may lack perspective.  Geriatric nurses, and I am referring to the nurses, not patients have not been communicating well with the younger generation of nurses. Heck, where I live there are hardly any youngsters.  Most of my colleagues have went on to their great reward and I am not far behind them. So I am going to start this off with some foolish memories from yesteryear. I have experience in OR, med-surg nursing, and neuro ICU with a brief stint in forensic psych when it used to be called getting beat up by assaultive psychopaths.  Anyhow, on with the recollections

The aroma of a metal bedpan being steam "cleaned" in a hopper. When you opened that hopper door with your clinic shoes a big brown cloud materialized right before your watering eyes. Impressive.

Using methylene blue to dye white silk sutures so the surgeon could see it and. when you thread that suture needle make sure to pull enough through the eye. If the suture falls out when you pass it to the surgeon you're going to hear a roar like a mountain lion in heat!

Wearing beanies during nursing school hell week (initiation) and being sent to Central Supply to pick up a set of Fallopian tubes.  Your big sister (preceptor in present times) threatened to practice nursing procedures on you and had an array of latex tubing and vessels of water to back up these threats.

Bovies in the OR that looked like Maytags and made that reassuring deep HUMM noises to verify they worked properly. No beeping, clicking, flashing lights and the ground looked like a cookie sheet with camel spit smeared all over it. This was ceremoniously placed under the patients rump just prior to induction.  What a great memory before recieving anesthesia. "Oooh that sure is cold"

Setting the sigh setting on mechanical ventilators. PEEP was a yellow Easter candy.

Collecting saliva to test for Digoxin toxicity based on the notion that more potassium would be in their saliva if they were toxic. This could be confusing to some and graphic descriptions of the difference between spit and sputum were common.  Yechh

Being taught how to insert a Foley with 3 sterile finger cots.

Being yelled at, belittled, and accused of trying to bring financial ruin to the hospital if you wore gloves while cleaning up a "Code Brown"  I learned that last term from the youngster nurses-very clever we used to have to call it poop.

Well, it's getting past my bedtime but there is much more foolishness to follow.